Letter From Kellie Ann Forbes BScN RN 2015

A Nursing Perspective - Argument Against Outlawing Vaping in Public Kellie Forbes, BScN RN THRA Board Member, Director of Harm Reduction Education Smoking is the number one preventable cause of disease and death everywhere in the world, and the most common addiction in Canada. Smoking cessation is more achievable with vaping than any other nicotine replacement therapy (21% vs 6% in controlled clinical trials). Replacing smoking with vaping will reduce the incidence rates of smoking-related diseases, human suffering and associated social costs. Vaping must be utilized in public places to facilitate its full potential on improving population health outcomes. Nurses are responsible to assist their patients to attain better health by adopting less harmful behaviours. Public vaping bans are irresponsible & unethical from a nursing perspective because it violates our Charter of Rights and Freedoms, specifically our right to life, by significantly reducing the chances of successfully quitting smoking using what is rapidly becoming recognised as the most effective method, for the following reasons: 1. Exhaled vapour is of no danger to public health. 2. Bans prevent the patient from maintaining their nicotine serum levels within a therapeutic range. 3. Bans impede the patient from learning how to use the device. 4. Bans greatly increase the chances of smoking relapse. 5. Bans deceivingly imply vaping is dangerous. 6. Healthcare facilities are an ideal environment to implement harm reduction strategies. Exhaled vapour is of no danger to public health Over 9000 observations of vapour constituents have been analyzed using the latest technologies and found them to be less than 1% of Workplace Exposure Standards levels; aside from 2 which were less than 5%. It took decades to understand the harm potential of tobacco smoke because it took decades to develop the technology to analyse the smoke. Since then, science has analyzed thousands of known substances and catalogued the levels of each substance in relation to how it affects human health. An example of this knowledge is feeling safe breathing city air because we have determined that the levels of carcinogens, heavy metals and toxins from vehicle exhaust are too low in the air to cause us harm. There is nothing new in ‘e-liquid’, the fluid used in a vaporizer. Unlike a burning cigarette, there is no side-stream vapour: the exhaled vapour is the only vapour entering environmental air; and is of no danger to bystanders…period. Let us consider what we do allow in public in our free country. One out of a hundred people has a peanut allergy. Consider this situation: person “A” holds a Snickers bar and opens a door with that hand and then person “B” touches the same door handle. If person “B” has a peanut allergy they can have an anaphylactic reaction and die unless they receive immediate medical attention. Peanuts are of no benefit to the public but they are allowed in public despite the severe health risks. Vaping, however, is an effective treatment for tobacco addiction which every year kills 37,000 Canadians and inflicts over 1 million Canadians with chronic disease at a cost to the taxpayer of at least $20 billion. We are so compelled to help patients stop smoking that Champix continues to be prescribed as a smoking cessation treatment even though it has been linked to several Canadian deaths. One of its side effects is suicidal ideation and some patients have followed through with killing themselves. Page 1 of 2

To address the ‘nuisance’ reason Edmonton City Council used to outlaw vaping: I am referring to normal vaping not ‘cloud-blowing’. Regular vaping produces small volumes of thin vapour while cloud-blowing produces large volumes of thick vapour. This is much like the difference between sipping a glass of wine and doing ‘shots’. Establishments can enact policy to restrict cloud-blowing. We allow nuisances in public such as screaming children, body odor and eating with your mouth open because this is a free country. Bans prevent the patient from maintaining their nicotine serum levels within a therapeutic range To effectively reduce the craving for tobacco smoking, the levels of nicotine in the blood (serum levels) must be within a range that is high enough to satisfy the nicotine addiction (therapeutic range). A good example would be a patient that is attempting to quit smoking by using an NRT (nicotine replacement therapy) such as a nicotine inhaler, gum or patch. We would teach him/her to use the NRT regularly, including when in public, to maintain their nicotine serum levels within a therapeutic range. We term this as ‘medication compliance’. Bans impede the patient from learning how to use the device Achieving and maintaining therapeutic serum levels is a challenge for new vapers because vaping has a different delivery of nicotine than smoking. Vaping has 10% of the nicotine content that is found in tobacco smoke and does not have the multitude of chemicals added to cigarettes that boost the effects and the delivery of nicotine. This means it takes longer via a higher number of puffs for the patient to reach and maintain therapeutic levels. This challenge is compounded with new users. Vaping effectively, requires a longer, slower draw then smoking; and does not have the added ‘kick’ of the 4000 chemicals in tobacco smoke. Studies have shown that there is a learning curve for new vapers to get their nicotine levels into a therapeutic range as quickly as experienced vapers. Bans greatly increase the chances of smoking relapse So, in the case of public bans, when a new vaper is trying to transition off tobacco and is in a public place, their serum levels 'trough' and they experience a “nic-fit” (withdrawal symptoms). Then, they are forced to repeat the ritualistic behaviours of their tobacco addiction by standing outside in the smoking pit. They are then cued by the smell of smoke and observing smoking which increases their craving to smoke thus encouraging relapse. The vaporizer will not raise their serum levels as fast as the rate they’re used to from smoking. Their typical behaviour in the smoking pit when experiencing withdrawal is to ‘bum a smoke,’ meaning they would ask another smoker for a cigarette. Once the relapse occurs, they’re significantly more likely to continue smoking because they may conclude that vaping did not work for them and they have internally experienced the greater, more satisfying effects of tobacco smoke. Bans deceivingly imply vaping is dangerous Outlawing vaping in public gives people the false impression that there is something dangerous about it, like the case with loaded firearms. This deceiving message would likely make the public afraid of the vapour and discourage them from being comfortable with vaping around them. This false belief would likely make smokers afraid of trying vaping and reduce support from their loved ones, coworkers, friends and community. Page 2 of 2

Healthcare facilities are an ideal environment to implement harm reduction I disagree with vaping being banned within healthcare facilities or grounds. Propylene glycol (PG) is the base ingredient of e-liquid. Typically, a vaper will vape 1-5ml per day. Within the hospital, I regularly administer nebulizers to patients with respiratory diseases (the vast majority are or were smokers). Nebulizers are medicines dissolved in PG placed in a reservoir in a face mask, covering nose and mouth. The solution is about 2.5ml and is atomized with high-flow medical air or oxygen via a tube from mask to the wall outlet, in about 10 minutes. The atomized PG is inhaled, exhaled and airborne via holes in the mask into the environmental air. We will often give more than 5 ml via multiple medications such as Ventolin, Atrovent, Pulmicort, three to six times a day per patient. Our air sanitizers are also PG based. My point is that hospital air already has plenty of PG in it. Our injectable medicines are also PG based and the recommended daily limit is 60 ml per day. Health care agencies and professionals have an ethical responsibility to promote harm reduction strategies, facilitate informed decision-making and advocate for vulnerable populations (in this case tobacco addicts). Hospitals are an excellent opportunity to transition smokers to vaping. It would reduce the risk of injury and aggravation of disease by keeping the patient in the hospital where they are safe instead of going outside to smoke. Most importantly, the patient will have the opportunity to learn how to use the device with the teaching and support of nurses, which would implement transition from the most deadly delivery of nicotine (smoking) to an up to 99% safer alternative (vaping). Conclusion As a registered nurse, advocating for fair regulation on vaping is not a selected battle; it is a moral imperative as dictated by my professional code of ethics. As per the six points discussed, outlawing public vaping promotes tobacco addiction, chronic disease and human suffering. The Liberal party has the opportunity to be a world and Canadian leader in fair vaping legislation; leaving a legacy of promoting Canadians’ right to life, harm reduction and smoking cessation. Page 3 of 2