Vaping is quickly becoming a lot more popular with Canadians, despite what little is known of its long-term health effects.
Experts say part of the reason for the surge in use in such a short time is the evolution of the devices themselves.
"We used to say that cigarettes are the most effective way of consuming nicotine, but e-cigarettes have replaced them," said Dr. Robert Schwartz, a senior scientist at Toronto's Centre for Addiction and Mental Health (CAMH).
"They're so small and discreet and these new devices don't create the huge clouds that the previous devices did — people can use them anywhere, all the time."
Newer devices such as Juul or Vype, which came to the Canadian market last fall, mimic the physical feeling of a cigarette on the throat and use what are known as "nicotine salts" to deliver higher concentrations of the drug to the brain — much in the same way that cigarettes do.
"It used to be that if the nicotine concentration was too high, it would give you a harsh or aversive feeling on your throat," says David Hammond, a public health professor at the University of Waterloo who researches vaping in youth.
"Juul solved that. That's why Juul is somewhere around half the market. That's why most of the other major brands in Canada, including Vype and the smaller ones, have switched to nicotine salts."
E-cigarettes themselves aren't new, having been first introduced in Canada in 2004, according to the Heart and Stroke Foundation, but the chemistry behind the devices has changed dramatically in the past two years with new players on the market.
Schwartz says before the use of nicotine salts in products like Juul, the highest nicotine concentrations commercially sold in Canada were typically upward of 20 milligrams per millilitre, which is the regulated limit in the European Union.
The maximum amount of nicotine content allowed in e-cigarettes in Canada is currently 66 milligrams per millilitre, according to Health Canada. The Canadian Cancer Society says the highest amount used in Juul products is 59, and 57 in Vype.
Juul says one of its cartridges, or pods, has roughly the same amount of nicotine as a pack of 20 cigarettes.
"Once they solved the chemistry of palatable nicotine delivery, then all those others factors that were responsible for vaping becoming popular," Hammond says.
"You throw in tasty flavours and boom you have a wonderful little drug delivery device that sits in your pocket."
'It's very easy to get addicted'
Eva Egnatieva, 16, started using an e-cigarette two months ago and admits she doesn't know exactly why.
"My friends, they're older than me and they're all smoking this," the Toronto high school student said while inhaling a Juul e-cigarette between classes.
"I think when I'm nervous or I have some problem, I smoke it and I'm relaxed, not worried."
Egnatieva says that while she's never smoked a cigarette, she started using an e-cigarette without nicotine at the age of 15. She says the first time she tried an e-cigarette with nicotine in it she hated it, but stuck with it.
"I only smoke Juul," she says. "I don't like to smoke cigarettes because I hate the smell of cigarettes."
Egnatieva says she has little knowledge of the long-term health effects of using the device, but it doesn't discourage her from using it and has no plans to quit.
Dylan Mendonca, a 24-year-old University of Toronto student, says he occasionally smoked cigarettes in social settings but used a Juul to successfully transition off both.
"One thing I really liked about it was that it actually completely made me feel like cigarettes were gross," he says, adding that he then began using the device every day.
"It took me a couple of months to stop, I just stopped buying them. And then I just left the e-cigarette at home, 'lost' the e-cigarette … It's very easy to get addicted."
Surge in popularity
Hammond says the growing popularity of e-cigarettes in Canada is in part because of their use as a tool to quit smoking, but also because of their attractiveness to young people.
"Juul has both made them more likely to help smokers quit, it's also made them more likely to bring new non-smoking youth into the market," he says.
"We need to make them available to adult smokers; we still have five million Canadians that smoke, but we've done a poor job at framing these products as something you use to quit smoking, rather than something you take to a party on Friday night when you're 17."
Hammond led a study published in the British Medical Journal last June, based on online surveys of Canadians aged 16 to 19 in 2017 and 2018, which found that the number of Canadian teens who said they had vaped in the last month had grown 74 per cent, from 8.4 per cent in 2017 to 14.6 per cent in 2018.
New data from the U.S. National Institute on Drug Abuse show a significant increase in teenagers in grades eight, 10 and 12 who say they have used an e-cigarette since 2018. One in 11 U.S. students in Grade 8 reported they had vaped in the past month in 2019, one in five in Grade 10 and one in four in Grade 12.
"What we're seeing now is rapidly increasing rates of e-cigarette use in teens and young adults," says Dr. Nicholas Chadi, a pediatrician at CHU Sainte-Justine in Montreal and addiction medicine specialist.
"They've been very aggressively marketed in all sorts of forms — social media and big billboard ads — to target young people, even though companies will say the contrary. The marketing strategy has worked very well."
On Wednesday, health officials in London, Ont., announced what's believed to be the first case in Canada of a respiratory illness linked to vaping. The high-school-age individual used e-cigarettes daily, was initially on life-support, and is now recovering at home.
While it's not yet known what was in the cartridge, Health Canada says it's concerned by reports of severe pulmonary illness as well as the increase in vaping reported among Canadian youth and it's considering "additional measures" regarding the role of flavours, nicotine concentration and product design, and how all of that contributes to vaping's appeal to youth and non-smokers.
Toronto Public Health reported Thursday they had also encountered a small number of patients in recent weeks who potentially had a vaping-related illness.
The U.S. Centers for Disease Control and Prevention reported 530 confirmed and probable cases of lung injury related to e-cigarettes as of Sept. 17, including at least seven deaths.
"This remains a relatively new phenomenon in our country so we're still wrestling to understand the long-term health effects, but certainly the short-term are incredibly concerning," says Terry Dean, president and CEO of the Canadian Lung Association. "We certainly cannot view them as harmless, because they're not."
Dean says appropriate regulation, policy and education led to the curbing of tobacco consumption rates in Canada and he believes a similar approach should be taken as soon as possible with e-cigarettes and in particular where they're accessible for youth.
"If you're not vaping today — don't start. Blanket statement," he said. "If you are vaping to help stop smoking, your end goal should be to stop vaping."
Chadi says there has never been such a "rapid uptake" in the history of recorded substance use in teens, many of whom may not know how addictive they are and how much nicotine they contain.
"There is some research that shows for young people ages 25 and under with a brain that's still changing, these devices are not an effective smoking cessation tool because you can get very hooked up to the nicotine that comes with it," he says.
"Doctors, pediatricians, but also dentists, social workers and school nurses need to ask the right questions to teens to know if they're using them, what they think about them and try to help."