Editor’s note: Jan. 19-25 marks Canada’s National No Smoking week, with the Ottawa Model for Smoking Cessation conference to be held Jan. 24-25.
“Dual users,” people who both smoke cigarettes and vape, are a large but neglected group in Canada. They have not been adequately studied, and they have received very little media attention.
Yet, if dual users give up vaping and go back to smoking, more than one quarter of a million of them would die from tobacco-related diseases. The Canadian Tobacco & Nicotine Survey reported that there were 532,000 dual users in Canada in 2020-2021. Public Health England estimates that vaping is 20 times safer than smoking.
Health Canada warns that “During the transition from cigarettes to nicotine vapes, people may experience a period of using both products – this is known as dual-use. Dual use means that you are not completely avoiding the risks of harms of smoking cigarettes. Smoking any amount of cigarettes is harmful. Stop smoking all cigarettes as soon as possible.”
This is reasonable advice and applies equally to people who are using medical nicotine replacement therapies (NRT) such as nicotine gum, lozenges or patches. No one expects these patients to stop smoking as soon as they put on a patch or chew some gum. For a while, they are “dual users” of cigarettes and NRT.
The Canadian Cancer Society says “E-cigarettes are less harmful than tobacco cigarettes if you don’t use both (dual use).” However, Canadian scientific research demonstrates that dual users have lower levels of biomarkers of exposure to toxic compounds than people who are exclusively smoking, demonstrating that dual use is safer than smoking.
In general, “the dose makes the poison.” If someone cuts their cigarette consumption from a pack a day to half a pack a day, they have reduced their risk of suffering from a smoking-related cancer by as much as half, even if they use vape to substitute for the missing cigarettes, as the risk of cancer from vape is only 0.4 per cent of the risk of cancer from smoking.
In a six-year longitudinal study, 59 per cent of dual users stopped vaping and 32 per cent of them stopped smoking. The authors concluded that “Most dual users maintained long-term cigarette smoking or dual use, highlighting the need to address cessation of both products.” Media reported that “When People Both Vape and Smoke, They Don’t Swap Cigarettes for E-Cigs.” A fairer summary of the research findings, however, would be “One third of people who use both cigarettes and vape end up quitting smoking, even if that was never their intention. We need to do more research to find out how we can get more dual users to quit smoking.”
Suppose you want drivers to transition completely to electric vehicles to decrease urban pollution and reduce carbon dioxide emissions. How would you feel about a family that sold one of its two internal combustion vehicles, bought an electrical vehicle and then used the e-vehicle for short errands and the polluting gas-guzzling vehicle for longer trips. Most likely you would praise them for taking a major step in the right direction. You might sympathise with their “range anxiety” and agree that more recharging infrastructure was needed. You might point out an app that helps locate charging stations, or mention that on a recent trip you found a great place where you could eat a cheap and tasty meal while recharging. You would not demand that they instantly sell their polluting car and buy a second e-vehicle.
Now imagine you are a vegan. You believe that eating animals is ethically insupportable, and that meat farming is a major threat to the environment. A neighbour told you she was planning to cut down on eating meat and eating vegetarian meals one day a week. Would you be outraged that she still barbecued steak and ribs on weekends? Or would you congratulate her, and have her over for a grilled veggie-burger? You might point out that vegetarian options on take-out menus are cheaper than meat options. But you might have to accept that she will always want a bit of bacon with her pancakes.
Pretend you had a colleague at work who drank too much, to the extent that it was interfering with his work. You were able to persuade him to stick to soft drinks during the week, but he insisted he would continue to drink alcohol during weekends. You might still be worried about his Saturday night drinking. But for now, his liver has a chance to recover, his work performance should improve, and he should be saving money. It is a step in the right direction that deserves praise and encouragement and may lead to quitting drinking altogether.
We need to treat dual users the same way as we already treat “dual drivers,” flexitarian eaters and “dual drinkers”. We should celebrate when they do the right thing – every cigarette not smoked is a good thing – while exploring what is preventing them from transitioning completely to a better alternative. We must ensure that cigarette alternatives are always cheaper than cigarettes with high taxes on cigarettes and low or zero tax on vapes. We must ensure that the infrastructure is in place so that they are as easy to obtain as cigarettes by insisting that any location that sells cigarettes must also sell alternative products. And we must make them as pleasant, as enjoyable and as safe as possible, for example by ensuring that they are available in a range of fruit and dessert flavours. We should ensure that their friends, relatives and health-care professionals support them, and encourage them to switch completely to vaping.
Maybe we should even be encouraging triple-use or quadruple use of nicotine products. Imagine, for example, someone vapes during their lunch break to avoid smelling of tobacco during an afternoon meeting. During the meeting he or she discretely uses nicotine pouches or snus. And then, at home in the evening, goes out to the porch to smoke a cigarette, a cigar, a pipe or, better still, a heated-tobacco product. Yes, that is not a 100 per cent success, and yes, that person is still dependent on nicotine, but the risk of tobacco-related disease has dropped enormously. Let’s take that as a win and avoid making perfection the enemy of progress.
They have recognized that smoking combustible tobacco is the main risk to their lives and health. They have taken action by buying a vape and learning how to use it. They are exploring a healthier alternative to smoking while reducing their cigarette use. With the right encouragement and incentives, they might eventually quit smoking.
As physicians our goal should be to reduce death, disease and disability, not to tell other people how to live their lives. Dual users deserve our praise and encouragement.
