The document outlines the development of CAMH's Lower-Risk Nicotine Use Guidelines, which were created to educate the public on lower-risk options for nicotine use given the changing landscape of tobacco and nicotine products. The Guidelines development process included a literature review and formulation of recommendations by a guideline development group. The Guidelines contain 6 recommendations on nicotine products and aim to empower lower-risk choices while acknowledging that complete abstinence from nicotine is the safest option.

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2. March 3, 2022
Presenters: Dr. Peter Selby
Facilitator: Emily Clark
The Centre for Addiction and Mental Health (CAMH):
Lower-Risk Nicotine Use Guidelines

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8. Presenter
Dr. Peter Selby
Senior Medical Consultant and
Clinician Scientist at the Centre for
Addiction and Mental Health (CAMH)

9. Lower-Risk
Nicotine Use
Guidelines
March 03, 2022
Dr. Peter Selby
MBBS, CCFP, FCFP, MHSc, dipABAM, DFASAM
Senior Medical Consultant and ClinicianScientist –
Addictions, CAMH
Professor, DFCM, Psychiatry, and the Dalla Lana
School of Public Health, University of Toronto
@drpselby www.nicotinedependenceclinic.com

10. Presenter Biography
Peter Selby is a Senior Medical Consultant and Clinician Scientist at the Centre for Addiction and Mental
Health (CAMH). He is the (Interim) Vice Chair of Research, Clinician Scientist, and Giblon Professor in the
Department of Family and Community Medicine, and Full Professor in the Departments of Psychiatry
and the Dalla Lana School of Public Health at the University of Toronto. His research focus is on
innovative methods to understand and treat addictive behaviours and their comorbidities. He also uses
technology to combine clinical medicine and public health methods to scale up and test health
interventions. His cohort of >300,000 treated smokers in Ontario is an example.
He has received grant funding totaling over 100 million dollars from CIHR, NIH, and Ministry of Health
and has published 150 peer reviewed publications. He has published 6 books (including 5 edited), is the
author of 31 book chapters, and 38 research reports prepared for the government. He is the Chair of
the Medical Education Council for the American Society of Addiction Medicine. Dr. Selby mentors
Fellows in Addiction Medicine and Addiction Psychiatry, junior investigators and medical students. The
use of innovative methods to communicate messages makes Dr. Selby a sought after speaker for
various topics including addictive disorders, motivational interviewing, and health behavior change at
individual and system levels.
Peter Selby, MBBS, CCFP, FCFP, MHSc, DipABAM, DFASAM
Senior Medical Consultant, Centre for Addiction and Mental Health (CAMH)
Clinician Scientist, Addictions Division, Centre for Addiction and Mental Health (CAMH)
Professor, Departments of Family and Community Medicine and Psychiatry, and Dalla Lana School of
Public Health, University of Toronto
peter.selby@camh.ca
(416) 535-8501 ext. 36859

11. Grants/Research Support:
• CAMH, Health Canada, OMOH, CIHR, CCSA, PHAC, Pfizer Inc./Canada, OLA,
• Medical Psychiatry Alliance, ECHO, CCSRI, CCO, OICR, Ontario Brain Institute,
• McLaughlin Centre, AHSC/AFP, WSIB, NIH, AFMC, Shoppers Drug Mart,
• Bhasin Consulting Fund Inc., Patient-Centered Outcomes Research Institute
Speaking Engagements (Content not subject to sponsors approval)/Honoraria:
• Pfizer Canada Inc., ABBVie, Bristol-Myers Squibb
Consulting Fees:
• Pfizer Inc./Canada, Evidera Inc., Johnson & Johnson Group of Companies,
• Medcan Clinic, Inflexxion Inc., V-CC Systems Inc., MedPlan Communications,
• Kataka Medical Communications, Miller Medical Communications, Nvision
• Insight Group, Sun Life Financial
Other: (Received drugs free/discounted for study through open tender process)
• Johnson & Johnson, Novartis, Pfizer Inc.
NO TOBACCO or ALCOHOL or FOOD INDUSTRY FUNDING
Disclosures

12. Copyright © 2017, CAMH
Learning Objectives
4
1
Describe the
broadening
landscape of the
tobacco epidemic
that necessitated
the creation of the
LRNUG Guidelines
2
Examine the
Recommendations
and dissemination
plan
Investigate the
formulation of the
Guidelines
3

13. Copyright © 2017, CAMH
Describe the broadening landscape
of the tobacco epidemic
1

14. Copyright © 2017, CAMH
Current Cigarette Smoking in Canada
• 12% of Canadians (3.7 million)
Youth (aged 15-19)
• 5% (142,000)
Young Adults (20-24)
• 13% (240,000)
Adults (25+)
• 13% (3.3 million)
6
Background
Statistics Canada 2019

15. Copyright © 2017, CAMH
Who Smokes Cigarettes in Canada?
In 2019, 12% of Canadians 15 years or older
reported being a current smoker
13%
Males
11%
Females
Statistics Canada, 2015; Health Canada 2015
Statistics Canada 2019

16. Copyright © 2017, CAMH
Use of Other Tobacco Products (past 30 days)
3%
(873,000)
Cigars
0.4%
(127,000)
Water-pipe
Statistics Canada, 2015; Health Canada 2015
Statistics Canada 2019
0.4%
(127,000)
Chew

17. Copyright © 2017, CAMH
Use of Vaping Devices
5%
(1.5 million)
Past-30-day
38% current
smokers
25% former
smokers
37% never
smokers
84% used
nicotine
16%
(5 million)
Ever vaped
2.1%
(656,250)
Daily Vapers
Why Vape?
27%
smoking
cessation
20%
curiosity
20%
enjoyed it
Statistics Canada 2019

18. Copyright © 2017, CAMH
Global
Canada
• healthcare expenditure due to smoking-attributable diseases
• over US$422 billion in purchasing power parity (PPP) in 2012
• 5.7% of total global health expenditure
• Total economic cost of lost productivity
• estimated US$1 trillion in PPP in 2012
• equivalent to 1.8% of the world’s annual GDP
Goodchild et al. 2016
10
Economic cost of smoking
• economic burden from tobacco smoking is estimated at 18.7
billion annually
Krueger et al. 2015

19. Copyright © 2017, CAMH
Alternate nicotine delivery devices
• Broadening the landscape of the tobacco epidemic
Gravely et al. 2019
11
Nicotine
• Primary addictive component in tobacco

20. Copyright © 2017, CAMH
T A R G E T
In 2019, 24% (7.6 million) of Canadians 15+ reported
being a former smoker
• 3% quit <1 year
Cited Cessation Methods
• 70% - quitting on their own without special
preparation or help
• 54% - reducing their number of cigarettes
• 35% - switching to vaping
12
Quitting Smoking in Canada
5 % p r e v a l e n c e by 2 0 3 5
StatCan, 2019
H o w d o w e g e t h e r e ?

21. Copyright © 2017, CAMH
13
Challenges with Cessation
INDIVIDUAL
CLINICAL
SYSTEM
attitude knowledge and skills,
undermining efforts
lack of knowledge and belief in harms of
smoking, attitudes towards getting
assistance and or meds to quit
coverage, accountability

22. Copyright © 2017, CAMH
14
Nicotine Dependence Service Goals
Increase access to
free treatment for
Ontario smokers
Build practitioner and
system capacity for
delivering treatment
Decrease
prevalence of
smoking in Ontario

23. Copyright © 2017, CAMH
Investigate the formulation of
the Guidelines
2

24. Guideline Development
Funded by Health Canada’s
Substance Use and Addictions Program

25. Copyright © 2017, CAMH
17
Lower-Risk Nicotine Use Guidelines
• evidence-based information on how to lower risk when
choosing/using nicotine products
• educate and empower lower-risk nicotine use

26. Methodology
Guideline Development Group Formation
Development of a Research Question
Selection of Priority Topics
Review of the Literature
Guided by GRADE Principles

27. Literature Review
Search strategy developed in partnership with CEP
Systematic Reviews
Supplementary
e-cigarette RCT search
“Up-to-the minute”
literature search
3 rounds
of literature
search

28. • Vaping evidence is emergent
• many systematic reviews will not pass full AMSTAR
• prohibitively small research pool
• “rapid AMSTAR” approach:
• excludes less rigorously performed reviews
• enables inclusion of well-done studies
Literature Review: Vaping Evidence

29. Appraisal of Literature & Recommendation Development
GDG Review of
literature tables
independently
2 day in person
meeting in
Toronto
Presentations
and
Recommendation
Development

30. Guideline Development Group
Peter Selby, MBBS, CCFP(AM), FCFP, MHSc,
dipABAM, DFASAM
CAMH; UofT
John Atkinson, MSW
Canadian Cancer Society
Bruce Baskerville, MHA, PhD, CE
Canadian Institutes of Health Research
Mark Eisenberg, MD, IMHL, MPH
Jewish General Hospital; McGill
Brent Friesen, MD, FRCPC
Alberta Health Services
Milan Khara, MBChB, CCFP, Dip.
ABAM
Vancouver Coastal Health; UBC
Jane Ling, R.Ph., BScPhm
North Durham Family Health Team;
Pharmacists for a Smoke Free Canada
Claudia Mariano, MSc, NP
Nurse Practitioners Association
of Ontario
Nadia Minian, PhD, MA
CAMH
Alice Ordean, MD
St. Joseph’s Health Centre; UofT
Ron Pohar, BSc.Pharm, APA
Consultant Pharmacist
Robert Reid, PhD, MBA
University of Ottawa Heart
Institute
Robert Schwartz, PhD
Ontario Tobacco Research Unit;
UofT
Laurie Zawertailo, PhD
CAMH; UofT

31. Guidelines
Level of Evidence
• Very Low, Low,
Moderate, High
• Quality of available
evidence
• Rapid AMSTAR
review
Strength of the
Recommendation
• Strong, Conditional
• Confidence that
adherence to
recommendation
will cause good
• Quality of evidence
& GDG expertise

32. 24
Lower-Risk Nicotine Use Guidelines
Smoking related health outcomes and their severity
are modifiable by consumer choice
• Full abstinence from nicotine products is the only way to completely
avoid the associated health risks
• Quit, or reduce to quit with pharmacological and/or behavioural supports
is always encouraged first
• For those who do choose to use nicotine, health risks and outcomes are
modifiable through consumer choice

33. Recommendations

34. Category and Recommendations
Level of
Evidence
Strength of
Recommendation
Smokeless Tobacco
1. Use of Smokeless Tobacco (SLT) should be
discouraged.
Low Strong
Heated Tobacco Products
2. Use of Heated Tobacco Products (HTP) should be
discouraged.
Moderate Strong
Water–Pipe Smoking
3. Water-pipe smoking should be discouraged. High Strong
Reproductive Health
4. Use of SLT, HTP, water-pipes, and e-cigarettes
should be discouraged in women who are pregnant
Very Low Strong

35. Vaping and Addiction
Recommendation 5a.
Use of e-cigarettes with nicotine
should be discouraged among non-
smokers due to risk of addiction

36. Vaping and Addiction
5a. Summary Statements
There is substantial evidence that:
•e-cigarettes with nicotine are addictive, and that their
use results in symptoms of dependence on e-
cigarettes
•e-cigarette use increases the risk of ever using
combustible tobacco cigarettes among youth and
young adults. However, transition to regular use of
tobacco cigarettes is unclear at this time

37. Vaping and Addiction
5a. Considerations
• use of high-dose nicotine salts may increase risk of addiction
• youth and young adults should be advised that e-cigarettes are
addictive and that nicotine addiction may increase the risk of
using combustible tobacco cigarettes.
• patients should be advised to restrict the use of e-cigarettes to
protect non-users from airborne particulate matter.

38. Vaping and Cessation
Recommendation 5b.
E-cigarettes with nicotine may be
an effective cessation aid for
people who use combustible
tobacco.

39. Vaping and Cessation
5b. Summary Statements
• Systematic reviews provide some evidence of the
effectiveness of e-cigarettes as a cessation aid.
• More frequent use (ie: daily) of e-cigarettes is associated
with an increase in cessation outcomes.
• People who use combustible nicotine products should try to
quit using approved smoking cessation treatments first. If
they are unable or unwilling to quit, e-cigarettes can be
considered.

40. Vaping and Cessation
5b. Considerations
• E-cigarettes as a cessation aid are most effective when combined with
behavioural counselling
• Smokers should be advised to switch completely from combusted
tobacco to e-cigarettes and to use e-cigarettes when they would
normally have smoked tobacco cigarettes
• Device type and nicotine dose is a matter of personal preference
• Switching completely to e-cigarettes will significantly reduce the harms
associated with combusted tobacco. However, smokers should be
advised that harms associated with long-term e-cigarette use are
currently unknown
• Continued use of e-cigarettes may reduce risk of relapse to
combustible tobacco

41. Vaping and Health Outcomes
Recommendation 5c.
People who do not use any
tobacco products should not
use e-cigarettes

42. Vaping and Health Outcomes
Recommendation 5d.
People who are currently using e-
cigarettes should stop or switch to
safer forms of nicotine such as
NRT.

43. Vaping and Health Outcomes
Recommendation 5e.
People who switch from
combustible tobacco to e-cigarettes
will reduce their exposure to
numerous toxicants and
carcinogens

44. Vaping and Health Outcomes
Recommendation 5f.
For people who use
combustible tobacco products
and cannot quit by other means,
e-cigarettes may be a lower-risk
alternative.

45. Vaping and Health Outcomes
5c-f. Summary Statements
• The long-term health effects of e-cigarette use are
unknown.
• There is some evidence of mutagenesis and DNA damage
related to e-cigarette use that is a marker for increased
cancer risk.
• There is evidence that e-cigarette exposure can cause
cough and mouth and throat irritation.

46. Vaping and Health Outcomes
5c-f. Considerations
• E-cigarettes are less harmful than combustible tobacco, but are
not completely harmless. In addition to nicotine, most e-cigarette
products contain and emit substances with unknown harms when
inhaled.
• Receive instruction on the use of the device given the variability in
device types, etc.

47. Vaping and Health Outcomes
5c-f. Considerations
• If you use these products, you should consider the following:
• Do not purchase unsafe illicit/black market e-liquids, pods or
devices
• Don’t adulterate your products (THC, vitamin E, other oils, etc.) or
modify the device
• Keep the products away from children
• It is unclear what risks are associated with using e-cigarettes and
combustible tobacco concurrently

48. Copyright © 2017, CAMH
Examine the Recommendations
and Dissemination Plan
3
40

49. Copyright © 2017, CAMH
41
Quick Tips
• Tips for lowering risk when using
nicotine
• Chart of product contents and health
risks
Recommendations
• Recommendations, Summary Statements,
Considerations
Evidence Brief
• Digestible recommendations
Products at a Glance

50. Copyright © 2017, CAMH
42
When is the Recommendations document used?
• HCP-facing document
• Contains all
Recommendations and
Considerations
• Links to Executive
Summary with
Methodology and full
reference list

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43
When is the Evidence Brief used?
• HCP-facing
• Making the
Recommendations
more accessible
• Refer to this document
when clients ask
questions

52. Copyright © 2017, CAMH
44
When are the Quick Tips used?
• Patient-facing resource
• Refer to this document when advising
clients
• Share this with your clients

53. Copyright © 2017, CAMH
Dissemination

54. Copyright © 2017, CAMH
NDS website
(>1,000 unique
visitors)
TEACH webinars
(>400 attendees)
TEACH Listserv
(>900 HCPs)
STOP
Teleconference
(110 attendees)
ORTU newsletter
(~777 views)
46
Product Creation with
partners at CEP
Usability
Testing with
HCPs and
consumers
Finalization of
Knowledge
Products
Dissemination Strategy
Soft Launch
06-07/2020 05/2021
01/2020

55. Copyright © 2017, CAMH
47
Creation
of French
translation
Follow-up
Surveys
Manuscript
Dissemination Strategy ongoing
Distribution
amongst
partnership
networks
NCCMT
CEP
PSFC

56. Copyright © 2017, CAMH
48
Acknowledgements
Team
• Guideline
Development
Group
• Rosa Dragonetti
• Chantal Fougere
• Danielle Dawson
• Anne Dabrowski
• Sophie Blackmore
Partners Funded by
Supported by

57. Copyright © 2017, CAMH
49

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