There’s no smoke but plenty of fire in the debate over e-cigarettes and tobacco control. By Megan Howe.
Controversy over e-cigarettes and ’vaping’ heats up
A few months ago, Stacey Shipton decided she’d had enough of smoking. Her lungs felt heavy, it was a costly habit and, after 15 years of puffing, it was time the 30-year-old gave it away. But how to quit?
Shipton turned to “vaping” – inhaling nicotine via a smoke-free, electronic cigarette – and became part of a worldwide trend that has seen the e-cigarette industry grow from one manufacturer in China in 2005 to an estimated $US3 billion global business with 466 brands, according to the World Health Organisation.
“Vape” was recently named the Oxford Dictionary’s 2014 word of the year. But the term is driving a sharp wedge through Australia’s public health profession. On one side of the divide are tobacco control advocates who warn that e-cigarettes threaten the decades of work done to reduce smoking rates, especially among young people. On the other side are those who hope vaping could prove the best means yet to help smokers quit.
The legal situation surrounding e-cigarettes in Australia is complex. The devices – which are shaped to look like anything from cigarettes to lipsticks – have been banned in Western Australia, and Queensland has just amended the Tobacco Act, effective in January, to prevent e-cigarettes being sold to children, ban their use in indoor or outdoor public places and ban promotion and advertising of the products in retail outlets. This makes it the first state to subject e-cigarettes to the same laws as tobacco cigarettes. The devices remain legal in other states and territories, but the nicotine liquid that is vaporised in them remains classified by law as a “dangerous substance”, meaning it is illegal to sell, possess or use it without approval.
That hasn’t stopped the proportion of Australians who have tried e-cigarettes jumping from 2 per cent in 2010 to 16.8 per cent in 2013, according to one study.
Shipton, from Sydney, says she tried buying nicotine liquid from an online supplier, but the website stated they didn’t export to Australia because the product would be seized by customs. (Several other e-cigarette companies do advertise shipping to Australia on their websites.) The ban didn’t prove much of a barrier – Shipton soon found “obliging” tobacconists who supply the nicotine and has now largely switched to vaping, although she occasionally lights up a cigarette when out with friends. She believes banning e-cigarettes that can help smokers quit doesn’t make much sense, when tobacco cigarettes – which all agree are more damaging to health – remain readily available.
Professor Simon Chapman, professor of public health at the University of Sydney and long-time tobacco control activist, says the e-cigarette issue has split the health profession into two camps: those who focus on the benefits of e-cigarettes at an individual level in helping a smoker quit and those, such as himself, who are looking at the issue at population level.
“We don’t just look at the potential to help people who use tobacco, but at the implication of products becoming widely available, with advertising and use of flavours that are extremely friendly towards kids.”
He has grave fears e-cigarettes could lead to the uptake of both vaping and cigarette smoking by young people, and could actually bring former smokers back into nicotine addiction. The liquid in e-cigarettes is heated to create a fine vapour, which contains nicotine, together with flavouring, usually dissolved in propylene glycol or glycerine. Unlike cigarette smoke, the vapour does not contain monoxide or other toxic products of combustion, and proponents of e-cigarettes often state that people “smoke for nicotine, but die from the smoke”. E-cigarettes eliminate the dangerous smoke, they argue.
However, a World Health Organisation (WHO) report on electronic nicotine delivery systems published in September states that the amount of nicotine users inhale via e-cigarettes varies widely, ranging from very low levels to levels similar to that of cigarettes, depending on the product, the users’ “puffing behaviour” and the concentration of the nicotine solution, which varies.
Nicotine is potentially addictive, no matter how it is consumed. But most public health experts agree there is simply not enough evidence yet to determine if e-cigarettes are addictive, whether the inhaled nicotine is harmful to the user and whether the emitted vapour poses any health risk to bystanders.
The WHO report, which describes e-cigarettes as an “evolving frontier filled with promise and threat for tobacco control”, urges caution: “While they are likely to be less toxic than conventional cigarettes, e-cigarette use poses threats to adolescents and foetuses of pregnant mothers using these devices.”
Dr Ross MacKenzie, lecturer in health studies at Macquarie University, believes the vaporised nicotine may prove harmful. He says there is a growing body of literature on health risks linked to nicotine, including head and neck and liver and kidney cancers, among others, as well as impacts on the lung and vascular systems.
“Given these concerns, and nicotine’s well-established addictive properties, it seems an unlikely substance to position at the centre of harm-reduction or smoking-cessation strategies,” he wrote on The Conversation.
While studies are emerging weekly about e-cigarettes, Chapman warns many are far from rigorous. A review of the scientific literature on e-cigarettes’ effect on health by a Danish researcher, published in October, concluded: “Due to many methodological problems, severe conflicts of interest, the relatively few and often small studies, the inconsistencies and contradictions in results, and the lack of long-term follow-up, no firm conclusions can be drawn on the safety of e-cigarettes. However, they can hardly be considered harmless.”
There is some research suggesting e-cigarettes are a better means of helping smokers quit than other nicotine replacement therapies (NRT), Chapman concedes, although he stresses that is a “very modest bar to jump over”, as NRT success rates are low.
A Belgian study published last month followed 48 smokers who were trying to quit – 21 per cent of those given e-cigarettes stopped smoking entirely, while an additional 23 per cent reported cutting their consumption in half. In comparison, only 3 to 5 per cent of smokers using willpower alone to quit remained smoke-free.
On the flip side, Chapman believes a study that shows vaping and smoking has skyrocketed among Polish adolescents in the space of a couple of years could prove to be “the real canary in the coalmine”.
The study found the proportion of 15- to 19-year-olds currently using e-cigarettes leapt from 5.5 per cent in 2010-11 to 29.9 per cent in 2013-14. Even more concerning were the rise in dual use of tobacco and e-cigarettes (from 3.6 per cent to 21.8 per cent) and increasing prevalence of smoking tobacco cigarettes – up from 23.9 per cent to 38 per cent.
The Royal Australasian College of Physicians also has raised concerns that smoking e-cigarettes is a gateway behaviour to smoking. And in its report, the WHO urged greater global regulation of e-cigarettes, while raising concerns about the growing role of the tobacco industry in the e-cigarette market.
British American Tobacco is among the firms chasing profits from vaping – it set up a company called Nicoventures in 2010 to focus on e-cigarettes. Nicoventures has already met with the Therapeutic Goods Administration in Australia in a bid to get its products approved as therapeutic.
Professor Wayne Hall is among those who believe there is merit in making e-cigarettes available in a regulated fashion. Hall was one of 53 specialists who signed a submission to the WHO earlier this year stating that e-cigarettes could become a viable alternative to smoking. A director of the Centre of Youth Substance Abuse Research at the University of Queensland, Hall says Australia’s e-cigarettes ban is “policy by default” rather than a considered decision.
“The current policy doesn’t make a lot of sense. It’s not rational or reasonable,” he says, pointing out that regular cigarettes are freely sold to adults. While he shares others’ concerns about the marketing of e-cigarettes to children, Hall says a compromise could be to restrict the sale of approved e-cigarette products to adults, via licensed sales outlets. Such a move would not only reduce cigarette smoking, he argues, but minimise the black market, provide consumer protection and allow the collection of data to inform future decisions about how to regulate e-cigarettes.
Meanwhile, there is a growing community of vapers who link up through online chatrooms, extolling the virtues of e-cigarettes with something akin to religious fervour. “Vaping has become my crux, my hobby and has given me something to ease my addictive personality in a way that is cheaper and healthier than all the addictions before,” writes one Melbourne man on the aussievapers.com forum.
A 60-year-old nurse from Tasmania, who smoked 30 to 40 cigarettes a day for 40 years and has emphysema, describes how vaping helped her quit smoking. She urges: “If any organisation or government bans the use of ecigs it will be an ethical crime as it will force ex-smokers (now vapers) to return to smoking. This, I see, would be a death sentence. For me anyway.”
Chapman agrees on one point — the way e-cigarettes are regulated is a crucial health issue. “The biggest preventable public health problem in the world is tobacco smoking,” he says. “The community deserves public health and regulatory authorities to take a deep breath and think: who could benefit from e-cigarettes and who could be potentially harmed.”
This article was first published in the print edition of The Saturday Paper on Dec 6, 2014 as "Vapour trials".
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