Studies show never-smokers are three times more likely to take up tobacco smoking after vaping.
A new systematic review has delivered another blow to tobacco companies, finding “strong evidence that young never-smokers and non-smokers who use e-cigarettes are about three times as likely as non-users to start smoking tobacco and to become regular smokers”.
In a week when the National Party, which accepted at least $275,000 in tobacco industry money between 2015-16 and 2021-22, announced it wants to ease regulation of nicotine-containing vaping products, ANU researchers delivered an unequivocal message.
Writing in the Medical Journal of Australia, Professor Emily Banks and colleagues said:
“There is substantial evidence that nicotine e-cigarettes can cause dependence or addiction in non-smokers, and strong evidence that young non-smokers who use e-cigarettes are more likely than non-users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e-cigarettes used with clinical support are efficacious aids for smoking cessation.”
Health Minister Mark Butler was quick to shut down the Nationals, saying the party “have a blatant conflict of interest in this debate, they are still the only major party that excepts donations from tobacco companies”.
“The tobacco industry has found a new way to develop a generation of nicotine addicts and we will not stand for it,” Butler said.
Professor Banks and her colleagues have provided even more evidence to back the Minister up.
She said it was “important to get things in perspective”.
“Eight-nine per cent of the population of Australia are not current daily smokers,” she said.
“About two-thirds to three-quarters of people who quit smoking successfully do so unaided. Then for those people who need support to quit, there are a range of products which are licensed by the TGA and found to be safe and effective.
“The people who are left, who have tried everything else, they could potentially benefit from vaping.”
Professor Banks said tobacco companies and vaping advocates were using the possible benefits to a small proportion of smokers to justify “something which is affecting the whole population, including the 89% who don’t smoke daily”.
“The vast majority of young people don’t smoke,” she said. “Our youth are leading the way with smoking cessation.
“E-cigarettes have been used like a cross between a Trojan horse and Pandora’s box. They’ve been brought to the community, saying this is really helpful for smokers to quit. And when you open it up, there’s bubblegum-flavoured vapes that are being promoted to 13-year-olds to use in the school toilets.
“That’s not what the community signed up for.”
Banks et al found “strong evidence” from 25 studies showing that “young never-smokers and non-smokers who use e-cigarettes are about three times as likely as non-users to start smoking tobacco and to become regular smokers”.
“The relationship between e-cigarette use and smoking was deemed likely to be causal according to the Bradford-Hill criteria.”
Additionally the review found “limited evidence” that freebase nicotine e-cigarettes used with clinical support “are as efficacious as smoking cessation aids as approved nicotine replacement therapy or usual care/no intervention,” Banks et al wrote.
It also found evidence of increased risk of addiction, poisoning, toxicity from inhalation (including seizures), and lung injury (largely attributable to THC/vitamin E acetate-containing products) and adverse effects on blood pressure, heart rate and lung function.
“For non-nicotine e-cigarettes, we found no benefits in terms of smoking cessation, harms related to devices, and uncertainty regarding health effects, indicating overall harm,” the paper said.
Professor Banks called on medical professionals to “do a little thought experiment”.
“What would it look like if e-cigarettes were truly targeted to smokers who wanted to quit?” she asked.
“[Tobacco companies] would have applied to have them licensed. They have not been licensed by any medical authority worldwide.
“These companies are saying this is really great for quitting smoking, but they’ve never had it tested. They’ve never put it to the FDA – they’ve never tried to get it licensed. The Medicines and Healthcare Products Regulatory Agency in England has even said, ‘we want companies to submit to us’. They are actively calling for submissions and nobody’s submitted to them,” Professor Banks said.
“It seems to me that the pro-vaping lobby thinks that they can dismiss evidence because they disagree with it,” Professor Banks said.
“But we need to have safety for our kids. We have to actually look at what the data are really saying.”
Professor Banks wants an enforced, comprehensive approach that addresses supply and demand.
“At the moment, the market has been flooded by e-cigarette products, and they’re freely available. The first thing is we need to shut down that flood. There’s been this huge, concerted campaign by cigarette companies to flood the market to undermine the legislation. And then they say, look, it doesn’t work.
‘Ban sales’ of non-prescribed e-cigarettes
Associate Professor Becky Freeman, writing in the Sax Institute’s Public Health Research and Practice journal, said “predatory” retailers, manufacturers and importers of vaping products had exploited loopholes in regulations to flood the market with illicit products that appeal to young people, resulting in a “skyrocketing” uptake of vaping by young people.
“Distinguishing between a legal non-nicotine vaping product and an illegal nicotine-containing device requires laboratory testing, which hamstrings effective enforcement of the regulations,” Professor Freeman wrote.
“Stopping the importation of all vaping products into Australia, regardless of nicotine content, unless bound for a pharmacy, would simplify and increase the effectiveness of enforcement and stop the flood of illicit products. This would also end young people’s easy access to vaping products.”
Speaking with OR, Professor Freeman said:
“We have a massive blind spot about vaping. Non nicotine-containing vaping products are not regulated and although they are meant to not have nicotine in them, when we test them in laboratories they often do.”
The tobacco, gambling, alcohol and fast food industries have been “quick to seize” on the distraction effect of the covid pandemic, she said.
“The Australian Government has been caught off guard by an aggressive industry that seeks to undo decades of effective tobacco control,” she wrote.
The good news is that “after 10 years of minimal action”, the government may be regaining its focus when it comes to tobacco control.
“I’m optimistic,” Professor Freeman said.
“We have three control measures and initiatives which are in the pipeline – the health ministers have endorsed the new National Tobacco Strategy; the federal government has announced a package of new control measures, including updated graphic warnings on tobacco products, prevention of the use of additives such as flavours and menthol, and a requirement for tobacco companies to be transparent about their sales volumes, pricing, product ingredients and emissions, as well as their advertising, promotion and sponsorship activities.”
None of those proposed measures have yet been introduced to Parliament.
The third reason for optimism, according to Professor Freeman, was a TGA public consultation on potential reforms to prevent children and adolescents from accessing vaping products. Submissions closed on 16 January and the TGA is yet to publish any response.
“I am hopeful that we will see real reform,” Professor Freeman said.
Meanwhile, British American Tobacco Australia has teamed up with a group of retailers, including Merivale and Merlino and Co, to form a group called Responsible Vaping Australia. The group’s stated aim is to change “Australia’s prohibitionist vaping policies” which have led to “the creation of a thriving black market for nicotine vaping products”.
A spokesperson for BAT Australia said:
“RVA is an initiative of British American Tobacco established to represent adult consumers, responsible retailers and industry associations who advocate for the responsible regulation of nicotine vaping products.
“Supporters of RVA are advocating to end the black market trade of nicotine vaping products by ensuring Australian … adult consumers are able to purchase products in a responsible and regulated way.
“Despite Australia’s ban on the adult retail sale of nicotine vaping products aided through the failed prescription model, a rampant black market exists run by illegal operators who are selling unregulated products to anyone – including children.
“RVA is calling for the introduction of strong adult consumer regulations which have been proven to work in other comparable countries to enable the Australian government to control the market and reduce the demand for illicit products.”
Comment has also been sought from Merivale and Merlino and Co, but neither had responded by deadline.