Public Health Concerns

Vaping is a controversial topic in public health in Australia. Some experts feel that vaping has the potential to save the lives of hundreds of thousands of smokers who are unable to quit smoking with conventional treatments. By switching to vaping, smokers are dramatically reducing their exposure to harmful chemicals for themselves and the people around them. This is known as tobacco harm reduction.

However, some public health experts are concerned that vaping may have unwanted effects. For example, there is concern that vaping devices may entice young people to start smoking and they may ‘renormalise smoking’ (make smoking look more socially acceptable again). There is also concern about possible unknown long-term risks.

Vaping for harm reduction is supported by the Royal Australasian and New Zealand College of Psychiatrists and Drug and Alcohol Nurses of Australasia.

However, most of Australia’s public health and medical organisations are taking a precautionary approach until more is known about vaping. This includes the federal and state health departments, the National Health and Medical Research Council, the Therapeutic Goods Administration, the Cancer Council, the Heart Foundation, the Australian Medical Association and the Thoracic Society of Australia and New Zealand.

Other countries

Most other developed countries support vaping. In the UK, vaping is supported by the UK government (Public Health England), the Royal College of Physicians, the British Medical Association, Cancer Research UK, the Royal Society for Public Health, the Royal College of General Practitioners, Action on Smoking and Health UK, the British Heart Foundation, the United Kingdom Centre for Tobacco and Alcohol Studies and most other, but not all, public health organisations and medical associations.

Vaping with nicotine is legal and freely available as a consumer product in the 27 countries of the European Union and in the United States.

Vaping with nicotine was legalised in April 2018 in New Zealand and in Canada.

Policies on vaping vary widely from one country to another. The Johns Hopkins Bloomberg School of Public Health maintains a database of international vaping regulations and policy, available here.

Gateway to smoking for youth

It would be a serious concern if vaping was leading more young people to smoke (the ‘gateway theory’). In fact, the opposite may be true, ie that vaping is a gateway out of smoking. According to a comprehensive report of the University of Victoria, Canada in 2017:

‘There is no evidence of any gateway effect whereby youth who experiment with vapour devices are, as a result, more likely to take up tobacco use. The available evidence is that tobacco use by youth has been declining while use of vapour devices has been increasing’

Other evidence that suggests that vaping is not leading to smoking in young people:

As vaping rates have been increasing in countries where nicotine vaporisers are readily available like the UK and US, smoking rates are declining rapidly in young people and are at record low levels. The evidence suggests that vaping may be reducing smoking uptake.
Although about one in five teens try vaping, regular vaping (at least weekly) is almost exclusively confined to those who already smoke. Of young people who have never smoked, less than 5 in one thousand are regular vapers. Teens are curious and some may try it for a while and then most stop.
One theory is that adolescents who would never have smoked, will become addicted to nicotine from vaping and then progress to tobacco cigarettes. However, the majority of adolescent who vape do not use nicotine.
Some young people are using vaping devices to quit smoking or reduce cigarette use.
‘Common causality’. Many young people who try vaping will go on to become smokers later. However, there is no evidence that vaping causes smoking. It is more likely that ‘kids who try stuff, try stuff’ ie young people who are more likely to experiment with vaping are more likely to also try smoking. In fact, the vast majority of regular vapers started smoking first.

Uptake by adult non-smokers

Another concern is that non-smoking adults may try vaping and become regular users or ultimately smokers. However, according to the UK Royal College of Physicians:

‘e-cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely’.

Numerous studies have found that the use of vaping devices by adults who have never smoked is rare. In surveys in the UK, US, European Union, Greece and Germany, only between 1 and 5 in a thousand adults who had never smoked were currently using a vaporiser.

Renormalisation of smoking

Another legitimate concern about vaping is that increased visibility of an activity that resembles smoking may make smoking appear more socially acceptable again. Some fear that this may undermine many years of tobacco control which has ‘denormalised’ smoking.

However, there is no evidence that e-cigarettes are undermining tobacco control or leading to the renormalisation of smoking. In fact, the very opposite is occurring. Smoking rates in many countries where vaping productsd are widely available are falling faster than in Australia. It is very likely that e-cigarettes are a contributing factor to this rapid decline although it is not possible to prove cause and effect.

According to Public Health England:

‘There is no evidence that e-cigarettes are undermining the long-term decline in cigarette smoking among adults and youth, and may in fact be contributing to it’.

Big Tobacco

Personal vaporisers were invented in 2003 by Hon Lik, a Chinese smoker who was looking for a less harmful alternative to smoking. The rise of vaping has been a grassroots consumer movement, taken up by smokers wanting to improve their health and save money.

The tobacco industry became involved much later to avoid becoming redundant from this new technology. They have been playing catch-up ever since in this rapidly evolving field. Most vaping devices internationally are not made by the tobacco industry. Currently, no vaping devices sold in Australia, New Zealand or Canada are made by a tobacco company.

Some commentators want to ban vaping because they do not trust Big Tobacco and speculate that their agenda is to get people to smoke and vape. The past behaviour of Big Tobacco has been appalling and their behaviour needs to be closely monitored. However, it is wrong to automatically assume anything they do is bad. Vaping has the potential to dramatically reduce death and illness from smoking and this should be our priority.

Dual use

Some commentators have expressed concern that many vapers are continuing to smoke (dual use). The concern is that being able to vape at times and places where smoking is not allowed may delay attempts to quit smoking.

However, there is no evidence that dual use delays or prevents quitting. Research shows that dual users are more likely to quit smoking than people who just smoke.

Many smokers go through a transition stage of smoking and vaping together before finally quitting smoking permanently. This transition stage can take weeks or years. The same process occurs with nicotine replacement products, ie that many smokers do both for a while before quitting.

In any case, evidence suggests that even long-term dual use is less harmful than smoking alone because most dual users significantly reduce the number of cigarettes they smoke thereby lowering their exposure to toxins. Consequently, health conditions such as emphysema, asthma and high blood pressure improve after switching to dual use.

However, quitting smoking completely should always be the preferred goal for smokers.