AUSTRALIA was a world leader in tobacco control over recent decades and smoking rates fell steadily. Mike Daube and colleagues should be rightly proud of their efforts at the helm of tobacco control during this time.

However, despite the highest cigarette prices in the world, plain packaging and comprehensive tobacco control policies, Australian smoking rates have stalled for the first time in decades, while declines accelerated in some other countries such as the US.

There was no significant fall in Australian smoking rates from 2013 to 2016, according to the 3-yearly National Drug Strategy Household Surveys. Adult smoking rates increased in New South Wales from 13.5% to 15.1% between 2015 and 2016, and cigarette consumption rose in 2017 for the first time in a decade according to the National Accounts.

We need to have a polite and respectful debate about Australia’s tobacco policies and consider possible new strategies to help achieve the national smoking rate target.

Stop tobacco tax rises

Increasing tobacco taxes is a proven strategy for reducing smoking rates but may not work as well at the upper end of the price range. A 20-pack of Marlboro costs an eye-watering $26 in Australia but only $9.30 in the US and $2 in Indonesia. At these levels, tobacco prices in Australia may be doing more harm than good in Australia.

It is very likely that tax rises have a decreasing net impact at these very high levels (the law of diminishing returns). Many addicted smokers continue to smoke regardless of the price.

Very high tobacco taxes are also a social justice issue. They exploit the most disadvantaged members of the community, such as Indigenous people, low socio-economic status groups and people with mental illness who have lower quit rates. For those unable to quit, high taxes are regressive, punitive and increase financial hardship and health inequalities.

Another unintended consequence of high prices has been the exponential growth in the illicit tobacco industry. Illicit tobacco from smuggling and illicit tobacco crops make up 15% to 28% of the total tobacco market and funds organised crime and terrorism.

Other effects of illicit tobacco include lost government revenue of $2–4 billion per annum, substantial enforcement costs, robberies of small businesses, and loss of profits to retailers.

Encourage tobacco harm reduction

Tobacco harm reduction refers to substituting lower risk products such as e-cigarettes for combustible tobacco products for smokers who cannot or will not quit. Harm reduction, along with demand reduction and supply reduction are the three pillars of Australia’s National Drug Strategy, but smokers are strongly discouraged from using these products.

We cannot know in advance with absolute certainty the future impact of e-cigarettes, so we have to go with the best available evidence, which indicates that:

  • e-cigarettes are far safer than smoking;
  • where e-cigarettes are widely available, adolescents are giving up smoking at an unprecedented rate;
  • e-cigarettes are now the most popular quitting aid in the UK, the US and Europe;
  • e-cigarettes appear to be increasing smoking cessation in population studies, especially among daily users;
  • millions of ex-smokers report quitting with e-cigarettes overseas;
  • even if e-cigarettes cause some never-smoking adolescents to try smoking, a moderate rate of increased smoking cessation by adults vaping produces a net public health benefit.

It would be a mistake to delay these products for another 20–30 years until we have total scientific certainty. Too many lives are at stake. The known harms from smoking far outweigh any uncertainties around tobacco harm reduction options such as vaping. Continuing to smoke carries a two in three risk of being killed by smoking.

The Big Tobacco myth

Tobacco companies have a long history of dishonest, manipulative and illegal behaviour and it is right to be suspicious of their motives. However, it is wrong to automatically assume that everything they do is harmful to public health.

Vaping is a grassroots, consumer-led movement by addicted smokers wishing to reduce their harm from combustible tobacco, at no expense to the public purse. Big Tobacco has been forced to enter the reduced-risk products market with e-cigarettes and heat-not-burn products to avoid being made irrelevant by a new and disruptive technology.

Big Tobacco is only a minority player and owns less than 15% of the e-cigarette market in the US (Wells Fargo, April 2018) and UK, and sells no e-cigarettes in Australia, Canada or New Zealand.

Some tobacco control activists are consumed by a commitment to destroy the tobacco industry. However, the focus should be on reducing smoking-related death and disease, not on destroying the tobacco companies. It is better for public health if tobacco companies switch to making less harmful alternatives rather than lethal cigarettes.

Help smokers to quit

The most effective way to reduce smoking is to combine strategies to motivate smokers to quit along with support to help them succeed. Mass media campaigns are effective at stimulating quit attempts and should be reintroduced but have once again been neglected in the recent Budget. However, the majority of attempts triggered by these campaigns are unsuccessful. In particular, the quit rate from unaided quitting is less than one in 20.

Significant and sustained funding should be provided to help smokers quit, especially those from disadvantaged groups where smoking rates are very high. Of the current $12.5 billion collected annually in tobacco excise and GST, very little is allocated to cessation support, although it is one of the most cost-effective medical interventions. Some of the tobacco excise should be hypothecated to help the smokers who pay it.

Substantial resources should be allocated to training health professionals, funding smoking cessation clinics, reimbursing smoking cessation services and subsidising a wide range of nicotine replacement products for combination therapy (nicotine patch plus gum, spray, lozenge or inhalator).

More carrots and less stick

A more compassionate and effective approach will kick-start the decline in smoking rates. Instead of increasing financial penalties for addicted smokers, we need to provide more professional support to help them quit. For those who still cannot or will not quit, safer alternatives such as vaping should be made available. The human cost of the continued high smoking rates is too great to be complacent.

Colin Mendelsohn is an associate professor at the University of New South Wales’ School of Public Health and Community Medicine. He is chairman of the Australian Tobacco Harm Reduction Association. He has received payments for teaching, consulting and conference expenses from Pfizer Australia, GlaxoSmithKline, Johnson and Johnson Pacific, and Perrigo Australia.

 

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18 thoughts on “Time for a new approach to tobacco control

  1. Dr Scott says:

    Why should we introduce a new, somewhat harmful product (ecigarettes/vaping) to the market for everyone including adolescents to use. Why not make ecigarettes available as a smoking aid available on prescription by doctors in the way that Champix and similar are? Some might say that will deprive certain people of the opportunity to quit because they can’t be bothered/afford/don’t have access to a GP but the people who aren’t willing to go to put in the effort/cost to go to a GP are unlikely to be in the “ready to quit” stage, more likely they are the ones who will just continue to vape without quitting. This would make it harder for young people to take up vaping and also get the benefit of the additional smoking cessation consult/opportunistic health promotion that GPs do.

  2. Lennert Veerman, Professor of Public Health, Griffith University says:

    Colin Mendelsohn rightly points to the fact that high tobacco prices are hurting people who are addicted to nicotine, and that more can be done to support them with nicotine replacement therapy.

    But I think Australia should take more radical action than he proposes. It’s time for Australia to quit.

    Banning all importation and production of tobacco products in Australia will make it much easier for smokers to quit: if none of your friends or family members smoke any more, and cigarettes are simply unavailable, the temptation to light another one will be much reduced. Illegal tobacco will be easier to detect, since any tobacco found is sure to be illegal.

    Of course there would have to be generous support with counselling and nicotine replacement therapy available free of charge for as long as necessary. Overseas addict can be offered the same. But with that done, the drain on the purchasing power of many low-income Australians that is the tax can stop, and young people will no longer be recruited into this lethal addiction.

    It is mind-boggling that a product that is highly addictive and that kills over half of its long-term users is legally sold, and it is time to stop allowing that abuse of vulnerable Australians.

  3. Dr Steven Donohue says:

    Not convincing, Colin. The piece reads more like an advertorial than balanced argument. Claims that a vast illicit tobacco trade is linked to ‘terrorism’ in Australia, or that the vaping industry is ‘a grassroots, consumer-led movement’, are just silly.

    Yes, we need to restart health promotion campaigns and help more people quit – lets fully apply what we know works, rather than going backwards.

  4. Simon Chapman AO says:

    Dr Mendelsohn is a clinician who for years has pushed the barrow of pharmaceutical solutions for smoking cessation. He may well be wanting to change song sheets because we now understand that the success of NRT in the real world without professional assistance is lower than from unassisted cessation. Moreover, a recent study found, after controlling for “propensity to quit”, there was no evidence that use of varenicline, bupropion or NRT increased the probability of ≥30 days smoking abstinence at one-year follow-up.
    Perhaps knowing this, Mendelsohn is now writing and talking about little else than the Next Big Promise in cessation: e-cigarettes. Sadly, that promise is a very long way from where he believes it to be today. Among the key conclusions of the authoritative Jan 2018 doorstopper report of the US National Academies of Science, Engineering and Medicine were these:
    Conclusion 17-1.Overall, there is limited evidence that e-cigarettes may be effective aids to promote smoking cessation.
    Conclusion 16-1. There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.
    And the US Preventive Health Task Force isn’t that keen either, stating “current evidence is insufficient to recommend electronic nicotine delivery systems (ENDS) for tobacco cessation in adults”. Throw in Australia’s National Health and Medical Research Council (“There is currently insufficient evidence to conclude whether e-cigarettes can assist smokers to quit”) and the consensus about ecigs that some like to talk about starts to look quite a bit thin.
    Over the years we have rarely heard or read any contributions from Dr Mendelsohn on population-wide tobacco polices and regulations. But here he is in this piece now telling us all that we should ease off on tobacco tax rises because these are no longer effective and they harm low income groups.
    Now who have we heard saying that before? The tobacco industry, if you didn’t guess. There has not been a major report on tobacco control published in the last 20 years which has not put price rises through tax policy in the very top tier of evidence-based policy. But Colin Mendelsohn has a different view, which just happens to be shared by the tobacco industry. This is why every day, that industry tweets that prices are too high and that illicit tobacco is out of control. This is all about trying to see price falls in smoking. This would perversely “help” the poor by making smoking more affordable. Taxation is what the industry fears most.

    It has always been the case that when tobacco prices rise, many smokers keep on smoking. But many also quit, reduce the amount they smoke and many young people are deterred from taking it up because of the cost.

    The tobacco companies in Australia have been undermining the potential impact of tax rises by aggressively reducing their margins on cheaper brands and roll-your-own tobacco.

    Mendelsohn’s counsel is that we should all be more trusting of the tobacco industry as they woo us with their latest harm reduction products (remember the lights and milds fiasco? The promise of reduced harm via filters? Kent’s micronite filter (with asbestos)? Reduced carcinogen brands? And early versions of heat not burn tobacco products? All these failed and worse, gave smokers false reassurances that they could switch instead of quit. This is the big worry with ecigarettes: that they may falsely keep many smokers who would have otherwise quit smoking, erroneously believing that merely reducing the amount smoked is harm reducing. In the US, 93% of vapers continue to smoke cigarettes 83% in France, and 60% in the UK. How many of these might have quit altogether had it not been for ecigs?

    Colin Mendelsohn has banged his drum about the fall in smoking having “stalled” before. Readers should look at the considerable problems with his analysis here. Most importantly, using the same data that he cites to argue that the number of smokers has risen slightly in Australia, we have 870 000 extra non-smokers in Australia in 2016 than there were in 2013 — more than 80 times the number of extra current smokers (and more than 40 times the number of extra daily smokers) that he is so concerned about.

  5. Simon Chapman AO says:

    My response above had many hyperlinks which did not carry over into the text. Happy to post them all as footnotes tomorrow.

  6. Joe Kosterich says:

    Rates of smoking cessation(including measures of cigarettes stick sales) in countries where e-cigarettes are supported (Japan UK USA to name but three) show that it significantly increases quit rates. Given that use of e-cigarettes are 95% less harmful to users than regular cigarettes only a heartless country would condemn smokers to a quit or way or die approach. Very sad that this is the ideological stance in Australia.

  7. Wayne Kramer says:

    The following are more important than supporting tobacco harm reduction to improve/save smoker’s lives in Australia:

    1. Smearing people/government departments/organisations in positions of authority that support it.
    2. Exaggerating/falsifying claims of unprovable ‘gateway’ hypothesis.
    3. Using trace amounts of chemicals (sometimes) found to create fear, uncertainty and doubt and even publicly stating that it may cause cancer.
    4. Creating the narrative of the a predatory ‘vaping industry’ that wants to recruit ‘children’ to nicotine addiction by using bad examples of advertising and blaming
    tobacco harm reduction strategies instead of advertising regulation/standards.
    5. Conflating the tobacco industry with vaping by incorrectly stating that its a tobacco company initiative where in fact tobacco company vaping product
    not used in Australia.
    6. Cherry-picking badly designed ‘research’ that seeks to attract more funding and creating fear (see any research that claims excessive aldehyde emissions).
    7. Rejecting any evidence that doesn’t fit the anti-harm reduction agenda. Continually pushing anything negative in the media (whether its false/true).
    8. Ignoring/downplaying examples of countries where tobacco harm reduction strategies have worked (see Sweden, Iceland).
    9. Manufacturing fear/panic by exaggerating increased youth experimentation (but not habitual use) in places like US while ignoring plummeting youth smoking rates.
    10. Whipping up fear as a distraction from the fact that tobacco control policies are now failing and smoking rates not falling in Australia.
    11. Using the ‘we don’t know the long term effects’ to create fear around tobacco harm reduction strategies.
    12. Prioritising the destruction of the tobacco industry over smoker’s lives.
    13. Framing support/non-support of THR as a right/left issue.
    14. Prioritising total nicotine (regardless of delivery mechanism) abstinence over smoker’s lives.

    I’m sure there are more, but in summary I’d say that generally keeping tobacco harm reduction (whatever its form) illegal and out of reach for smokers is *the* most important for the stakeholder industries in Australia.

  8. Dr Attila Danko says:

    Please Simon, 93% dual use in the USA? Reference please. I suggest looking at the data from the PATH survey which paints a very different picture and shows how dual use is a pathway out of smoking for many people. https://www.ncbi.nlm.nih.gov/m/pubmed/29695458/?i=1&from=dual%20use%20path%20e-cigarettes

  9. Simon Chapman AO says:

    USA: https://www.sciencedirect.com/science/article/pii/S0091743516302687?via%3Dihub “Among current e-cigarette users, 93% were also current cigarette smokers.”
    France: https://www.ncbi.nlm.nih.gov/pubmed/26687039 “smoking prevalence was high among those who vape: 83.1 % were smokers (74.7 % were daily smokers)”
    UK: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2014 “Of the former e-cigarette users, around three-quarters said they were currently smoking cigarettes and 59% of the current users said they also used cigarettes.”

  10. Peter says:

    In reply to Simon Chapman above:

    Prof Chapman, like Prof Daube you have selectively cherry-picked certain statistics to support your own line, and in marked contrast to the conclusions of the authors of the studies you cite. Whilst I applaud much that the two of you have done in the area of smoking cessation I am very disappointed in your dogmatic stance regarding e-cigarettes and misrepresentation of the evidence you are citing to support that stance. At a minimum it is disingenuous, but at worst may be causing real harm to those that you seek to help.

    To quote a figure that a high percentage of people that vape continue combustible cigarette use on its own is rather meaningless. For example the French study you cited states that 80% of that cohort self-report reduced combustible cigarette use whilst vaping. There are people that still smoke when using nicotine patches or gum, however we would not frown upon that concomitant use if it produced an overall reduction in use of combustible cigarettes and put them on the path to cessation.

    For a more complete picture of the conclusions from the references you cite:
    USA: https://www.sciencedirect.com/science/article/pii/S0091743516302687?via%3Dihub “Among current e-cigarette users, 93% were also current cigarette smokers.”
    “The most common reasons for e-cigarette use were cessation/health (84.5%), consideration of others (71.5%), and convenience (56.7%).”
    “Cessation- and health-related factors are primary reasons cited for e-cigarette use among adults, and flavorings are more commonly cited by younger adults.”

    France: https://www.ncbi.nlm.nih.gov/pubmed/26687039 “smoking prevalence was high among those who vape: 83.1 % were smokers (74.7 % were daily smokers)”
    “Smoking prevalence was high among those who vape: 83.1 % were smokers (74.7 % were daily smokers) and 15.0 % were former smokers. Four out of five vapers considered that they had reduced their cigarette consumption through e-cigarette use. Vaping ex-smokers represented 0.9 % of 15-75-year-olds, which are approximately 400,000 people. This figure represents an initial estimate of the number of smokers who have successfully stopped smoking, at least temporarily, thanks to e-cigarettes.
    CONCLUSIONS:
    E-cigarettes in France were on the whole used by smokers. The e-cigarette could have helped several hundreds of thousands of individuals to quit smoking, at least temporarily.”

    UK: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2014 “Of the former e-cigarette users, around three-quarters said they were currently smoking cigarettes and 59% of the current users said they also used cigarettes.”
    “53% of e-cigarettes users vape as an aid to quit smoking.”

    As public health advocates it is your duty to stick to the tenets of evidence-based medicine, including not cherry picking data, stating when the evidence is conflicting or absent, plus aiming to design better studies to establish evidence.

    It would be negligent for any clinician or public health advocate to miss any opportunity for harm reduction, no matter who proffers or sells it, if at a population level it could reduce total morbidity and mortality and at an individual level reduce harm.

    It seems that the youth gateway phenomenon is more related to the flavourings than the nicotine. There is no reason why this could not be regulated to reduce the allowed flavourings, thereby markedly reducing the youth uptake. Regulated use by age already exists.

    The e-cigarette data regarding convenience and impact on others is very useful too. It could be used as a pivot for health marketing campaigns directed at smokers and vapers.

    To take the other side of the gateway argument though, it would be a crying shame here to miss a potential gateway to cessation and harm reduction. I assume you have no problem with methadone programs – not ideal, in that the substance of addiction is still at the centre of the therapy, but a much more humane and evidence-based approach to addiction with real impact on harm, morbidity, mortality and cessation at both an individual and population level.

  11. Dr Attila Danko says:

    Simon, you might have missed some further research that has been done on dual use prevalence since those figures from 2014. Remember, 2014 was still fairly early in this technology and many smokers were just starting to transition. Dual use rates decline every year as the technology improves, for example in the US they declined from 93% to 58% in 2015.

    https://www.cdc.gov/mmwr/volumes/65/wr/mm6542a7.htm

    If you can find more up to date data that would be appreciated.

    In the UK dual use is now only 45% as of 2017.

    http://ash.org.uk/media-and-news/press-releases-media-and-news/large-national-survey-finds-2-9-million-people-now-vape-in-britain-for-the-first-time-over-half-no-longer-smoke/

    In many ways it reflects other gradual transitions from combustibles. We are not upset that countries do not change instantly from coal fired energy to solar and wind. We encourage the transition as technologies improve. In the same way we should celebrate the fact that recreational nicotine users are transitioning more and more every year to non combustible alternatives.

  12. Donna says:

    Reply to Dr Scott,

    You say…

    “Why should we introduce a new, somewhat harmful product (ecigarettes/vaping) to the market for everyone including adolescents to use. Why not make ecigarettes available as a smoking aid available on prescription by doctors in the way that Champix and similar are?”

    I reply with….

    The TGA and other NGO”S have said the same thing but no one is knocking down their doors to have a product approved. I’d suggest it’s because not one product has been put up anywhere in the world and come to market and Australia is but a pimple compared to the number of smokers in other countries. This is because medicalisation of vaping doesn’t work. Get 100 ex smoking vapers in a room and you’ll find that there are not two products that are the same. What works for one doesn’t work for another and it’s constantly moving. Why on earth would someone do it in Australia if they aren’t willing to do it in far larger markets than ours? It’s because they know what smoker’s want and it’s not another medicine.

    If you (or anyone) have the millions of $$’s required and the 3 years plus to achieve this end, I’d welcome it but I’d also advise you that it is money wasted because by the time you get anything approved, smokers and vapers will have moved on and your ‘approved’ product is no longer desirable.

    You say….
    “Some might say that will deprive certain people of the opportunity to quit because they can’t be bothered/afford/don’t have access to a GP but the people who aren’t willing to go to put in the effort/cost to go to a GP are unlikely to be in the “ready to quit” stage, more likely they are the ones who will just continue to vape without quitting.”

    I reply with….
    See above firstly on product choice. Secondly, most smokers don’t consider themselves sick. What you have missed are the accidental quitters (who try vaping and find they like it more and switch) and those that are unwilling to quit who find that the health benefits or the lesser cost make it such a carrot rather than a stick.

    Consumer product regulation for vaping is a carrot. (with obvious age restrictions, packaging, advertising and place of purchase etc.)

    Medicalisation of a single vaping product make it undesirable for most and difficult for many. Not only that, there is no manufacturer in the world that chooses to do it. So in other words, prescription only is continued prohibition without any regulation for an unregulated market which is increasing daily.

    As a vaper that has worked hard to have Australia regulate vaping and failed, I suspect the black market will win this war on safer nicotine.

    Finally, nicotine is not the problem, it’s the smoke that is.

  13. Simon Chapman AO says:

    Cherry picking is a funny thing, isn’t it Peter. Those who throw it around as an accusation are always filled with rectitude that they never engage in it themselves and that all those whose views they agree with, like them, never do it either.

    That’s why we have protocols for evidence assessment in science. A great example of the application of such protocols is the NASEM report. You can read its conclusions here. I’m sure you won’t cherry pick the ones you agree with and the ones you reject. https://www.nap.edu/resource/24952/012318ecigaretteConclusionsbyOutcome.pdf.

    You seem impressed with data that shows a lot of vapers are vaping to quit smoking. Here’s some news: a lot of people using snake-oil approaches to quit (like laser therapy) are also doing it to quit smoking. And quit status can of course be measured the next day, the next week, month, 3 months or 12 months. 12 months is the gold standard particularly when combined with “smokefree for at least 3 months.” When we talk about those two criteria, the picture is far from that you might hope it to be.

  14. Wayne Kramer says:

    While the academics, health charity/quit org industries and government departments pontificate the population of vaping ex-smokers grow. Word of mouth is a powerful thing. Even a smoker seeing a vaper on the street (plenty around CBD) makes a smoker wonder if he/she should give it a crack. The only thing that can be done to stop nic e-liquid at customs.

    Perhaps that should be the aforementioned parties next mission in their wondrous mission to improve public health and save lives.

  15. Peter says:

    Prof Chapman,
    not sure if you are insinuating that I’m somehow cherry picking the data, by presenting fuller abstracts from the references YOU cited, to ensure they were quoted in the context in which the authors intended. If this is indeed your insinuation, then please point out how I have done so.

    I read the NASEM report conclusions previously when Prof Daube cherry-picked from them in an opinion piece here earlier this year.
    https://www.doctorportal.com.au/mjainsight/2018/16/tobacco-in-australia-time-to-get-back-to-basics/

    My overall assessment of all of the conclusions from that document is that it is difficult to determine whether the net impact is favourable or harmful when assessing all conclusions about evidence regarding impact on health, harm reduction and cessation. For a prominent public health academic in the area I was also sadly disappointed with Prof Daube’s slanted portrayal of those conclusions. In reply, I quoted the conclusion of the highlights page of that study i.e. I prefer to get it from the horse’s mouth in context, rather than cherry-picked parts out of context to support a particular stance.
    For your benefit, verbatim the first paragraph of the conclusion of the NASEM highlights page (leaving out second paragraph, as it is only calling for more and better research, with no commentary on harm vs benefit – link here to it if you wish to satisfy that I am not cherry-picking the overall conclusion about harm vs benefit p4 of https://www.nap.edu/resource/24952/012318ecigaretteHighlights.pdf).

    “Although e-cigarettes are not without risk, compared
    to combustible tobacco cigarettes they contain fewer
    toxicants; can deliver nicotine in a similar manner;
    show significantly less biological activity in most, but
    not all, in vitro, animal, and human systems; and might
    be useful as a cessation aid in smokers who use e-cigarettes
    exclusively. However, young people who begin
    with e-cigarettes are more likely to transition to combustible
    cigarette use and become smokers who are at
    risk to suffer the known health burdens of combustible
    tobacco cigarettes. The net public health outcome of
    e-cigarette use depends on the balance between positive
    and negative consequences.”

    I have no personal or professional conflicts in this area, my interest is quite simply to steer the debate back to the evidence on what is the best interests for those that are still smoking. I am frequently asked by smokers about vaping and as a clinician, I have to conclude that to date there is insufficient evidence to make a call one way or another. I would hope this can be redressed in the future, by public health researchers in the area, so I can at least advise based on robust evidence.

    Emotive language such as “snake oil”, is rather beneath you and adds nothing to the simple point I am making about sticking to available evidence and presenting it in full context.

    There is a multitude of evidence in other areas of substance abuse and addiction that harm reduction can be very helpful at both population and individual levels. Dogmatic and prohibitionist stances are seldom helpful.

    Similarly, as a public health academic it is your duty to steer away from dogma, especially when there is insufficient evidence to back it up. Conflicting and equivocal evidence should be labelled as such, whether it supports your stance or not.

    I don’t have a position, other than trying to work out what is best for helping current smokers, based on the evidence. I am not promoting vaping as a solution, but at this stage, based on the current evidence, neither am I denying it.

    I have not seen convincing evidence presented by either you or Prof Daube on the claims you are making about vaping being on balance, only harmful – if it exists then please present it, in full, in context. You could easily cite evidence about the 3 month and 12 months smoke-free rates, if it supports your position and also makes an appropriate comparison to already promoted cessation and reduction methods i.e. at least rule out non-inferiority. I am more than willing to be convinced by robust evidence – just haven’t seen any yet.

    New therapies and interventions are often approved on the basis of single digit percentage improvements in absolute risk ratio. Given that there are still a large number of smokers, surely any intervention that reduced overall harm, however small, would have significant, measurable benefits at a population level.

    I am concerned by your attempt to continue to deride any detractors from your view, rather than citing full evidence to back your claims. Whether your “instinct” that any discussion of vaping in harm reduction or as an adjunct to cessation is sending the wrong message is neither here nor there until we have the evidence to support whether it has net benefit or harm. Until the evidence is in, please stop being surprised when people like me ask you to stick to the evidence – something I previously thought was the professional duty of any clinician or academic.

    Quite simply, if it exists, then show me the evidence to support your stance, with the same academic rigour that should be afforded any public health debate. If I don’t find the evidence convincing then that academic rigour should also be extended to accepting healthy questioning of the evidence you cite.

    I see recalcitrant smokers in front of hospitals every day (often standing in front of no-smoking signs). The current regime obviously does not work for them. I would sincerely like to help them reduce harm, in whatever way is best supported by evidence. I hope that you and Prof Daube can continue to contribute to this evidence (not opinion) base.

  16. Aki Nilanga Bandara says:

    According to available best evidence, it is too premature to categorize e- cigarette as either beneficial or harmful. Meanwhile, most recent pragmatic clinical trial published in the New England Journal of Medicine (NEJM) also shown that e-cigarettes is not effective smoking cessation tool (1). We strongly believe that the recent clinical trial findings need to be appropriately reflected in any future e-cigarette clinical guidelines, in order to assist physicians’ informed decision making.

    REFERENCE:

    (1). Halpern S, Harhay MO, Saulsgiver K. A pragmatic trial of e-cigarettes, incentives, and drugs for smoking cessation. N Engl J Med 2018; DOI: 10.1056/NEJMsa171.

  17. Repiratory Physician says:

    As a clinician who spends a great deal of time on smoking cessation/harm minimisation and as a researcher who is studying a harm-minimisation strategy for smokers, I would say just three things.
    1. “healthy” smokers are actually quite difficult to recruit, far more difficult than patients with a smoking-related disease and hence it may be some time before there is robust evidence available to support the appropriate use (or avoidance) of e cigarettes
    2. as for any medical intervention, an approach tailored to the smoker, preferably incorporating their input and preferences is important. Although I am not recommending e cigarettes at present, I can see that there may be a place for them in a small, select group of my patients, who want to quit but cannot.
    3. e cigarettes are here, Australians are using them (with most users unaware of the legalities), whether we clinicians are pro or con. Hence, we need to see this product regulated. At least then, we clinicians will know the specifics of what substances our patients are vaping.

  18. Bruce Butler says:

    For 25 years I was a smoker.25 years ago I used Nicorette gum for six weeks and gave up smoking for good.I heard a woman on the radio say she is giving up smoking by vaping.She also said she has been vaping for two years and is still doing so. I read online a guy saying he has been vaping for four years, and still at it, in an attempt to give up smoking.No one fools themselves more than a drug addict. I believe it would be hard to give up nicotine with vaping because it is too much like a cigarette. You hold a thin object between your fingers, and give it big sucks.It is smoking by another name.

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