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LEADING public health experts have rejected warnings that a new ban on importing nicotine vaping products without an Australian doctor’s prescription could drive vapers back to smoking, as evidence for the potential harms of vaping grows.
As of 1 October, it is illegal for Australian consumers to import products such as nicotine e-cigarettes, nicotine pods and liquid nicotine without a prescription from an Australian doctor. The changes close a loophole through which many vapers had been purchasing the Schedule 4 substances from overseas websites without a prescription. They also make it harder for convenience stores to obtain the products for illegal sale, including to minors.
The Therapeutic Goods Administration (TGA) said the changes strike a balance between “the need to prevent adolescents and young adults from taking up nicotine vaping products while allowing current smokers to access these products for smoking cessation with appropriate medical advice”.
“There is evidence that nicotine vaping products act as a ‘gateway’ to smoking in youth and exposure to nicotine in adolescents may have long-term consequences for brain development,” the TGA said.
It noted that between 2015 and 2019, e-cigarette use by young Australians increased by 96%.
With more than 200 000 Australians estimated to be using vaporised nicotine, the Royal Australian College of General Practitioners (RACGP) has told GPs to prepare for an increase in patients seeking scripts for vaping products.
The College stressed that nicotine vaping products are not a first line treatment for smoking cessation, and that their long term health effects are unknown.
RACGP President Dr Karen Price said: “It’s important that GPs are wary of being pressured into prescribing these nicotine vaping products”.
“A prescription for these products should only be used as a last resort; vaping is not a risk-free, harmless version of smoking cigarettes,” she said. “These are addictive and harmful products that can prove fatal if ingested in certain amounts.”
However, Dr Colin Mendelsohn, a GP who advocates vaping nicotine as a safer alternative to cigarette smoking and an effective quit aid, said the potential harms were often exaggerated in the media.
“There’s been such a beat-up over the harms of vaping that people have forgotten what’s really killing people – smoking cigarettes,” he told InSight+.
“The clinical question is the relative risk versus smoking, as vaping nicotine is almost exclusively used by smokers and former smokers,” he said. “Comprehensive reviews by leading, independent health organisations agree that vaping is considerably less harmful than smoking.”
Dr Mendelsohn argued the new laws would be a “public health disaster”.
“It will make it harder for many people – especially disadvantaged people lacking internet access, organisational skills, and support – to continue to access vaping products,” he said. “Some vapers will return to smoking and it will also be much harder for current smokers to begin vaping.
“The black market will flourish, with an increased risk of unregulated supplies,” he added.
But antismoking campaigner, Professor Simon Chapman, Emeritus Professor in Public Health at the University of Sydney, said the laws were likely to be effective in curbing youth vaping uptake.
“It will make it a whole lot more difficult for the average high school kid to work out where they can buy a vaping product, when they can’t just walk into a convenience store and get it under the counter,” he said.
Professor Chapman said stopping young people accessing vaping products was a national emergency.
“We had smoking rates down to the lowest ever recorded level and now we’re seeing kids who would never have used any kind of nicotine going through the hand-to-mouth, blowing smoke ritual,” he said. “It’s no surprise when vapes are available in lemonade flavour.”
Although vaping advocates argue that nicotine vaping doesn’t kill anybody, Professor Chapman said it was too early to make that assumption.
“Nobody had died of lung cancer for at least the first 20 years that smoking became endemic, but we soon learnt the folly of that reasoning,” he said. “The case reports are the first signals to start coming in, and then the notifications to the Commonwealth start to add up.
“I’m not saying vaping-related harms will follow the exact same pattern – I think we will see more cardiovascular and respiratory harms than cancer,” he said. “That said, it’s still very early days.”
He noted a case reported in the MJA this month of suspected vaping-related lung injury in a Sydney adolescent.
The 15-year-old female patient was febrile and hypoxic and had bilateral pulmonary infiltrates on chest x-ray and computed tomography, with no pulmonary infection. She reported regular vaping with a flavoured nicotine-containing device over the previous 7 months, as well as using tetrahydrocannabinoids (THC) via a water pipe, smoking cigarettes, and occasionally taking diazepam, alprazolam, methylphenidate and lisdexamfetamine (not her medications).
Conjoint Associate Professor Betty Chan, Head of the Clinical Toxicology Unit at the Prince of Wales Hospital and colleagues said the case fulfilled the Centers for Disease Control and Prevention case definition of e-cigarette or vaping product use-associated lung injury (EVALI) and had a similar presentation to other reported cases.
The patient, who was successfully treated with antibiotics and corticosteroids, had been using a vape device she purchased at a local convenience store. Testing showed the vape fluid contained glycerol, nicotine, and flavouring agents ethyl-maltol and menthol. THC and vitamin E acetate were not detected, despite the latter being strongly linked to a major outbreak of EVALI in the US between 2019 and 2020 (2807 cases, 68 deaths as of 18 February 2020).
In the absence of vitamin E acetate, Dr Mendelsohn argued the case was “almost certainly not EVALI and very unlikely to be related to nicotine vaping”.
“They didn’t do a bronchoscopy and bronchial lavage, which would have provided more information,” he said, “and there are other potential causes, such as a pulmonary infection secondary to smoking, urosepsis, allergic sensitisation reaction or a toxic response to another undisclosed chemical.”
However, Professor Chan defended the suspected diagnosis, telling InSight+: “Looking at the literature, about 10–15% of EVALI cases reported were using only nicotine-based products.
“We are not sure what chemicals cause this severe pneumonitis in this patient but it is likely to be associated with e-cigarette products,” Professor Chan said.
“It is also likely that this e-cigarette-related lung injury is not well recognised in Australia and could be underdiagnosed,” she added.
Dr Sarah White (PhD), director of Quit, said the potential role for vaping in smoking cessation was often overplayed by its advocates.
“These products are just nicotine delivered a different way, with a similar kind of hit,” she said. “In fact, it seems they can actually increase some peoples’ addiction; cigarettes at least have a natural end after 10-12 puffs, whereas with vapes you can get 600 puffs or more in succession.”
As for warnings the new laws may drive ex-smokers back to using cigarettes, Dr White commented: “Doesn’t that just prove that they’re still addicted to nicotine and at risk of relapse? Hardly an effective treatment.”
It comes as new research, published in the MJA, shows e-liquids contain a wide variety of chemicals for which information on inhalation toxicity is unavailable.
The study tested 65 e-liquids purchased from Australian online and physical stores for a selection of pre-determined chemicals – both before vaping, and after a process that simulated the effects of vaping.
“All e-liquids contained one or more potentially harmful chemicals, including benzaldehyde, menthol, trans-cinnamaldehyde, and polycyclic aromatic hydrocarbons,” the authors reported.
Although all of the products were marketed as nicotine-free (only pharmacists can legally dispense nicotine-containing vaping products), nicotine or nicotyrine were detected in a small proportion of e-liquids, albeit at extremely low concentrations.
For more details on the potential health harms of individual chemicals, a podcast with lead study author Associate Professor Alexander Larcombe is available here.
There are no TGA-approved nicotine vaping products in the Australian Register of Therapeutic Goods, but doctors can prescribe them for dispensing at an Australian pharmacy through the Special Access Scheme for a single patient or by becoming an Authorised Prescriber.
The federal government has created new telehealth smoking cessation Medicare Benefits Schedule items, which can include provision of a script for nicotine vaping products.
Doctors can also write a script for a patient to import the products themselves for up to 3 months through the Personal Importation Scheme. However, the RACGP has strongly cautioned against this pathway as products imported from overseas are less likely to meet Australian requirements, including child-resistant packaging and restrictions against certain known toxins.
The RACGP also recommends that if vaping devices are to be used, unflavoured, closed systems should be preferred, as there is limited evidence about the long term safety of inhaled flavourings.
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The facts speak for themselves in my view:
“Use of an ENDS with cigarette-like nicotine delivery can reduce exposure to a major pulmonary carcinogen” https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00022-9/fulltext
“Exclusive e-cigarette users have biomarker concentrations that are similar to those of former smokers” https://cebp.aacrjournals.org/content/early/2021/08/17/1055-9965.EPI-21-0140.abstract
“The CDC initially suggested that the cause of the outbreak was nicotine vaping because the outbreak followed a large increase in nicotine vaping among US adolescents. Case–control studies revealed that the majority of cases had vaped illicit cannabis oils that were contaminated by vitamin E acetate.” https://onlinelibrary.wiley.com/doi/abs/10.1111/add.15108
“Among nonsmoking youth, vaping is largely concentrated among those who would have likely smoked prior to the introduction of e-cigarettes, and the introduction of e-cigarettes has coincided with an acceleration in the decline in youth smoking rates.” https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntab102/6276227?login=true
“Results show little evidence that e-cigarette use is increasing cigarette smoking among youth.” https://www.sciencedirect.com/science/article/abs/pii/S0306460321002586
“if young people are predisposed to both smoking and using e-cigarettes, bans which aim to prevent e-cigarette use may encourage smoking” https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003555
“Increased accessibility of nicotine e-cigarettes in Australia could improve the overall success of attempts by Australian smokers to quit tobacco cigarettes.” https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Chambers%2C%20Mark%20Poster%20Submission_0.pdf
Vaping leads to smoking? Smoking rates decline in all countries and at faster rates than Australia as Vaping increases including in young adults and youth. In areas where vaping bans take place smoking rates increase. It doesn’t take a genius to figure it out.
The UK yellow card reporting system has shown incredibly few to no adverse effects from Vaping nicotine liquids over the long term. The case of the girl with “EVALI” has all the telltale signs (to anyone with an ounce of knowledge of these cases) of vitamin E acetate an ingredient that is not soluble with glycerine based Nicotine carrying e-liquids.
There is no vaping epidemic in Australia, there is a smoking epidemic. An often overlooked fact is that youth’s Nicotine intake of choice is still cigarettes and not cherry or banana flavoured cigarettes either, just plain old disgusting tar flavoured. The cancer council and lung foundation have such disdain for vaping for no legitimate reason that they are now fabricating hack studies that look as though they were put together by school kids. This is going to be embarrassing for them (again).
Meanwhile less biased clearer heads (link below) are coming to what was always going to be the case. A straight forward conclusion that accepts the facts over the hyperbole. Vaping drastically reduces harm to smokers and improves public health overall.
https://ajph.aphapublications.org/doi/10.2105/AJPH.2021.306416?fbclid=IwAR1ix2MBV2hUurFsY_vxCD2juJbvBUTB7A5LZ8mn8lIzVRNptkiD_bREG7A
I was told 8 years ago that vaping “would probably kill me”, 8 years later i am a model of health for a 65 year old, have had no colds or flu for 8 years, improved circulation, improved energy, 100% lung capacity. Zero cigarettes in 8 years, and over $100,000 saved. I have also helped over 50,000 adult Australians quit smoking successfully. By the way I started at 12mg nicotine and now vape at 1mg nicotine. I have very little doubt that if I had not discovered vaping I would be in the grave now. I tried everything to quit prior to vaping – short of government recommended Champix (which has now been recalled due to detected carcinogens, N-nitrosovarenicline) Note, despite the international recall the TGA still says “Consumers are advised to continue to take their varenicline medicines as prescribed. Patients should not stop taking their varenicline medicines unless instructed to by their health professional.” Personally I would rather not join the 544 suicides and 1,869 attempted suicides Champix takers who have committed suicide, 20 of those in Australia. Although it is anecdotal evidence, the 600,000 Australian vapers are proof that vaping works to help quit smoking.
I will not prescribe vaping products. If the patient chooses to smoke, he is responsible for harming himself. If I prescribe a vaping product, I am then responsible for the patient harming himself. Of course I will prescribe other smoking cessation aids instead, even though the success rate is minimal (9% at 1 year, much less long term).
We all need to commend Australian initiative aimed to save our vulnerable children. Vaping among youth is a serious public health issue globally. The free and unregulated availability of e-cigarettes has led to increases in use of these devices by youth. In the past decade, vaping has increased among all age and demographic groups and is more popular than traditional cigarettes among adolescents. However, I believe that this policy should apply not only to nicotine vapor products but also cannabis vapor products. There is extensive research to suggest that adolescents often use e cigarette devices to vapor cannabis. Moreover, increased availability of cannabis will inevitably lead to some increase in uptake by adolescent users.
Effective programs and policies to prevent nicotine and cannabis vaping among youth and young adults, challenges to reducing e-cigarette use and vaping, and program and policy implementation strategies such as innovative new Australian public health community initiative that can be used to address those challenges While originally used as a way to vape flavored liquids with or without nicotine, adolescents are increasingly using these devices to vape cannabis derived compounds, such as tetrahydrocannabinol (THC) or cannabidiol (CBD), and other drugs, though it is worth noting that some cannabis-based products are harmful for adolescent’s developing brain. The additional evidence indicates that cannabis adversely affects the ability to drive safely and doubles the risk of being involved in a serious traffic crash. The high rates of motor vehicle use following cannabis use among youth would appear to be related to the fact that youth do not necessarily believe that cannabis impairs the ability to operate a motor vehicle safely.
In more tolerant times, public health professionals were quite accepting that the role of legislation and prohibition be confined to situations where the public had no way of being able to assess risk themselves.
So in the classic example – it is impossible to differentiate with the human eye a glass of water full of Vibrio cholera from one that is clean, so public health laws were needed to protect the public.
For everything else, their role was to educate the public on risk and lead them to calibrate risks and benefits and make healthy choices.
But increasingly and more vehemently they now advocate for prohibition and restricted access over many aspects of our lives, rather than education. It’s funny, paternalism seems out of vogue in all aspects of medicine unless you’re a public health professional.
– banning vaping where smoking is banned
Allowing vaping on beaches, national parks, urban parks and outside spaces (where often smoking is banned for no scientific reason) is not ‘open slather”.
– comparable tax rates
Taxing vaping like smoking is ridiculous as harm is greatly reduced and sends the signal that vaping is as bad as smoking so smokers might as well smoke. Having a reasonable GST tax on vaping is not ‘open slather’.
– nicotine limits
Unreasonable nic levels (like the EU 20mg one) is stupid. New vapers that are heavy smokers need at first high nic levels for the switch to have a better chance. Of course extremely high nic levels shouldn’t be available to general public (100mg highest is reasonable). Allowing new vapers access to nic limits appropriate to their needs is not open slather.
– prescription access
Prescription access alongside a doctor’s advice is fine as long as vapers can choose whether they want that or not. Forcing them to become patients and removing their autonomy and agency is infantilising authoritarianism. Allowing adult smokers to go to a vape store and get set up with everything they need to switch is not open slather.
– flavour restrictions
Flavour restrictions where its been proved that a particular chemical increases risk (like Diacetyl and cinnamaldehyde) is reasonable. Overseas flavour bans have been completely ridiculous, based on the idea that adults don’t like flavours and also that allowable flavours (menthol and tobacco) in of themselves are not flavours. Allowing vapers to choose their own flavour to make vaping more attractive / effective for them is not ‘open slather’
– display bans
Not allowing hardware and e-liquid to be displayed in vaping retail stores is ridiculous. Hiding hardware under frosted glass and not allowing brands to be displayed in vape stores is just plain backwards. Allowing vaping products to be displayed inside stores is not ‘open slather’.
There is nothing intrinsically unethical in the consumption of nicotine in a much safer form and in moderation, much like caffeine, sugar, alcohol. The stigma embossed into tobacco smoking over the years should not be applied to vaping.
“No vaping advocate wants ‘open slather’” Oh really? I have seen huge opposition from vapers to:
* banning vaping where smoking is banned
* comparable tax rates
* flavour restrictions
* display bans
* prescription access
* nicotine limits
The only policies I’ve seen vapers support are childproof packaging and lame motherhood stuff like no sales to under 18s. So which policies do you support BakerB?
Simon. Nicotine is as much a medicine as caffeine (which you are drinking now apparently) is so your well worn analogy cannot apply here.
No vaping advocate wants ‘open slather’. Its useful for you to misrepresent, but its not the truth of the matter as you’ve been told many times.
Smoking rates in countries where vaping isn’t crypto-prohibited are falling faster than us.
Youth access to vaping (via black market) will not waver because of this knuckle-dragging policy it will increase. Prohibition and lack of regulation created the under-the-counter vapes phenomenon in the first place and those who lobby to prohibit are to blame.
The whole policy is a mess. There’s absolutely no regulation at all. You can get a prescription and import any old e-liquid from wherever, its like we’ve de-regulated to be honest. I’m sure the criminal gangs who smuggle truckloads of illegal tobacco a year will now be adding vapes to their product line (if they haven’t already).
Dr Mendelsohn seems to be either clutching at straws or trying to confuse the issue when discussing the case of the young woman diagnosed with EVALI. EVALI does not mean “vitamin E acetate-caused” injury; EVALI is the name given to lung injuries associated with inhaling chemicals (not just vitamin E acetate) from an e-cigarette or vape.
BBaker seems to think that requiring a prescription means that a de facto prohibition. What amazing nonsense. Tell that to almost every Australian who at some or many points in every year gets one of the ~280m scripts that are written every year here for everything from the pill, blood pressure, high cholesterol, sleep problems, pain relief and prescribed smoking cessation products. The public health community has spent decades tightening up the sort of open slather regulatory disaster that vaping advocates want to see happen again for nicotine vaping products. We’ve won advertising bans, tax rises, smokefree policies, retail display bans, graphic health warnings, plain packs, personal import bans, and ended light & mild misleading descriptors. All these policies are opposed by the vaping and tobacco industries & their enablers. Smoking rates have never been lower.
I nearly sprayed my coffee when I read “no early bio-markers of potential harm detected”. I put a few reviews of that evidence on my my blog here. https://simonchapman6.com/vaping-research-alerts/
We stand alone in the western world with our less than progressive stance. We turn people who weren’t previously into patients. This de-facto prohibition policy is badly implemented and will cost lives and those who lobbied for it will never be held accountable. The public health/quit/cancer charity industries have a lot to answer for creating a scenario where smoking (which causes millions of deaths a year globally) is more accessible than vaping (no deaths attributed and no early bio-markers of potential harm detected).
Its a simple choice. Either support harm reduction (and make it easier to access and properly regulate it) or support death to smokers.
The question should also have referred to the impact of the legislation on vaping for the whole population. It will have a negative impact on those who need to cease cigarette smoking and those who have decided on their own volition to stop cigarette smoking. The impact will unreasonably fall on those who are marginal and who are mentally ill and who so commonly smoke tobacco; those living in the community with psychosis, tobacco smoking is of the order of 60%. The impact on adolescents will only be known with the efflux of time. The study reporting the range of substances in vaping products is an argument for consumer law and controls on the quality of substances available to the population, as in NZ.