A MAJOR review on the health effects of e-cigarettes reflects what public health advocates have feared – escalating use of e-cigarettes in school-aged children, early warning signs of increased smoking rates in young Australians, and direct health harms of vaping in all ages.

The review, which was released on Thursday 7 April, was commissioned by the federal health department and conducted by researchers at the Australian National University.

Overall, it found the health risks from e-cigarettes significantly outweighed any potential benefits.

The review should silence lobbyists, who have long used data selectively to promote the sale of e-cigarettes. This is despite the fact previous , none as comprehensive and rigorous as this latest review, have delivered similar findings.

What does the review tell us?

The review looked at the evidence behind the health impacts of e-cigarettes or “vapes” – a diverse group of devices that aerosolise a liquid for inhalation. These are touted as a safer alternative to cigarettes and an aid to quit smoking.

The review found conclusive clinical evidence e-cigarettes cause acute (short-term) lung injury, poisoning, burns, seizures, and their use leads to addiction. They also cause less serious harms, such as throat irritation and nausea.

Evidence e-cigarettes produce airborne particles in indoor environments (potentially harming non-users) was also conclusive.

Among evidence ranked as strong, the review confirms what has worried tobacco control experts since patterns of e-cigarette use first emerged. People who have never smoked or are non-smokers are three times as likely to smoke if they use e-cigarettes, compared with people who have never used e-cigarettes.

This is a dream for tobacco companies and their retail allies.

Weighing up the harms and the benefits

The review found limited evidence e-cigarettes assist individuals to stop smoking. But this is no stronger than evidence showing e-cigarette use might also cause former smokers to relapse and revert to tobacco.

There is no conclusive or strong evidence in the review for any beneficial outcome from e-cigarettes.

E-cigarettes might help some individuals stop smoking. So they should only be available via a prescription from authorised medical professionals trained in helping people to quit. Any access beyond this risks serious harm for no benefit.

Young people are vaping

Australian Institute of Health and Welfare data show the age group most likely to use e-cigarettes in their lifetime are 18 to 24-year-olds. This has risen from 19.2% in 2016 to 26.1% in 2019.

Of e-cigarette users who identify as smokers, the second largest user group is 14 to 17-year-olds. Dual use is starting young, from the limited Australian Institute of Health and Welfare data we have.

The Australian Institute of Health and Welfare data precedes increasingly visible use of e-cigarettes in Australian schools, reported in the media.

The review also shows young males are the leading e-cigarette user group by age and sex. Australian males aged 18-24 are also the only age group which, on the latest Australian Institute of Health and Welfare data, are smoking at greater rates than they were three years earlier.

We need to limit access

Whatever benefits might be delivered by e-cigarettes, such as helping people to quit smoking, would, according to the review, be modest compared with the harms they are likely to cause.

Unfortunately, public policy on the regulation of e-cigarettes is at risk of influence from powerful commercial interests. In the interests of public health, these forces must be resisted.

What should governments do?

Federal, state and territory governments have enacted policies aimed at providing e-cigarette access to individuals who might benefit from them to quit smoking, while protecting everyone else.

But the evidence on how widely e-cigarettes are used shows these policies need to be more tightly enforced.

It’s still easy to buy e-cigarettes online, they are available without prescription from petrol stations, tobacconists, specialty “vape” stores and are on-sold by entrepreneurs – all of them acting unlawfully. Heavy fines will end their cash incentive.

The review shows the risks to public health posed by e-cigarettes will only grow unless governments enforce their laws.

This is to protect young Australians from becoming the first generation since trend data was collected to smoke and use nicotine at higher rates than their predecessors.The Conversation

Paul Grogan is an Adjunct Senior Lecturer at the The Daffodil Centre, University of Sydney.

Guy Marks is Professor of Respiratory Medicine at the South Western Sydney Clinical School, UNSW Sydney.

This article is republished from The Conversation under a Creative Commons license. Read the original article.




The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


The health risks from e-cigarettes significantly outweigh any potential benefits
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12 thoughts on “Damning review of e-cigarettes shows vaping leads to smoking

  1. Dr Alex Wodak AM says:

    The transition from combustible cigarettes to smoke free ways of inhaling nicotine is an example of a ‘disruptive innovation’. Other examples of disruptive innovations include the transition from manual to electric typewriters, and from electric typewriters to personal computers; film to digital cameras; records to cassette tapes to compact discs to streaming; internal combustion engine to electric vehicles and fossil fuels to renewable energy. Traded tobacco companies are transitioning from combustible to smoke free options though with varying speed. The share price of tobacco companies rose spectacularly for many decades. After reaching a peak in 2017, tobacco company shares dropped by more than half over the following years, even though these companies continued to be extremely profitable. It seems that investors started bailing out of cigarette companies anticipating that Big Tobacco would have its own ‘Kodak moment’. The share price of tobacco companies transitioning more rapidly from combustible to smoke free options, such as Swedish Match and Philip Morris International, are higher than companies making a slower transition. The proportion of profits of PMI accounted for by smoke free options increased from 0.2% in 2015 to 30.7% for the final quarter of 2021.
    It is indefensible that the availability of a much safer option, vaping, is restricted in Australia while deadly cigarettes are readily available for adults from 20,000 outlets. Current anti vaping policy perversely protects tobacco company while exacerbating economic inequality and health iniquities.

  2. Anonymous says:

    Can someone please show me any evidence that heavy fines and enforcement has led to less access to psychoactive drugs?I’ll help you out – there is zero evidence that increased enforcement and penalties reduces access to psychoactive drugs. In fact there is a very large body of evidence showing that these approaches end up incentivising organised crime groups to take control of the market. You may think that you are controlling vaping by making it prescription only. In fact – you have handed control of vapes to organised crime groups. Nice work.

  3. Mark Chambers says:

    The statistics used to imply incidence of e-cigarette use amongst youth in Australia in this article are grossly misleading. Quoting lifetime e-cigarette use rather than current use is a tactic frequently used to overstate the incidence of e-cigarette use. The reason it is so misleading is because most people that try e-cigarettes do not continue to use them.

    The same data source cited in this article reveals that current e-cigarette use among non-smokers is 2.9% (not 26%). Furthermore, if a more thorough analysis had been done, it would have been found that among this category of non-smokers that currently vape, the proportion that were smokers when they first started vaping is more than 70%! That is, many if not most of these people probably used e-cigarettes to quit smoking! The proportion of Australian never smokers that go on to become regular users is miniscule.

    Current evidence suggests that e-cigarettes probably have greater efficacy for smoking cessation than nicotine replacement therapy, for example. See my paper currently in press for a (rigorous) analysis of the effect of e-cigarette use on success of smoking cessation by Australians in 2019.


  4. Aki Nilanga Bandara says:

    E-cigarette manufacturers now comprise a multi-billion-dollar industry and their sophisticated marketing strategies are so pervasive and powerful, and adolescents simply cannot resist. As a result, more significantly, the popularity of their use by adolescents has reversed much of the progress made in the past decade toward reducing nicotine addiction in these vulnerable children world-wide. Both traditional conventional combustible cigarettes and e-cigarettes deliver similar levels of nicotine with strong potential for dependence (1, 2). Meanwhile, the percentage of adolescents who used e-cigarettes- who reported an unsuccessful quit attempt was 4.1%, compared with 2.3% of adolescent conventional combustible cigarette smokers who reported an unsuccessful attempt to quit smoking (3).
    According to proponents of e-cigarettes- a benefit of these products is helping smokers to both reduce their exposure to tobacco-associated toxins and to quit the habit. However, the most recent JAMA article shows that current as well as former cigarette smokers showed that switching to e-cigarettes did not appear to help them avoid relapse (4). For these accumulating strong evidence e-cigarettes are not currently approved by the FDA as a smoking-cessation tool (5).
    Furthermore, emerging literature shows that e-cigarettes as nicotine-delivery systems that set the stage for youth to develop nicotine dependence (5, 6, 7). The National Academies of Sciences, Engineering, and Medicine, there is substantial evidence that e-cigarette use “results in symptoms of dependence on e-cigarettes” and “increases risk of ever using combustible tobacco cigarettes among youth and young adults.” (8).
    (1). Mantey DS, Case KR, Omega-Njemnobi O, Springer AE, Kelder SH. Use frequency and symptoms of nicotine dependence among adolescent E-cigarette users: Comparison of JUUL and Non-JUUL users. Drug Alcohol Depend. 2021 Nov 1;228:109078. doi: 10.1016/j.drugalcdep.2021.109078. Epub 2021 Sep 24. PMID: 34614433; PMCID: PMC8595823.
    (2). Miech R, Leventhal AM, O’Malley PM, Johnston LD, Barrington-Trimis JL. Failed Attempts to Quit Combustible Cigarettes and e-Cigarettes Among US Adolescents. JAMA. 2022;327(12):1179–1181. doi:10.1001/jama.2022.1692
    (3). National Institute on Drug Abuse (NIDA) (nih.gov)-Monitoring the Future https://nida.nih.gov/drug-topics/trends-statistics/monitoring-future
    (4). Pierce JP, Chen R, Kealey S, et al. Incidence of Cigarette Smoking Relapse Among Individuals Who Switched to e-Cigarettes or Other Tobacco Products. JAMA Netw Open. 2021;4(10):e2128810. doi:10.1001/jamanetworkopen.2021.28810.
    (5). CDC Electronic Cigarettes (cdc.gov) Electronic Cigarettes (cdc.gov) https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
    (6). Rest EC, Mermelstein RJ, Hedeker D. Nicotine Dependence in Dual Users of Cigarettes and E-Cigarettes: Common and Distinct Elements. Nicotine Tob Res. 2021 Mar 19;23(4):662-668. doi: 10.1093/ntr/ntaa217. PMID: 33097952; PMCID: PMC7976930.
    (7). Miliano C, Scott ER, Murdaugh LB, Gnatowski ER, Faunce CL, Anderson MS, Reyes MM, Gregus AM, Buczynski MW. Modeling drug exposure in rodents using e-cigarettes and other electronic nicotine delivery systems. J Neurosci Methods. 2020 Jan 15;330:108458. doi: 10.1016/j.jneumeth.2019.108458. Epub 2019 Oct 12. PMID: 31614162; PMCID: PMC7012754.
    (8). National Academies of Sciences, Engineering, and Medicine. 2018. Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies Press. https://doi.org/10.17226/24952-https://nap.nationalacademies.org/catalog/24952/public-health-consequences-of-e-cigarettes

  5. Colin Mendelsohn says:

    I disagree with Dr Bandara’s suggestion that vaping is not an effective quitting aid.

    The Hedman study quoted has major flaws and its conclusions are unreliable. The meta-analysis aggregates studies that are completely different in design, exposure, user characterisation, quitting intentions and outcome measures and should not be pooled. There are also problems with selection bias, confounding and unsatisfactory study design.

    You referenced the 2020 Cochrane study, but the most recent Cochrane review (September 2021 concludes) “There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to NRT (RR 1.53)” and “For every 100 people using nicotine e-cigarettes to stop smoking, 9 to 14 might successfully stop, compared with only 6 of 100 people using nicotine-replacement therapy”. More studies are needed, but this supports the effectiveness of vaping as a quitting aid.

    More importantly, the RCT data is supported by combining the results of real-world studies such as observational studies, population studies and trends in smoking rates where vaping is popular. ‘Triangulation’ of all the data provides a more accurate picture than relying on just one type of evidence, and increases the confidence that vaping is an effective quitting aid.

    Vaping may not be endorsed by respiratory or pediatric societies but it is endorsed by the British Lung Foundation and many health and medical associations, such as the RANZCP, the UK RCP, the British Medical Association, the Royal College of General Practitioners, UK Royal College of Nursing, the New Zealand Ministry of Health and many more.

    Could i suggest this reference: https://colinmendelsohn.com.au/wp-content/uploads/2020/01/Mendelsohn-C-Hall-W-Borland-R.-Could-vaping-help-reduce-smoking-rates-in-Australia.-Drug-Alcohol-Rev-2020.pdf

  6. Aki Nilanga Bandara says:

    E-cigarettes or vaping have not been endorsed as a smoking tool by a single major respiratory or pediatric clinical society because their effectiveness in smoking cessation is unproved (1). Not even a single clinical guideline in the world endorses e cigarette as a proven and safe tobacco cessation too. US Preventive Services Task Force’s smoking cessation practice guideline did not endorse e cigarette as a tobacco cessation tool (2). Meanwhile, the most recent Cochrane Review urged more well-designed clinical trials to understand the therapeutic effects of vaping (3). Similarly, the most recent systematic review concluded that “We did not find quality evidence for an association between e-cigarette use and smoking cessation. Although RCTs tended to support a more positive association between e-cigarette use and smoking cessation than the cohort studies, the grading of evidence was consistently low” (1).
    (1). Hedman L, Galanti MR, Ryk L, Gilljam H, Adermark L. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: A systematic review and meta-analysis. Tob Prev Cessat. 2021 Oct 13;7:62. doi: 10.18332/tpc/142320. PMID: 34712864; PMCID: PMC8508281.
    (2). US Preventive Services Task Force, Krist AH, Davidson KW, et al. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265–279. https://doi.org/10.1001/jama.2020.25019 Crossref, Medline, Google Scholar
    (3). Hartmann-Boyce J, McRobbie H, Lindson N, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2020;10(10):CD010216. https://doi.org/10.1002/14651858.CD010216.pub4 Medline, Google Scholar

  7. Dr Carolyn Beaumont says:

    This review presents many selective and inaccurate messages. In my view as a nicotine prescribing clinician, the potential vaping associated RISKS are highly exaggerated, whilst the potential health BENEFITS as a smoking cessation aid are almost entirely ignored.

    In reality there are two very different but equally important issues we must address:

    Firstly, regarding the uptake of unregulated vaping products in TEENAGERS: The tantalising colours and flavours, with variable nicotine content, in a black-market unregulated supply chain, is rightly of major concern. This must be addressed urgently, as teenage vaping uptake appears to be increasing since the Covid pandemic (based on substantial anecdotal reports from many schools). It is conceivable that the combination of remote learning, more social media use and mental health difficulties with isolation has been a major driver of this. We need fresh data on this.

    But secondly, for ADULT EX-SMOKERS, vaping can provide the only route out of heavy smoking. They have a right to easily access safe and legal vape products. As an authorised prescriber for adult ex-smokers, who have demonstrated an inability to convincingly quit using other methods, I can attest to the huge health benefits and relief they experience upon changing to vaping.

    The review’s focus on the message that ‘vaping leads to increased smoking uptake’ and ‘vaping doesn’t help smoking cessation’ is misleading. Much of the data the authors rely on does not show the more nuanced picture. From my clinical experience, some heavy ex-smokers may continue to smoke whilst vaping (‘dual use’), but at much LOWER rates of smoking. They report substantial health benefits, and are almost universally keen to continue reducing smoking. The existing data does not appear to show this level of detail, in an up-to-date manner.

    The review states that e-cigarettes may cause burns, including explosions in the mouth. The references they provide point to UNREGULATED products being the main culprit. Which leads to a further key concern of mine: In Australia, because of the current highly unregulated nature of vaping device and fluid access, such risks are indeed present. There is currently a TGA safety standard (TGO110) for liquid nicotine, but not for the vaping device itself (including the batteries and other hardware). Such burn and explosion injuries would be hugely reduced if Australia had a proper safety standard which addressed these hazards.

    Finally, the review states that e-cigarettes may cause seizures. The vast majority of references suggest that not only is this an extremely rare event, but it also tends to occur in adolescents not adults, and without any longterm neurological sequelae. The references are not consistent about other underlying medical conditions and drug use which occurred at the time of seizure. In short, it is too simplistic to claim that e-cigarettes may cause seizures.

  8. Anonymous says:

    the message is not ‘ smoking is better ” the message is BOTH are bad.

  9. Dr Alex Wodak AM says:

    There is almost universal national and international agreement that smoking cigarettes is far more dangerous than vaping nicotine. The annual number of smoking related deaths in Australia is estimated at 21,000 and globally at 8 million but there are at most only a handful of vaping deaths a year in Australia. Cigarette smoke contains about 7,000 chemicals including about 70 carcinogens, most at high concentration, and carbon monoxide and tar. Vaping aerosol contains about 300 chemicals, most are at low concentration, and no carbon monoxide or tar. It is absurd that Australian government policy ensures deadly cigarettes are readily available but the safer option is much more difficult to obtain. In countries where safer nicotine options are readily available, smokers stampede for the exit from deadly cigarettes. Australian smoking rates since 2013 have only been declining by 0.3% per year but smoking rates sin the same period in UK and US, where vaping rates are much higher, have been declining at about three times that rate. Australia’s hostility to vaping is wrong and unsustainable.

  10. Anonymous says:

    If we’re worried about ‘health effects’ and are keen to deter substance abuse, why not go to the final common pathway and ban cigarettes?
    And alcohol while you’re at it.
    Oh; but legalise marijuana apparently.
    And have safe injecting rooms for heroin and crack (with vitamin C of course).

  11. Colin Mendelsohn says:

    The other fatal flaw in this review is that it fails to recognise the role of vaping for tobacco harm reduction. The question is not whether vaping is safe, but whether it is safer than smoking. Vaping is a substitute for deadly smoking.

    While there are certainly risks and potential risks from vaping, the UK Royal College of Physicians report states “the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco.”

  12. Colin Mendelsohn says:

    The headline that vaping leads to smoking is very misleading. It is based on observational studies which show that teens who try vaping are more likely to try smoking later than those who do not try vaping. However this cross sectional data cannot show causation. Just because vaping precedes smoking
    for these teens does not mean that vaping caused the subsequent smoking.

    The most likely explanation for the association between vaping and smoking is that young people who experiment with vaping are more prone to taking risks generally and have a ‘common liability’ for risk taking ( i.e. ‘kids who try stuff, try other stuff’). There is good evidence that young people who try vaping are also more likely later to binge drink, drink drive and use illicit drugs. This does not mean that vaping causes binge drinking, drink driving or illicit drug use.

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