Is it better to vape than smoke? Definitely, but it is still worse than quitting entirely, writes Dr Gideon Meyerowitz-Katz in The Guardian. The epidemiologist wrote in response to a major review from Australian National University that reports health harms and rising use of e-cigarettes among children, although vaping is outlawed in Australia without a prescription.
The excerpt below is from an article appeared in The Guardian on 17 April 2022. It is followed by earlier articles in The Conversation and from Australian National University (ANU), a link to the university research and a critique by Dr Colin Mendelsohn.
Vaping is better than smoking but worse than quitting
Gideon Meyerowitz-Katz is an epidemiologist working in chronic disease in Sydney, with a particular focus on the social determinants that control health. He wrote in The Guardian that the ANU report into vaping, which resulted in calls to ban vaping entirely for younger Australians, still leaves a great number of questions
Before the pandemic and its many controversies, vaping – the use of electronic nicotine (or non-nicotine) delivery systems or e-cigarettes – was one of the most contentious topics online.
Talking about vaccines would start arguments, discussing raw milk might get some hate, but even the slightest hint of a position on vaping would get you immediately inundated with passionate replies from whichever side you had offended.
There are many reasons for all this passion, but the main thing has to do with uncertainty, and how we make public health decisions.
The new fantastically comprehensive report into vaping in Australia, which has resulted in calls to ban vaping entirely for younger Australians, merely the latest in a long line of intense discussions.
Depending on who you listen to, vaping is either a direct threat to human life, and children in particular, or the best public health intervention of the last 100 years, which has only fuelled the controversy on the practice.
The basic idea behind this discussion is simple, Meyerowitz-Katz continues in The Guardian: vaping is a way of ingesting nicotine (and other substances) that is far safer than smoking.
If we move people from cigarettes to e-cigarettes, as the World Health Organisation (WHO) review into the topic notes, it is almost certain that their health will improve, because e-cigarettes (and vape pens, cartridges etc) produce far lower levels of the most harmful chemicals that you inhale when you smoke.
Some important issues
But there are several obvious issues with this.
Firstly, vapes aren’t a homogenous intervention – there is enormous variability in vaping products and devices. The market is largely unregulated, which means the term ‘vape’ covers everything from solid, reliable devices to something that will explode when you put it in your mouth.
These harms, while real, are thankfully pretty rare – even the biggest short term issue, which is to do with serious lung disease caused largely by vapes containing a specific additive derived from cannabis, has only been seen a relatively small number of times.
Yes, they’re important, but they aren’t really what we’re interested in when discussing vaping policy more broadly. No, the real debate centres on a series of incredibly complex problems that continue to divide the topic of vaping today. The Guardian story continues:
On the one hand, switching to vaping from smoking (that is, giving up cigarettes entirely) is probably good for your health. That being said, the epidemiological evidence shows that this is relatively uncommon – while some people do use vaping to quit smoking entirely, most become what is known as ‘dual users’ who both vape and smoke in differing amounts.
The evidence on whether dual use is beneficial (as opposed to just smoking) is mixed, because the practice itself covers everything from people who rarely smoke and predominantly vape to those who basically add vaping to their current smoking regime.
To add fuel to the fire there is experimental research, where people are randomised to either vape or quit smoking cold turkey, that seems to indicate some benefit for vaping. Unfortunately, these studies tend to be low quality and it is hard to know whether their results hold up outside of a clinical setting, although there is some evidence that they will.
Moreover, vaping is obviously worse for your health than quitting entirely.
According to Meyerowitz-Katz in The Guardian, while long-term problems have yet to be fully identified – vaping only became common in the last decade or so – there is certainly reason to believe that vaping is not entirely harmless, particularly given the massive spectrum of products you can use to vape.
On top of this, there’s pretty good evidence that vaping nicotine products is habit-forming and addictive, and there’s a great deal of concern among epidemiologists that specifically in young people vaping can lead to smoking, which is obviously a bad thing.
Even this is hotly debated, because it’s hard to know whether vaping causes smoking or if it’s just that young people who start vaping are more likely to become smokers in the future anyway.
In addition, because somehow this topic gets even more complex, the recent evidence in Australia shows that people are vaping at ever-increasing rates.
A 2019 report from the Australian Institute for Health and Welfare found that about 3% of Australians are vaping regularly, which is low but also double the proportion from 2016.
In counterpoint to this, we have got data from the United Kingdom, where vaping has been deregulated for some time, showing that vaping rates have stabilised at about 6% to 7% of the population, even in younger people.
All of this complexity brings us back to the reason behind the vigorous debate – the simple truth is that this is all horribly complicated.
See the link below to the full story in The Guardian.
A damning review of e-cigarettes shows vaping leads to smoking, the opposite of what supporters claim
The Conversation published an article on the Australian National University research on 6 April, by Paul Grogan, an adjunct senior lecturer at the University of Sydney, and Guy Marks, professor of respiratory medicine at the University of New South Wales in Sydney. The following is a short excerpt:
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, write
The review 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 reports, 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 that 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 that 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 that 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 that 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 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 to 24 are also the only age group that is 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.
This article is republished in full under Creative Commons licence.
Australian National University story – E-cigarettes are harmful and addicting youth: report
This ANU story was published on 7 April:
E-cigarettes, or vapes, are causing harm and risk introducing a new generation to smoking, warn experts from the Australian National University following their government report into vaping.
The major review found use of nicotine e-cigarettes increases the risk of a range of adverse health outcomes, particularly in youth, including taking up smoking, addiction, poisoning, seizures, trauma and burns and lung injury.
“We reviewed the global evidence in order to support informed choices on vaping for Australia,” said lead author Professor Emily Banks from the ANU National Centre for Epidemiology and Population Health.
“The evidence shows e-cigarettes carry significant harms. Nicotine is a key ingredient and one of the most addictive substances known. Vaping is causing addiction in a new generation of users.
“Young non-smokers who vape are around three times as likely to take up smoking than non-vapers. Nicotine use in children and adolescents can lead to lifelong addiction issues as well as difficulties in concentration and learning. Vaping is also illegal if it isn't on prescription.”
The report found early warning signs of adverse effects of e-cigarettes on cardiovascular health markers, including blood pressure and heart rate, and lung functioning.
“The evidence is there for some of the risks but for most major health outcomes, like cancer, cardiovascular disease and mental illness, we don't know what the impacts of e-cigarettes are. Their safety for these outcomes hasn't been established,” Banks said.
“There are myths targeting young people; the false ideas that vapes wouldn't be widely available if they were dangerous and ‘it's just water vapour’.
“Vapes deliver hundreds of chemicals – some of them known to be toxic and many others with unknown effects.
“In Australia, over two million people have used e-cigarettes. Use is more common among youth, particularly young males, and among smokers and the majority is not for the purposes of smoking cessation.”
The report found more than half, 53%, of current e-cigarette use in Australia is by people who also smoke, 31.5% is by past smokers and 15.5% is people who have never smoked.
“The report found limited evidence that nicotine e-cigarettes were effective to help people quit smoking in the clinical setting,” Banks said.
“Most people who quit smoking successfully do so unaided.
“E-cigarettes are likely to be harmful for non-smokers and for people who use them while continuing to smoke – the commonest use pattern currently.
“E-cigarettes may be beneficial in the small number of smokers who use them to quit smoking completely and promptly, but there is a huge uncertainty about their effectiveness and the overall balance of risks and benefits for quitting.”
The report supports national and international efforts to avoid e-cigarette use in the general population, particularly in non-smokers and youth.
“Our young people have been through a lot and they deserve the best future possible,” Banks said. “The evidence is in that avoiding e-cigarettes should be part of that.”
Cancer Council's Public Health Committee Chair, Anita Dessaix, said the ANU report is the most comprehensive study of all the health impacts of e-cigarettes ever published worldwide and it sends an urgent message to Australian governments.
“Every week we're hearing growing community concern about e-cigarettes in schools, the health harms and the risks of smoking uptake among young people,” Dessaix said.
“Now we have the world's most authoritative independent scientific analysis showing us exactly why we're seeing those problems.
“A public health crisis is rapidly unfolding before our eyes.
“This thorough, rigorous, independent report, from one of the world's leading public health research centres, should put an end to the misinformation being spread by people trying to make money from e-cigarettes.
“These findings send a clear message to all governments: act now. Do more to protect the community, especially young people, from the harms of e-cigarettes.”
Australian National University project – Health impacts of electronic cigarettes
The study was undertaken by the National Centre for Epidemiology and Population Health at the Australian National University College of Health and Medicine,
Its work aims to maximise the health of Australians by providing evidence to support high-quality decision-making on e-cigarettes for the Australian context. The website outlines the programme of work on the health impacts e-cigarettes, commissioned by the Australian Department of Health.
See the link below to the ANU National Centre for Epidemiology and Population Health project and research report.
Flawed report on vaping will harm public health
Dr Colin Mendelsohn has a general practice in Sydney, has a special interest in tobacco harm reduction and vaping, was founding chairman of the Australian Tobacco Harm Reduction Association, and is the author of a self-funded book called Stop Smoking Start Vaping. He has not received payments from e-cigarette or tobacco companies.
The following report by Mendelsohn was published on his website on 6 April:
Researchers at the Australian National University published a detailed report today on vaping for the federal health department. As expected, the report Electronic cigarettes and health outcomes: Systematic review of global evidence, delivered what the paymaster wanted and is seriously flawed.
The report exaggerates the risks and potential risks of vaping and fails to compare them to the far greater risks of smoking. It makes unsubstantiated claims of harm and downplays the effectiveness of vaping as a quitting aid.
Risks not compared to smoking
The major flaw in the report is that it highlights the potential risks of vaping without comparing them to the far greater risks of the deadly alternative.
Vaping is not risk-free but it is far less harmful than smoking. It is a legitimate substitute for adult smokers who are otherwise unable to quit with other methods and would otherwise continue to smoke. Up to two in three long-term smokers will die prematurely from a smoking-related disease.
Switching to vaping has been shown to lead to substantial health improvements and should be encouraged. The UK Royal College of Physicians concluded in 2021: “E-cigarettes are an effective treatment for tobacco dependency and their use should be included and encouraged in all treatment pathways.”
For example, the report states that vaping causes cardiovascular disease, blood pressure and harmed lung function. However, these harms from vaping are small and far less than from smoking. The evidence indicates that when smokers switch to vaping, these conditions improve.
Flawed claims
Some of the more egregious claims in the 361-page report are listed below.
- It lists numerous risks of vaping, but fails to quantify them. Many of the risks are very small and of no clinical or biological significance, such as the concern that smoking causes ‘arterial stiffness’ (so do exercise, caffeine and scary movies)
- It falsely claims that nicotine vaping by non-smokers increases the risk of smoking. This ‘gateway theory’ has now been discredited. The ‘common liability’ explanation is far more plausible.
- Youth vaping is framed as a ‘serious public health risk’. Young non-smokers should not vape, but the evidence suggests that vaping is overall diverting young people away from smoking.
- It questions the effectiveness of vaping as a quitting aid. However, the evidence is now persuasive. There is moderate evidence from randomised controlled trials that vaping is more effective than nicotine replacement therapy and this is supported by the better quality observational studies, population studies and accelerated declines in smoking rates in countries where vaping is readily accessible.
- It falsely claims that nicotine vaping causes EVALI because some patients denied using THC vapes. However, self-reports of THC use are unreliable and many EVALI patients who denied using THC were later found to have done so.
- Some risks are exaggerated. For example, it states that vape malfunctions can cause serious harms and death. There have been two deaths from exploding vapes globally in the last 15 years.
- It refers to a significant number of accidental poisonings, but poisoning is rare and serious outcomes are very rare.
- It wrongly claims that dual use is the dominant pattern of use, ie that most vapers continue to smoke. In the United States, only 27% of vapers are also smoking (NHIS 2020). In the UK, 38% of users also smoke (ASH 2020). Dual use in Australia was 53% in 2019, but evidence from other countries shows that dual use reduces over time as more users switch to vaping only.
- It claims that vaping can cause seizures, however this claim has been discredited.
- The report claims that vaping increases the risk of relapse, when the evidence suggests it helps to prevent relapse.
- It claims that e-cigarettes can result in nicotine toxicity. However, there is no evidence for nicotine toxicity with normal use.
- Important studies are ignored. The report claims that there is no available evidence on the relationship of e-cigarette use to cancer risk. However, several studies have assessed the cancer risk as very low and only a tiny fraction of the risk from smoking.
- It claims there is limited evidence that vaping is less addictive than smoking. There are numerous studies that show vaping is less addictive.
Overall benefit of vaping
The report says that for current smokers, there continues to be insufficient evidence that the benefits of e-cigarettes outweigh their harms. This ignores the numerous modelling studies which show that by replacing smoking, vaping averts smoking-related death and reduces harm.
For example, one study found that if most smokers in the US switched to vaping, there would be up to 6.6 million premature deaths averted and 86.7 million fewer life years lost.
More information is needed, but there is sufficient evidence to support a positive population benefit versus harm for vaping.
Australian National University project – Health impacts of electronic cigarettes (Open access)
Colin Mendelsohn blog – Flawed report on vaping will harm public health (Open access)
See also from the MedicalBrief archives
Australia: New laws won’t drive vapers back to smoking, say experts
E-cigarettes: Misconceptions may prevent people from quitting smoking
Vaping raises chances of regular smoking threefold — Australian research review
Researchers expose the ‘pitiful quality’ of highly cited vaping studies