Leading public health experts in Australia have rejected warnings that a new ban on importing nicotine vaping products without a doctor’s prescription could drive vapers back to smoking, as evidence for the potential harms of vaping grows, writes Sarah Colyer for InSight+, published by The Medical Journal of Australia.
In the past week, the journal and The Conversation have published articles by researchers at Curtin University on chemicals they found in e-liquids that are known to cause respiratory problems and lung damage (see The Conversationand medical journal abstract below).
InSight+ on the new laws and smoking cessation
On 1 October 2021 it became illegal for Australian consumers to import products such as nicotine e-cigarettes, nicotine pods and liquid nicotine without a prescription from an Australian doctor, according to the InSight article published on 11 October 2021.
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 vapourised 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 of treatment for smoking cessation, and that their long term health effects are unknown.
According to the InSight+ article, RACGP President Dr Karen Price said: “It is 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.”
Mendelsohn argued that 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.
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 told InSight+.
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, 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.
Link to the full InSight+ article below.
Many e-cigarette vaping liquids contain toxic chemicals
In The Conversation on 12 October, Associate Professor Alexander Larcombe of the Telethon Institute and Curtin University wrote that since 1 October it has been illegal to buy e-liquids containing nicotine without a doctor’s prescription anywhere in Australia – except South Australia.
Vaping with nicotine-free e-liquids is not illegal, although in some jurisdictions, e-cigarette devices themselves are illegal.
Vaping is increasing in popularity in Australia, particularly among young people.
I co-led a research team that wanted to find out what’s in the nicotine free e-liquids that vapers inhale, and their potential health effects.
Our study, published this week in The Medical Journal of Australia, found most e-liquids contained chemicals known to cause respiratory issues and lung damage when inhaled.
Most contained ingredients that have since been banned by Australia’s drug regulator, the Therapeutic Goods Administration (TGA). We also found all e-liquids contained substances for which the health effects of inhalation exposure are unknown.
It’s clear vaping isn’t safe, and e-cigarettes haven’t been approved as smoking cessation devices.
What did we study?
A few years ago, we conducted a small study which involved chemically analysing 10 e-liquids purchased in Australia. All of them were labelled ‘nicotine free’.
Our research, published in The Medical Journal of Australia in 2019, was surprising and concerning. We found 60% of the liquids contained nicotine. In some instances, this was at levels high enough not to be just trace contamination.
We also found all 10 e-liquids contained a chemical called ‘2-chlorophenol’, which is often used in pesticides and disinfectants and is a known irritant to the skin and lungs.
Most of the e-liquids also contained ‘2-aminooctanoic acid’, which is an amino acid found in the biological products of mammals, including faeces, urine and blood. Its presence was potentially a result of contamination with one of these substances during the manufacturing or packaging processes.
Our findings prompted us to expand on our previous study.
This time we analysed 65 Australian e-liquids, including using a method aimed at better understanding how heating the e-liquids for vaping might change their chemical components.
This was the most expansive analysis of Australian e-liquids to date, and was led by Curtin University and the Wal-yan Respiratory Research Centre, in conjunction with Lung Foundation Australia, the Minderoo Foundation and Cancer Council Western Australia.
All of the e-liquids we studied were purchased online or from brick-and-mortar stores across Australia. All were advertised as being ‘best-sellers’, Australian made and nicotine free, so it’s likely they’re representative of what many Australian vapers might be using.
None of the e-liquids were labelled with a comprehensive ingredient list, so it’s impossible for users to know what chemicals they’re inhaling. It also means all the e-liquids we tested wouldn’t be compliant with European Unionlabelling regulations.
What else did we find?
Many of the flavouring chemicals we detected are “generally regarded as safe” by the United States Food and Drug Administration (FDA) when used in foods and drinks. But there’s a big difference between a chemical that’s safe to ingest and one which is safe to inhale long-term.
We also detected nicotine in some e-liquids. However, it was found much less frequently and at much lower concentrations than in our previous study. This may be indicative of a cleaner manufacturing process.
We only tested for ‘freebase’ nicotine, which is typically used in both conventional cigarettes and nicotine replacement therapies. So, the e-liquids may have contained a different type of nicotine, called nicotine salts, which are much more commonly used now than they were a few years ago.
We also found 2-chlorophenol again, although it was only in about half of the e-liquids tested. Regardless, the contamination of e-liquids with this known toxic chemical, which has no valid reason for being present, remains a significant problem.
A range of other chemicals of concern were commonly detected, including benzaldehyde, trans-cinnamaldehyde and menthol. These chemicals are added for their almond, cinnamon and mint flavours, respectively.
Benzaldehyde was found in every e-liquid except four, while menthol and trans-cinnamaldehyde were found in about three-quarters of the e-liquids. The presence of these chemical flavourings was concerning for a number of reasons.
Firstly, they’re all known to alter the effects of nicotine. Menthol makes nicotine more addictive.
Benzaldehyde and trans-cinnamaldehyde are known to inhibit an enzyme called ‘CYP2A6’. CYP2A6 is responsible for metabolising and detoxifying many drugs humans are exposed to, including nicotine.
When its function is impaired by these flavouring chemicals, it means a vaper using e-liquids containing nicotine is going to have nicotine in their body for a longer period of time before it’s processed by the body.
Benzaldehyde is also a respiratory irritant and can reduce a person’s ability to fight off lung infections. Trans-cinnamaldehyde has even more severe effects on the immune cells in the lung.
Both of these chemicals are now included on the TGA’s list of prohibited e-liquid ingredients, meaning they’re banned in Australian e-liquids. Menthol isn’t banned by the TGA, but it’s prohibited in tobacco cigarettes in some countries. In this study, the e-liquids were analysed before the ban came into force.
This research clearly shows Australian e-liquids contain a range of chemicals that are either known to negatively impact health, or for which the potential health impacts of inhalation exposure are unknown.
A lot more research is needed in this space before informed decisions on both nicotine free and nicotine e-cigarette usage can be made, and to better understand how vaping impacts our health.
Alexander Larcombe is Head of Respiratory Environmental Health at the Telethon Kids Institute and an Associate Professor in the School of Population Health at Curtin University. He acknowledges acknowledge Professor Ben Mullins and Dr Sebastien Allard of Curtin University, who were co-leads on this research project.
Disclosure statement: For this study Alexander Larcombe, Ben Mullins and Sebastien Allard received funding from Lung Foundation Australia, Minderoo Foundation and Cancer Council WA. Alexander Larcombe is affiliated with ACOSH – the Australian Council on Smoking and Health.
This article is republished from The Conversation under a Creative Commons licence. See the link to the original article below.
Chemical analysis of fresh and aged Australian e‐cigarette liquids
Alexander Larcombe, Sebastien Allard, Paul Pringle, Ryan Mead‐Hunter, Natalie Anderson and Benjamin Mullins
Published online in The Medical Journal of Australia on 11 October 2021
Abstract
Objectives
To assess the chemical composition of electronic cigarette liquids (e‐liquids) sold in Australia, in both their fresh and aged forms.
Design, setting
Gas chromatography–mass spectrometry analysis of commercial e‐liquids sold in Australia (online and physical stores).
Main outcome measures
Chemical composition of 65 Australian e‐liquids – excipients/solvents, flavouring chemicals, other known e‐liquid constituents (including nicotine), and polycyclic aromatic hydrocarbons – before and after an accelerated ageing process that simulated the effects of vaping.
Results
The measured levels of propylene glycol and glycerol often diverged from those recorded on the e‐liquid label. All e‐liquids contained one or more potentially harmful chemicals, including benzaldehyde, menthol, trans‐cinnamaldehyde, and polycyclic aromatic hydrocarbons. Nicotine or nicotyrine were detected in a small proportion of e‐liquids at extremely low concentrations.
Conclusions
Australian e‐liquids contain a wide variety of chemicals for which information on inhalation toxicity is not available. Further analyses are required to assess the potential long term effects of e‐cigarette use on health.
See also in the MedicalBrief archives
FDA approvals of e-cigarettes must be based on evidence, not politics
E-cigarettes: Misconceptions may prevent people from quitting smoking
E-cigarettes more helpful than nicotine replacement treatments for smokers
E-cigarettes: What we know and what we don’t – Cancer Research UK
WHO versus Public Health England over e-cigarettes