Posted on April 18, 2022 By Colin
It is difficult to have a balanced scientific debate on tobacco harm reduction in Australia. Pro-vaping views are often rejected by Australian medical journals.
Responsible scientific journals should present both sides of an issue to allow a proper discussion
A recent article published in the Australian and New Zealand Journal of Public Health on how to manage tobacco dependence in Australia totally omitted any role for tobacco harm reduction. I wrote a letter to the editor arguing that THR should be included in the national approach. The letter was rejected.
Rejection was based on the comments of two reviewers who were clearly opposed to vaping and were not well informed. The arguments raised by the reviewers were not evidence-based. There were factual errors, unsubstantiated claims and selective use of data. The comments showed a lack of understanding of tobacco harm reduction.
They claimed that
I wrote a further response to the journal challenging all the claims made by the reviewers. The submission was signed and endorsed by 20 other leading Australian experts. To the journal’s credit, the letter was immediately accepted without any changes.
However, other Australian medical journals have not been so willing to present both sides of the vaping debate. A previous letter I wrote to the Medical Journal of Australia was rejected without peer review.
My letter to the ANZJPH was published today and is available here and is pasted below:
Colin P. Mendelsohn
Buchanan et al. are quite right to lament the lack of recent progress in tobacco control in Australia and the continuing high smoking rate, particularly in disadvantaged communities. (1) Traditional strategies have been successful in the past but are having a diminishing effect and the rate of decline has slowed in recent years. Easier access to new and effective strategies for adult smokers such as vaping nicotine are urgently needed.
Tobacco harm reduction is an integral part of Australia’s stated tobacco control policy and is one of the three pillars of the National Tobacco Strategy. (2) Australia also has a legal obligation to implement tobacco harm reduction as a signatory of the Framework Convention on Tobacco Control, under article 1(d).3 However, tobacco harm reduction is mostly neglected in practice and policy.
As the authors note, vaping nicotine is now acknowledged by the Royal Australian College of General Practitioners as a valid second-line treatment for smokers who are not able to quit with other methods. (4) The federal government has recently approved the sale of nicotine e-liquids from Australian pharmacies and new minimum standards now apply for quality and safety. (5)
Many smokers are simply not able to quit with conventional treatments and will continue to smoke. Pharmacotherapies have quit rates of only 6–15% at 6–12 months. (6) The 2019 National Drug Strategy Household Survey found that there was no significant decline in smoking rates among smokers over the age of forty from 2016–2019 and these smokers remain at substantial and imminent risk of smoking-related illness and death. Vaping is not a ‘magic bullet’ but provides another option which could help some of these smokers.
Vaping is a more effective quitting aid than nicotine replacement therapy (7) and is the most popular aid for quitting and reducing smoking in Australia. (8) In 2019, it was used by 22% of smokers. Nicotine replacement therapy was used by 16.8% of smokers, 6.3% used stop-smoking tablets and 1.8% contacted the Quitline. (8)
The combination of effectiveness and the wider reach of vaping nicotine could lead to a substantial public health benefit.
The authors are concerned about ongoing nicotine dependence in long-term vapers. However long-term vaping is significantly less harmful than continuing to smoke. The UK Royal College of Physicians has concluded that “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”. (9) Dependence on vaping nicotine is also significantly less than for smoking and many long-term vapers will go on to quitting vaping altogether.10 Taxation, smoke-free laws, plain packaging and marketing bans have been optimised. GPs are not engaged and Quitline remains underutilised. Mass media campaigns have not been funded since 2012 due to fiscal constraints.
On the other hand, vaping involves no public expenditure or investment and is immediately available. All costs are paid by the user. In other countries where vaping nicotine is widely available, the decline in smoking rates has accelerated. In recent years, the smoking rate has declined three times faster in the UK (0.9% per year) and two times faster in the US (0.57% per year) compared to Australia (0.27% per year). (11) It is highly likely that vaping has been a contributor to this rapid decline. (12)
It is very likely that vaping nicotine could play a significant role in kick-starting a decline in smoking in Australia. It should be implemented urgently as a key component of Australia’s tobacco control strategy.
1. Buchanan T, White SL, Marshall H, Carson-Chahhoud KV, Magee CA, Kelly PJ. Time to rethink tobacco
dependence treatment in Australia. Aust N Z J Public Health. 2021;45(6):538-40.
2. Intergovernmental Committee on Drugs. National Tobacco Strategy 2012-2018 [Internet]. Canberra (AUST):
Australian Government Department of Health; 2017 [cited 2020 Jan 16]. Available from: https://www.health.
3. World Health Organisation. WHO Framework Convention on Tobacco Control (FCTC). Geneva (CHE):
4. Royal Australian College of General Practitioners. Supporting Smoking Cessation: A Guide for Health
Professionals. Melbourne (AUST): RACGP; 2020.
5. Australian Government Department of Health (Cth), F2021L00595 - Therapeutic Goods (Standard for Nicotine
Vaping Products) (TGO110) Order 2021(13 May 20210).
6. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: An overview and network meta-analysis. Cochrane Database Syst Rev. 2013;5:CD009329
7. Hartmann-Boyce J, McRobbie H, Lindson N, Bullen C, Begh R, Theodoulou A, et al. Electronic cigarettes
for smoking cessation. Cochrane Database Syst Rev. 2021;4:CD010216
8. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019 [Internet]. Canberra (AUST): AIHW; 2020 [cited 2020 Jul]. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/ contents/summary
9. Royal College of Physicians. Nicotine Without Smoke: Tobacco Harm Reduction [Internet]. London (UK): RCP; 2016 [cited 2021 Jul]. Available from: https://www. rcplondon.ac.uk/projects/outputs/nicotine-without-smoke- tobacco-harm-reduction-0
10. Shiffman S, Sembower MA. Dependence on e-cigarettes and cigarettes in a cross-sectional study of US adults. Addiction. 2020;115(10):1924-31.
11. Britton J. Electronic cigarettes and the precautionary principle. BMJ Opinion [Internet]. 2019 [cited 2021
Sep]. Available from: https://blogs.bmj.com/bmj/2019/09/20/john-britton-electronic-cigarettes-and-
12. Royal College of Physicians. Smoking and Health 2021: A Coming of Age for Tobacco Control? London (UK): RCP; 2021.