I HAVE TODAY launched ‘Dr Col’s Vape Truths’, an evidenced-based video campaign on nicotine vaping, designed to combat the rampant misinformation being provided by state health departments, particularly Queensland Health.

New South Wales and Western Australia are also running a vaping disinformation campaign called Do You Know What You Are Vaping? I have discussed this campaign in a previous blog here.

These campaigns are alarmist and untruthful and will only discourage adult smokers from switching to less harmful alternatives to deadly cigarettes.

Dr Col’s Vape Truths’ campaign consists of eight short videos correcting common misconceptions about vaping and is based on eight misleading and alarmist videos by Queensland Health. The videos cover the following key evidence:

1 Vapour is far less toxic than cigarette smoke.

2 Vaping significantly reduces the risk of cancer relative to smoking.

3 Vaping nicotine does not cause serious harm to the lungs.

4 Vapes incorrectly labelled as nicotine-free are dodgy disposable products sold on the black market, not from reputable businesses.

5 There has never been a single death caused by vaping nicotine.

6 When smokers switch to vaping, their breathing improves substantially.

7 Vaping is not completely risk-free but is substantially safer than deadly cigarettes.

8 Most of the chemicals in vapour are present at very low doses and most cause little or no harm.

Queensland Health makes the absurd and dishonest claim that vaping is more harmful than smoking when all credible health authorities agree that smoking is far more dangerous

Young people will see through the mistruths being targeted at them. Young people today have access to unlimited information through the internet. Lies from government organisations will lead to a loss of trust in important public health messages in the future. Some will rebel and try vaping because they are being told not to.

Adult smokers require accurate information to help them quit deadly cigarettes and vaping is the most effective quitting method available

Current state government education campaigns are providing wildly misleading information.

It is unacceptable for health authorities to provide untruthful information to the public and it will lead to more smoking-related deaths and illness

Dr Col’s Vape Truths are designed to help adult smokers get the facts on vaping so they can make informed decisions about switching.

I will also post the videos on social media over the next two weeks. Please share them freely.

Dr Col’s Vape Truths campaign website

A RECENT OPINION PIECE in The Examiner newspaper by two Tasmanian vaping opponents Dr Sukhwinder Sohal and Dr Kathryn Barnsley has sunk to a new level of misinformation and scaremongering. The Examiner has not responded to my request to correct the errors in the article, so they are published here.

Vaping risks exaggerated

Sohal and Barnsley greatly exaggerate the risks of vaping nicotine. All credible experts agree that vaping is a far safer alternative to smokers who are unable to quit and any risk must be compared to the harm from continuing to smoke.

The assertion that “e-cigarettes will likely cause head, neck and oral cancers, cardiovascular disease and strokes” is totally without evidence

The risk of cancer from vaping has been estimated to be less than 0.5% of the risk from smoking. There is no convincing evidence that vaping causes cardiovascular disease or stroke. In fact, studies have shown that when smokers switch to vaping their cardiovascular health and blood pressure improve.

The authors stoke anxiety by saying “there are many things we don’t know about the health effects of e-cigarettes”. While we don’t know everything, we do know a lot after 15 years of research and experience.

Leading health bodies agree that vaping is far safer than smoking because of the dramatic reduction in the number and dose of toxins compared to smoke. The UK Royal College of Physicians has concluded that long-term vaping is likely to be no more than 5% of the risk of smoking.

The authors also claim that “e-cigarettes are likely to exacerbate COVID-19 symptoms”. This is based on speculation from a laboratory test in smokers. However, in the real world, studies have not found any association between the use of e-cigarettes and the risk of COVID-19. Furthermore, hundreds of studies have now found that current smokers are at reduced risk of COVID-19 infection.

Vapes help smokers quit

Sohal and Barnsley falsely claim that “the evidence on successful quitting using e-cigarettes is very thin”. In fact,

there is now good evidence from clinical trials and real-world experience that vaping is at least 50-100% more effective than nicotine replacement therapy (patches and gum)

A recent analysis of 171 trials of all smoking cessation by the UK National Institute for Health Research found that vaping was the single most effective of all smoking cessation medications.

Evidence from randomised controlled trials is supported by observational studies, population studies and the rapid decline in smoking rates where vaping rates are high.

Vaping benefits public health

The authors claim that “numerous researchers agree that the development of electronic cigarette-related illnesses will outweigh any short-term benefits”. This claim is clearly wrong.

Multiple modelling studies have calculated the risks and benefits of vaping and concluded that the overall benefits are considerably greater than the harms and are likely to improve public health

One study estimated that under current patterns of vaping in the United States, nicotine vaping will translate into 1.8 million premature smoking and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060.

Compare vaping to smoking

Sohal and Barnsley state the obvious, that “lungs are designed for air”. Of course this is true and it is best not to smoke or vape. However, smokers are exposed to a poisonous mix of 7,000 toxins and carcinogens in high doses. Around 200 different chemicals have been found in vapour, mostly in trace or very low doses.

Any risk for smokers should be compared to the far more harmful alternative, continuing to smoke

The black market

The authors claim that “it is almost certainly the [tobacco] industry which is fuelling the black market”. This is patently false. The black market for vaping products is entirely comprised of cheap, unregulated Chinese imports, typically iGet, HQD and Gunpod. No vapes made by Big Tobacco are sold on the black market in Australia.

The black market has flourished because of the flawed prescription-only model for nicotine vaping. Getting a nicotine prescription and importing supplies from overseas is complex and simply too hard for many adult smokers. The black market has filled the gap and also happily sells illegal vaping products to children.

Smokers need to know the facts about vaping to make an informed choice about trying it. Vaping is far safer than smoking and is probably the most effective quitting aid available. Misinformation which discourages smokers from switching to vaping supports the cigarette trade and will result in more deaths and illness.

Another scathing review

Chris Snowdon has written a withering review of the Sohal and Barnsley article here
Delusional anti-vaping ignoramuses

 

THE REVIEW OF VAPING by Banks and colleagues commissioned by the Australian Department of Health is flawed and misleading according to an analysis by four leading Australian academics, published today in Drug and Alcohol Review.

The review from the Australian National University omitted important information, made critical scientific flaws and did not achieve its objective of providing an accurate analysis of the available scientific information.

The analysis concluded that the Banks review is not suitable for guiding Australian policy on vaping.

Vaping and smoking cessation

The review states that there is limited evidence that vaping is more effective than nicotine replacement therapies (NRTs)  i.e. nicotine patch and gum etc.

In reaching this conclusion, it undervalued the findings of randomised controlled trials (RCTs) which are the gold standard for determining that a treatment is effective.

RCTs have shown that vaping is 50-100% more effective than NRT

Furthermore, it disregarded supportive evidence from observational studies, population studies and declines in national smoking rates.

‘Triangulation’ of all types of data provides a more accurate picture than relying on RCTs alone and increases confidence that vaping is an effective quitting aid.

Surveys in Australia, the United States and the UK have found that smokers who used a vaping device were significantly more likely to quit than those who did not vape. Those who vape daily are two to eight times more likely to quit smoking than smokers who do not vape.

Accelerated declines in adult smoking rates have been seen in the UK and United States where vaping rates are much higher than in Australia.

Vaping as a gateway to smoking

The Banks review claims that ‘there is strong evidence that e-cigarettes increase combustible smoking uptake in non-smokers, particularly youth’.

However, in making this claim they make the fundamental error of confusing evidence of association for causation

Just because young people who try vaping are more likely to later try smoking does not prove that vaping caused the smoking. The most likely explanation is that young people who experiment with vaping are simply more prone to also take other risks, such as smoking, binge drinking and using illicit drugs.

Numerous studies have found that vaping more likely diverts young people from smoking than encourages them to smoke. Declines in youth and young adult smoking rates in the United States accelerated from around the time vaping became popular (graph below). This finding is the opposite of that predicted by the gateway hypothesis.

Accelerated decline in youth smoking in the United States
as vaping rates increased

Comparative harms of vaping and smoking

The Banks review does not address the critical issue of relative risk. Any meaningful assessment of the risk from vaping nicotine should compare it to the enormously greater risk of continuing to smoke tobacco. The vast majority of frequent vapers are former smokers who have been unable to quit using other methods and would otherwise be smoking.

The review focusses only on the small and theoretical harms of vaping. While vaping is not risk-free, studies have shown that any harm is dramatically less than smoking.

Smokers who switch to vaping dramatically reduce their exposure to toxins, have reduced biomarkers (toxins in the body), reduced cancer risk and experience substantial health improvement

The review also incorrectly claims that vaping nicotine causes EVALI, a serious lung disease from vaping black-market cannabis oils contaminated with Vitamin E Acetate. No case of EVALI has been shown to be caused by nicotine vaping and no causal agent has been identified.

Net public health effects of vaping

The review ignored the key public health question: is the net effect of vaping beneficial or harmful at a population level?

Vaping is the most popular quitting aid in Australia and is arguably the most effective single therapy for quitting.

Numerous modelling studies have concluded that the overall benefits of vaping are considerably greater than the harms and are likely to improve public health

Conclusion

The Banks review is flawed and should not be used to guide Australian policy on vaping.

Contrary to its findings, the evidence suggests that vaping nicotine is an effective smoking cessation aid; that vaping is substantially less harmful than smoking tobacco; that vaping is diverting young people away from smoking; and that vaping by smokers is likely to have a major net public health benefit if widely available to adult Australian smokers.

References

Mendelsohn CP, Wodak A, Hall W, Borland R. A critical analysis of ‘Ecigs and health outcomes – systematic review of global evidence’. Drug and Alcohol Review 22 July 2022

Banks E et al. Electronic cigarettes and health outcomes: systematic review of global evidence. A report for the Australian Department of Health. April 2022

THIS ARTICLE WAS WRITTEN for NSW Users and AIDS Association (NUAA) User News. It provides simple advice for smokers who want to start legally vaping legally but don’t know how.

[Also available at NUAA User News July 2022]

Dr Colin Mendelsohn works exclusively with smokers to help them quit. Colin uses evidence-based treatments including vaping nicotine when appropriate.

Colin has worked in tobacco treatment for 40 years as a doctor (general practitioner) and academic. He is on the committee that develops Australia’s national smoking guidelines and is the Founding Chairman of the Australian Tobacco Harm Reduction Association, a health promotion charity formed to raise awareness of safer alternatives to smoking. Colin is actively involved in teaching health professionals about smoking, writing articles in peer-reviewed journals, research and advocacy for tobacco harm reduction. He is the author of the recently published book Stop Smoking Start Vaping.

Users News interviewed Colin and got so much good stuff we couldn’t fit it all into one piece.

Part 1 (this article) is for people who want to start legally vaping nicotine but don’t know how.

Part 2 will be out soon and will be for people who want to understand more about the controversies around vaping. If you aren’t sure if vaping is a good idea, this article is for you. It talks about the evidence and the politics. It is full of myth busting.

UN: Why vape nicotine?

CM: Over 21,000 tobacco smokers die prematurely each year in Australia — it is the leading preventable cause of death. 2 out 3 smokers die prematurely and lose an average of 10 years of life.

Most smokers want to quit, but most fail repeatedly even with the best first-line treatments in Australia: varenicline (Champix), nicotine replacement therapy (patches, gum, lozenges, mouth spray, inhalator) and bupropion (Zyban).

Vaping nicotine is now the most popular quitting aid in Australia and is also the most effective. The UK National Institute for Health Research did an analysis of 171 randomised controlled studies of all medications used to stop smoking and they found that vaping nicotine was the most effective single treatment.

In Australia, vaping is a legitimate second-line quitting aid when other first-line therapies have failed.

UN: Why get prescribed nicotine instead of buying from the illicit market?

CM: The illicit market has thrived because the legal pathway is complex, difficult and expensive. Illicit vapes and nicotine e-juice are smuggled into Australia from China and are unregulated. We don’t know what is in them and we don’t have any information about quality or safety. Using them is risky.

Legal nicotine products are less risky because they must meet the TGO 110 standards set by the Therapeutic Goods Administration (TGA). This includes regulation of ingredients, labelling and packaging.

From 1 October 2021, consumers require a prescription for all purchases of nicotine vaping products, such as nicotine e-cigarettes, nicotine pods and liquid nicotine. This includes purchases from Australian pharmacies and from overseas. It remains illegal for other Australian retailers, such as tobacconists, ‘vape’ shops and convenience stores, to sell you nicotine vaping products, even if you have a prescription.

All nicotine vaping products sold by Australian pharmacies must satisfy the minimum standards. The standards do not apply to nicotine-free liquids. If you import nicotine vapes from overseas under the TGA Personal Importation Scheme, the TGA encourages you to check if the product has compliant labelling and packaging. Products purchased from New Zealand are regulated and generally comply with Australian standards. (Editor: More information about the TGO 110 standards can be found in the resource list at the bottom of this page).

UN: How can I get started with vaping nicotine? How can I get my doctor to prescribe me legal nicotine? What conversation will make it happen? Do I need a special doctor? What if I’m not dependent on tobacco/nicotine already and just want to have some fun vaping?

CM: The first thing is to do your homework about vaping.

Your local vape shop is a good place to start. They’re usually staffed by former smokers who now vape. Vape shops are legal. They sell vape hardware and nicotine-free e-liquid, which you don’t need a prescription for. You need to be over 18.

E-liquid (also known as ‘e-juice’) is what goes in a vape or e-cigarette. E-liquids may contain nicotine, as well as propylene glycol, vegetable glycerin or glycerol, flavorings and, in some cases, water.

There are also lots of good online resources and forums for vapers (Editor: Check out the resources at the bottom of this page). You could also speak to vaping friends.

Even though vaping nicotine is far less harmful than smoking, Australian authorities don’t support vaping, so most doctors won’t prescribe nicotine, and most don’t know how to.

Vaping is approved as a second-line quitting aid when other methods have failed, so they might want you to try another quitting method first, such as patches.

Any doctor can prescribe nicotine if you want to import it.

Confusingly, you need a script from a doctor who is an “Authorised Prescriber” to purchase nicotine from an Australian pharmacy.

There is a list of doctors willing to prescribe nicotine on the ATHRA website (Editor: Check out the resources at the bottom of this page). Also, some doctors are approved but aren’t on the list. (I am not on the list because I want to focus on training more doctors rather than writing scripts).

Vaping nicotine is only approved for smokers as a quitting aid or for preventing relapse. Doctors are not supposed to prescribe it if you say it is for recreational use.

UN: Do you recommend any particular vape?

CM: There is an overwhelming range of vapes available and it can be very confusing for beginners.

Choosing a vape depends on your preference for ease-of-use and maintenance, size, cost and a number of other factors.

The image below explains the various types of vapes:

Source: Stop Smoking Start Vaping

For beginners, the most popular models are pod vapes. Pod devices have a detachable pod which contains the e-liquid and a rechargeable battery. Some models have sealed, prefilled pods, so you just throw the pod away when it is empty and replace it with a new one. Others have refillable pods which you can refill easily from a bottle of e-liquid. Generally, you charge the battery daily.

Disposable vapes are also popular. These are sealed units. Put the device in your mouth, puff it like a cigarette and throw it away when it stops working. They come in a range of sizes and flavours.

There are more complex devices which have more features and some vapers progress to these later.

Doctors aren’t allowed to say where to find the shops or the websites or where to buy the vapes or nicotine. But there are many reputable online shops based in NZ.

UN: How much does it cost to get a legal vape and nicotine? How does that compare to smoking costs?

CM: Vaping is 5%-25% of the cost of smoking, depending on the type of device you use. A pack-a-day smoker (20 cigarettes) spends about $12,500 per year. Vaping typically costs $500-$3,000 per year.

Pod vapes cost $30-$40. Prefilled replacement pods cost $7-$11 depending on the brand and each pod is equivalent to about a packet of cigarettes. Refillable pod vapes require nicotine e-liquid, which is about $30 for a 30mL bottle (1-2 weeks supply on average).

Disposables range from $15-$35 depending on the size (up to 5,500 puffs) and brand.

UN: If I get a script, who will fill it? Will any pharmacy do it? Or can I order what I want online from Australia or internationally?

CM: Most vapers order nicotine e-liquids online from New Zealand websites and there are many reputable suppliers. When you place your order, you simply upload the script from your doctor and it is returned with your order to prove the importation is legal.

You can also buy nicotine e-liquid from selected Australian physical or online pharmacies. The number of pharmacy suppliers is currently small but is rapidly increasing. Some pharmacies sell pod vapes (with prefilled nicotine), disposable vapes (with prefilled nicotine), and nicotine liquid (for refillable vapes), but they don’t sell the refillable vapes (though you can get them from vape shops).

UN: I hear a lot of people are starting to use vapourisers for cannabis herb… is it safe to vape tobacco herb too?

CM: It is much safer to vape cannabis than to smoke it. Vaping heats the herb without combustion and avoids most of the deadly chemicals caused from burning organic matter. Cannabis vapes and nicotine vapes are usually not interchangeable. (Editor: Check out Dr Liam’s guide to vaping cannabis resource below).

UN: I hear a lot of people say they like vaping but that it doesn’t replace the feel of a cigarette or a cannabis & tobacco joint… how can they get a similar feel? I’ve heard of a thing called snus… I also have a friend who loves using a nicotine vape in one hand and a cannabis vape in the other and inhaling on them both at the same time – is this something you recommend? (And is this something you’ve heard of before? … Because he insists he’s the first person in the world to have this idea!)

CM: Smoking is very ritualized, and many people become attached to the habit of removing the cellophane, flicking open the box, lighting the cigarette etc. This behaviour is associated with the pleasure of smoking and is a conditioned response which diminishes over time after quitting.

Most established vapers say they enjoy vaping more than smoking. But it can take time to adjust.

Nicotine is an ‘alkaloid’. There are other alkaloids in smoke which some smokers miss when they switch to vaping. You can get these alkaloids from snus. Snus (or snuff) is a moist, tobacco product that comes in a small pouch. Snus is placed under the upper lip. Snus provides nicotine levels similar to smoking but also releases other alkaloids. Some vapers find the combination of vaping and snus more satisfying.

Snus can’t be sold legally in Australia but you can import 1.5kg without a prescription (you just need to declare it to customs). Customs will hold it and send you a letter and then you pay the import tax ($1.60 per 1 gram).

People often have to go on a journey to find the right vape and e-liquid. Some people prefer the flavor of heated tobacco products.

I’ve never heard of vaping cannabis and nicotine at the same time, but there is no reason why it should not work.

UN: What is your best advice on how to stop smoking tobacco / cigarettes?

CM: The Australian guidelines advise smokers to use first-line medication combined with counselling from a health professional. The first-line medications are:

Though it is unapproved, vaping is the most effective single therapy, however the most effective overall therapy is varenicline plus a nicotine patch.

However, most smokers have tried these products unsuccessfully. The next option for them is to try vaping nicotine, preferably with some expert counselling.

UN: What is your best advice for someone who wants to stop vaping nicotine?

CM: There is very little evidence on the best way to stop vaping, but it is much easier to quit vaping than smoking. The usual advice is to gradually reduce the nicotine concentration and frequency of puffs. You can also use nicotine patches, gum or lozenges to supply nicotine while you wean off the smoking/vaping behaviour.

UN: Can you vape if you’re pregnant?

CM: Although it is not risk-free, vaping has a role as a substitute for pregnant women who are otherwise unable to quit smoking. A recent study of 1140 pregnant smokers found that vaping was nearly twice as effective as nicotine patches in helping pregnant women to quit smoking and was just as safe. In fact, babies of vaping mothers were less likely to be low birthweight than those using NRT. Low birthweight is associated with higher risk of neonatal death and poorer health outcomes in the child.

Vaping should not be used by pregnant women who do not smoke.

UN: Is it bad to vape around your kids?

CM: Unlike secondhand smoke, there is no evidence so far that secondhand vapour is harmful. However, it is best to avoid vaping around children to reduce any exposure and to avoid modelling a behaviour that may look like smoking.

UN: How can readers learn more about your work and this area?

CM: It is hard to get accurate information about vaping as Australian health authorities are opposed and media reports are generally unreliable. Most Australians are seriously misinformed about vaping, even doctors.

I have written a book about vaping called Stop Smoking Start Vaping, which dispels the myths about vaping and outlines the evidence in an easy-to-read style. It provides step-by-step advice on how to make the switch from smoking tobacco, and why vaping is controversial. It is available as a paperback and e-book. More information is available here.

I also have a list of FAQs on my website and regular blogs on current vaping issues. My published peer-reviewed articles are available here.

Links to other resources:

A NEW STUDY published in the Medical Journal of Australia has found Indigenous people in the Northern Territory have a life expectancy 15 years less than the general population, with the gap unlikely to be eliminated for a further 60 years.

[Published in the Alice Spring News 9 July 2022]

The leading cause of this health gap is smoking and urgent action is needed to address this glaring inequality.

The smoking rate of Indigenous Australian adults is three times higher than non-Indigenous people. In 2019, 43.4% of Indigenous adults smoked, compared to 15% of non-Indigenous adults

The gap between Indigenous and non-Indigenous smoking rates has not reduced since 1995 despite the Closing the Gap program and hundreds of mill ions of dollars spent on ineffective strategies, not to mention Australia now commanding the highest cigarette prices in the world.

These eye-watering prices are a major source of financial hardship and poverty for Indigenous smokers as it leads to compromises in diet, clothing, accommodation, and other basic necessities.

But the Australian government continues to deny Indigenous people – like all Australian smokers – easy legal access to the most effective quitting aid, vaping nicotine.

Vaping is twice as effective as a quitting aid as nicotine replacement therapies such as nicotine patches and gum and is at least 95% safer than smoking, according to the UK Royal College of Physicians.

It is no surprise that vaping is the most popular quitting aid in countries where it is available.

The opportunity for vaping to reduce Indigenous smoking was demonstrated recently by its impact on Maori smoking in New Zealand where legislation to legalise vaping was passed in August 2020.

Maori daily smoking rates subsequently fell by an unprecedented 22% in 12 months from 2020 to 2021, according to the Annual New Zealand Health Survey.

This fall in smoking rates was almost certainly due to a corresponding uptake of vaping by Maori smokers.

Maori smokers have embraced vaping as a safer alternative to deadly cigarettes and have an adult daily vaping rate considerably higher than the general population : 15.3% compared to a national average of 5.8% [New Zealand Health Survey 2020-21]

Similar reductions in Indigenous smoking could be expected in Australia if vaping was more readily available.

However, restricted access to nicotine vaping products in Australia makes it almost impossible for disadvantaged people to obtain nicotine supplies legally. Australia is the only western democracy to ban the sale and use of nicotine for vaping without a prescription.

Although vaping is an approved and legitimate quitting aid in Australia, very few doctors are trained in vaping or in prescribing nicotine.

Another barrier is the need to order nicotine online and import it from overseas websites; a challenging process for vulnerable and disadvantaged smokers.

As a result, it is perversely much harder to purchase far safer vape products than deadly cigarettes. Instead, under the current regulations, many vapers are forced to access dodgy supplies from a thriving black market which offers no consumer protection and sells freely to young people.

Beyond its substantial health benefits, vaping would also have a huge financial benefit for disadvantaged Indigenous smokers. Vaping is about 10% of the cost of smoking, leaving thousands of crucial extra dol lars every year for the family budget.

If the Australian government is serious about reducing Indigenous smoking, vaping regulations must be urgently changed and brought into line with other western countries

Regulated vaping products are lifesaving and should be readily available from licensed premises for adult smokers as consumer products to help them quit smoking. Access should be restricted for young people, as with other adult products.

Simple regulatory changes would lead to substantial improvements in the health and financial inequalities currently experienced by Indigenous Territorians.

It is the right thing to do.

Dr Colin Mendelsohn MB BS (Hons)
Double Bay NSW

BELGIAN’S SUPERIOR HEALTH COUNCIL has delivered a comprehensive report in favour of vaping which is in stark contrast to the advice of Australia’s National Health and Medical Research Council. It supports vaping as a safer alternative to smoking or as a quitting aid which can lead to a significant reduction in health risks.

The Council prepares scientific advisory reports to guide Belgian political decision-makers and health professionals. The report took two years to prepare and was a consensus document prepared by a wide range of experts with different views.

The key message of the report is

The relative risk of the e-cigarette compared to smoking is clear: the e-cigarette is estimated to be substantially less harmful than smoking. It a better alternative than smoking and can be used as a smoking cessation aid

The report recognises a special role for vulnerable populations, such as those with mental illness, low income groups and prisoners.

Based on  the current state of knowledge, the report concludes

The exclusive use of e-cigarettes by (ex-)smokers, provided that they actually stop smoking, could lead to a significant reduction in health risks

The report also states that vaping is not risk-free and is therefore not recommended for non-smokers, especially the young. Further long-term safety data are needed.

Wisely, the guidelines advise risk-proportionate regulation of vaping. Vaping is much less harmful than smoking and should be regulated much more lightly in line with the lower risk.

While restrictions on vaping are prudent it warns that “limiting vaping and other nicotine use does not jeopardize the goal of reducing the prevalence of smoking.”

Education of smokers of the benefits of vaping is recommended. As in Australia, Belgian smokers have exaggerated perceptions about the risks of vaping.

Flawed Australian guidelines

The report’s conclusions are in stark contrast to those of Australia’s peak medical organisation, the National Health and Medical Research Council. The NHMRC examined the same evidence and has taken an overly cautious and hostile position.

The agenda and independence of the NHMRC has been called into question by its own findings which do not reflect the scientific evidence.

Report

Electronic cigarettes: Evolution. Belgian SHC, June 2022 (French and Dutch)

Translated into English by Google here.

A ROBUST STUDY of the vapour from a leading commercial nicotine vaping product has provided very reassuring safety data. The analysis of the Relx podvape found that 40 of the most harmful chemicals in cigarette smoke are undetectable or are at non-harmful levels in the vapour produced.

The study tested the five main categories of toxins in smoke identified by the US FDA as harmful to health. The findings were compared to a standard cigarette.

The main toxin categories in smoke are aldehydes and ketones (carbonyls), volatile organic compounds (VOCs), tobacco-specific nitrosamines (TSNAs), polycyclic aromatic hydrocarbons (PAHs), and heavy metals.

All the chemicals were undetectable or were at very low levels in the vapour but were very high in tobacco smoke

 

Further testing of the e-liquids in this study found no evidence of cytotoxicity (ability to kill cells) and mutagenicity (changes leading to cancer).

The study was funded by the Science Fund of Relx, peer-reviewed and published in the international Drug Testing and Analysis journal. It is good to see manufacturers doing robust research to study the safety credentials of their products and submitting it for independent scientific review.

Advice for the NHMRC

One of the fundamental principles of toxicology is that harm depends on the dose of a chemical, ie ‘the dose makes the poison’.  There are low doses of chemicals everywhere in the environment, including arsenic in tap water and nineteen known carcinogens in coffee. The important question is whether the dose is sufficient to cause a risk to health.

In this and in most other vaping studies, the dose of toxins does not exceed accepted safety limits, such as those set for occupational or environmental standards and is much lower than in cigarette smoke, supporting the claim that vaping is much less harmful than smoking.

Australia’s peak medical body, the National Health and Research Council recently breathlessly announced that up to 200 chemicals have been detected in e-cigarette vapour. However, the mere presence of chemicals is meaningless without information on the dose involved.

This scaremongering by the NHMRC is very misleading

There is no place for misinformation in public health and the NHMRC should know better.

Study

Xu T. et al. Chemical analysis of selected harmful and potentially harmful constituents and in vitro toxicological evaluation of leading flavoured e-cigarette aerosols in the Chinese market. Drug Testing and Analysis. 2022

THE NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL, Australia’s peak medical body has released its latest guidelines on vaping. However, the guidelines are alarmist, seriously flawed, do not reflect the latest evidence on vaping and will harm public health.

Some of the key flaws in the guidelines are outlined below.

Tobacco harm reduction

The review completely misunderstands the role of vaping nicotine for tobacco harm reduction. Vaping is a safer alternative for adult smokers who can’t quit with other methods. The key question is how vaping risks compare to smoking, and this was completely ignored.

The NHMRC focusses on the small and potential the risks of vapPreview Changes (opens in a new tab)ing but ignores the overwhelming evidence that it is far safer than smoking.

The review refers to up to 200 chemicals in vapour, but neglects to mention that smoke contains 7,000 toxic chemicals and carcinogens at far higher doses.

Concerns are raised about the potential impacts on cancer, CVD, respiratory, mental health risks from vaping. However, there is growing evidence that the risk of these conditions is dramatically reduced when smokers switch to vaping.

False claims

The review links nicotine vaping to EVALI, a serious lung disease caused by vaping black market cannabis oils contaminated with Vitamin E Acetate. EVALI is not caused by nicotine vaping.

There is also no scientific evidence that vaping causes seizures. Seizures are a late side effect of nicotine overdose but would present with critical warning signs long before a seizure occurs.

Incredibly the report implies that diacetyl from vaping can cause ‘popcorn lung’ when there has never been a case from vaping or smoking, ever.

Exaggeration of risks

Some potential risks of vaping are greatly exaggerated. The review emphasises nicotine poisoning. However, almost all cases of nicotine overdose result in vomiting and most cases are mild and quickly resolve. Four children have died from nicotine poisoning in the last 15 years globally. While tragic, we need to remember that 8 million smokers are killed by smoking every year.

There have been two known cases of death globally from explosions from vaping devices, although this is presented as a common risk.

The gateway theory

The review claims that taking up vaping leads people to smoking, when the evidence suggests the opposite.

The gateway theory has been debunked. Vaping more likely diverts young people away from smoking overall. Indeed, declines in youth and young adult smoking rates have accelerated from around the time vaping became popular in many countries. This population finding is the opposite of that predicted by the gateway theory,

Effectiveness as a quitting aid

It is simply incorrect that vaping is not a proven smoking cessation aid. It is well established that vaping is more effective than nicotine replacement therapy and is arguably the MOST effective quitting aid. (Thomas 2021)

The NHMRC encourages smokers to keep trying conventional treatments which have appalling quit rates. In clinical trials, only 6% of smokers using medication are still abstinent at 12 months. (Rosen 2019)

Dual use

The NHMRC falsely claims that most users become dual users of smoking and vaping. This is completely incorrect. Dual use is a transition stage for most vapers as they move towards exclusive vaping. In the UK and US, dual use rates are 33-36% and falling each year and millions of smokers have gone on to complete cessation of both.

Long-term safety

The NHMRC wants smokers to wait decades before switching to vaping. However, it is beyond reasonable doubt that vaping nicotine is far safer than smoking. The UK Royal College of Physicians and Public Health England estimate that it is at least 95% safer. Vapers are exposed to far fewer toxic chemicals after switching from smoking, have reduced toxins in their bodies (biomarkers) and have dramatic health improvements.

The impact of this flawed report

The NHMRC recommendations are irresponsible and deny the growing science that supports vaping. Unfortunately they will be referenced by anti-vaping groups and will guide Australian policy.

More smokers will be deterred from switching, some vapers may relapse to smoking and the cigarette trade will prosper. More people will die unnecessarily from smoking.

 

ABC News Radio | Interview with Colin Mendelsohn

Thu, 6/23 4:41PM • 8:34

TRANSCRIPT

Glen Bartholomew: Australia’s peak body for medical research says e-cigarettes are not a proven safe and effective way to quit smoking, and the growing use could actually lead to an increase in smoking rates. The National Health and Medical Research Council today released new data on the health impacts of vaping. Associate Professor Becky Freeman from the University of Sydney was a member of the expert committee that reviewed the evidence for the statement, and she told News Radio the council’s message is clear.

Becky Freeman: The key takeaway message that people need to focus on today is that e-cigarettes are not a safe product, that there is very limited evidence that they are helpful in helping people to quit, and that young people who use e-cigarettes are more likely to go on to smoke. If you use nicotine containing e-cigarettes, you’re likely to have throat irritation headaches, a cough, we don’t know a lot about is the long term health effects because I think a lot of people are really familiar with how deadly smoking is. We’ve been studying smoking for 50/60 years. And we have really solid data around cancer cardiovascular disease. And we don’t have long term high quality human studies for that for e-cigarettes. But we do know that users are exposed to hundreds of different chemicals and toxins that have the potential to cause adverse health effects if they use vaping products and e-cigarettes

Glen Bartholomew: Associate Professor Becky Freeman from the University of Sydney. Well, Dr. Colin Mendelsohn has worked in tobacco treatment for over 35 years and sits on the Royal Australian College of GPs expert committee that develops Australia’s national smoking cessation guidelines. Colin Mendelsohn, good afternoon.

Colin Mendelsohn: Good afternoon, Glen.

Glen Bartholomew: This advice states very clearly that the vapor from e-cigarette devices can be harmful and that there is limited advice that e-cigarettes are effective at helping smokers quit. Do you agree?

Colin Mendelsohn: Well, that is the position that the NHMRC is taking for some time. And this is the position of the Australian Government, although it’s very much at odds with many other organisations, including the New Zealand’s Ministry of Health and the UK Government, the Royal College of Physicians and many others. So yes, I have many concerns about some of the conclusions they’ve made.

Glen Bartholomew: How so?

Colin Mendelsohn: Well, the review completely misses the critical issue of the relative risk between vaping and smoking. So it’s all about can we find risks with vaping? Of course you can. Vaping is not completely safe. Nothing is. Everything has risks. But vaping is a tool to help adult smokers reduce their harm from smoking. It’s a harm reduction strategy. And the point is whether it’s safer to make the switch to vaping than continue to be a smoker, and there’s overwhelming scientific evidence that if you switch over to vaping, you’ll have substantial reduction in exposure to toxins, and significant health improvements.

Glen Bartholomew: The NHMRC says this is based on the most current advice on health impacts of e-cigarettes. It’s based on In Depth evidence reviews, the most up to date scientific research, and an extensive toxicology report. Tell us more specifically what your argument’s based on.

Colin Mendelsohn: Look, I think there are so many mistakes in this report to be frank. They say, for example, that vaping nicotine causes EVALI which was the serious lung disease in North America a couple of years ago. Look, we now know and it’s quite clear that EVALI was not caused by nicotine vaping but they conflate nicotine vaping with the causes of EVALI which was black market cannabis oils and we now know that. They say it causes seizures. There’s absolutely no evidence that vaping nicotine causes seizures. Yes, nicotine poisoning, in high doses, can lead eventually to seizures. But long before that you get very sick. So it’s not an effect of vaping. I mean, the actual, the evidence, the Royal College of Physicians, for example, in the UK, who have reviewed all the evidence on a number of occasions, vaping is at least 95% safer than smoking. Of course there are potential unknown risks. They always are with any new treatment. But when you look at the fact that a vaping product has maybe 100, 200 chemicals at very low doses, and a cigarette has chemicals, at least 7000 chemicals at high doses, it’s pretty obvious I think to most people, making the switch has got to be better for your health.

Glen Bartholomew: Better, I guess being perhaps the key wording relative. The NHMRC CEO Professor Anne Kelso says they know from data gathered nationally that the number of e-cigarette related calls to the Australian poisons Information Centers doubled between 2020 and 2021. Isn’t that a concern?

Colin Mendelsohn: It’s not really a concern in that the actual real number is actually very small. There were figures published from Western Australia yesterday and the number went up by four cases a year each year in the last few years. We’re talking about reports we’re not talking about poisoning, and most cases of nicotine ingestion result in vomiting and the outcome is mild and severe cases are actually very rare. There have been four children that have died in the world in the last 15 years from nicotine ingestion. One unfortunately in Australia. But I think that risk is exaggerated. I mean, many more people die from paracetamol and other household chemicals. And I think we need to keep it in perspective because smoking kills eight million people in the world each year. Yes, look, if there are risks, and there are small ones, I think we’ve got to weigh it up against a huge potential benefit to public health.

Glen Bartholomew: But isn’t it just as better to try and eliminate any of those potential adverse effects any way you can. I mean, the council says, as for smokers, the evidence remains unclear whether e-cigarettes help people quit. For example, it’s common for smokers to become dual users of both e-cigarettes and tobacco products, instead. It says there are many proven quitting aids to try before considering any cigarettes.

Colin Mendelsohn: I’ve been working in this field for nearly 40 years. And I can tell you that most people try repeatedly and fail with the approved medical treatments. Yes we have long term studies and the safety data, but the reality is, the vast majority of the time, they don’t work. What you then do with the people who have tried everything repeatedly and still can’t quit. That’s where vaping comes in. It’s an alternative for people who just can’t quit with other methods, which we know is much safer, which, for which there’s very good evidence of effectiveness. A Cochrane Review shows convincing evidence of effectiveness. We know in large population studies when vaping rates rise, smoking rates fall. The UK Government and New Zealand are very clear about vaping being a very effective treatment, if not the most effective treatment. But in Australia, unfortunately, we haven’t seen that.

Glen Bartholomew: The vaping is on the rise by about 2% on recent years. Beyond the debate about helping existing smokers quit, is the real concern the increasing uptake of the vaping habit by young people? Are we creating a new problem for a new generation? You can see that its use has never been more popular among kids and that the different flavors available serve to attract them to the product as well as its constant depiction from what I can see and things like television and movies.

 

Colin Mendelsohn: Yes, absolutely. There’s no question that vaping is not for kids. It’s like any other adult consumer product,

Glen Bartholomew: But you know, they’re using it in large numbers.

Colin Mendelsohn: They are. And the way to deal with that is to regulate it properly, like we do any other adult product. This black market, that’s arisen selling high nicotine disposable vapes to kids has arisen since the prescription model. So we made it so hard for people to get nicotine legally. The black market has got out of control and no one’s enforcing or policing it. So the Border Force isn’t stopping the container loads of black market products. No one’s stopping the tobacconists and convenience stores from selling these products. But what we need to do we regulate sales. So these products are sold with proper age verification in licensed outlets, age of sale is strictly policed, and the black market will just go away. But we’ve taken this prescription model which no one’s using, people do not get prescriptions. And it’s just too hard. So people just go to the corner store and buy the illicit products. And of course, the black market heavily sells to children. That model is just not working.

Glen Bartholomew: Can be hard to police either way, I suspect. Well, Australia’s Chief Medical Officer and Chief Health Officers from all states and territories say they support the NHMRC findings. They welcome the statement that will inform public health advice and policy decisions. So it sounds like they might be using it in determining their regulatory approach. Let’s see what if anything changes. Doctor, thanks for joining us.

Colin Mendelsohn: Thanks, Glen.

Glen Bartholomew: Colin Mendelssohn joining us there. He sits on the Royal Australian College of GPS expert committee that develops Australia’s national smoking cessation guidelines.

A COMPREHENSIVE REVIEW of youth vaping in the US has concluded that the harm from vaping is greatly exaggerated and that vaping is unlikely to be causing an increase in youth smoking.

The review by leading researcher Professor Riccardo Polosa and colleagues was published today in The Journal of Allergy and Clinical Immunology.

The review is a timely response to the regular alarmist media reports and government campaigns on vaping in Australia which have increased fears and misinformed the public.

There is a strong pattern of Australian media stories focussing on negative and sensational news about vaping and presenting one-sided views. Almost certainly, this positive review will get minimal or no media coverage.

Polosa is clear that vaping is a legitimate concern for young people. Young people should not vape, but many will do so despite what adults tell them, just as many binge drink, take illicit drugs and other risks. It is important that “authorities must enforce current regulations addressing illicit sales to minors”.

Key findings of the review are:

There is no teen vaping ‘epidemic’ in the US

Vaping rates rose substantially over the last decade but fell by 60% from 2019 to 2021 and vaping may be a passing fad, like fidget spinners. Most vaping is by young people who have previously smoked.

Most use by non-smokers is experimental and short-term and frequent use is rare

Only 3% of high school students who never smoked are vaping frequently (20 or more times per month).

Dramatic decline in youth smoking

At the same time that vaping has risen in popularity, high school cigarette smoking has declined dramatically and has almost been eliminated in the US. Smoking rates fell 77% from 8.3% in 2018 to 1.9% in 2021.

This suggests that vaping is highly unlikely to be increasing smoking uptake. It is much more likely that vaping is diverting young people away from smoking, helping some young smokers to quit and contributing to the rapid fall in youth smoking.

Minor health effects

The report reviews the science which shows that vaping is substantially less harmful to health compared to smoking. Polosa says

Most e-cigarette usage is infrequent and unlikely to increase a person’s risk of negative health consequences

The report finds that respiratory symptoms linked to vaping “tend to be transient and of uncertain significance”.

Polosa notes that some researchers believe that vaping harms the lungs, but many studies are flawed and incorrectly interpreted.

The most commonly reported adverse effects are throat/mouth irritation, headache, cough and nausea, which settle with continued use.

Some studies have found an association between youth vaping and asthma but there is no evidence that vaping causes asthma. Any association is much more likely to be related to present or past smoking.

Polosa rightly points out that we do not yet know if youth vaping can cause health consequences in adulthood and long-term studies are needed to clarify this.

Reassurance for parents

Vaping by young people is a legitimate concern for parents however, the evidence indicates that the risks are exaggerated.

This review of the scientific evidence confirms that most vaping by US teens is short term and unlikely to have any significant health consequences, although long-term risks are unknown.

In fact, vaping by young people appears to be reducing the risk of taking up smoking, which is much more harmful. Some youth smokers are switching to the safer alternative and non-smokers try vaping as an alternative to deadly cigarette smoking.

Overall, the public health impact of youth vaping may be positive. Australian parents should sleep better.

Reference

Polosa R et al. A close look at vaping in adolescents and young adults in the USA. The Journal of Allergy and Clinical Immunology, June 2022

THE WA STATE GOVERNMENT is threatening the survival of vape stores across the state with massive fines for selling any kind of vaping product.

The current legislation in WA (Tobacco Product Control Act 2006) bans the sale of devices that look like cigarettes. However, in a recent letter, vendors were told that they were told they could face penalties of up to $80,000 for selling ANY vaping products or components:

WA Health later confirmed the penalties apply to batteries, coils and nicotine-free liquids and all accessories

If enforced, this would shut down vape stores across the state, leaving only the black market in operation.

This threat does not appear legal or permitted by the current legislation which has not been changed. It may well be a politically motivated bluff, and may require vendors to make a legal challenge if the government proceeds with the plan,

The strategy is also misguided. It targets only current adult smokers and ex-smokers who have successfully quit smoking by vaping, whilst leaving the black-market free to expand un and sell illicit products freely to young people.

Furthermore, deadly cigarettes continue to be readily available at convenience stores, tobacconists, petrol stations and corner shops.

Youth vaping

The crackdown comes amidst a media blitz and panic about youth vaping in WA eg herehere and here.

WA Health announced a new initiative to ‘educate’ young people on nicotine addiction and chemicals in disposable vapes. This campaign is based on the NSW Health ‘Do you know what you’re vaping?’ campaign, which is alarmist, exaggerates risks and is riddled with misinformation.

Vape stores are not the problem

There is no doubt that youth vaping is on the rise and this needs to be addressed. However destroying the legal vaping market this is not the solution and is bound to fail.

Vape stores do not sell these illegal products, or any products containing nicotine. Instead, they sell refillable vaping devices, and accessories to adult smokers and former smokers to help them quit and avoid relapse to deadly smoking.

These businesses require frequent inspections from the Health Department and have been assured for many years that their business is legal.

The unregulated black-market is the problem. The State Government should be exclusively focused on policing and enforcing the laws on the sale of illicit, dodgy vaping products which are freely sold to kids.

Cracking down on small businesses who help tens of thousands of  adult West Australians remain smoke-free will force users onto the black market, or worse back to deadly cigarettes. Meanwhile, disposable vapes will become even more accessible to young people.

This will be a public health disaster

Vaping products should be regulated and approved as adult consumer goods. By doing so, the government would gain the ability to implement basic consumer protections, which are being ignored on the black market. These protections should include quality standards, elimination of harmful ingredients, child proof containers and strictly enforced age-of-sale laws like those which apply to combustible cigarettes and alcohol.

If the government remains on this misguided course, the black market will only grow, instances of use and misuse by teens will become more common, and tens of thousands of West Australian ex-smokers will be forced back to cigarettes.

Vapers and vendors should contact their local MP and the Premier urgently to voice their views about this draconian and possibly illegal threat. Their lives depend on it.

Further reading

WA’s misguided vaping move will be a public health disaster
My opinion piece in WA Today on 21 June 2022


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