THE TASMANIAN BRANCH OF THE AMA (Australian Medical Association) issued a media release yesterday criticising an opinion piece by Senator Tammy Tyrrell on vaping. The AMA’s response reveals a striking level of ignorance and bias about vaping, perpetuating myths that contradict the existing body of scientific evidence.

Let’s take a closer look at some of the AMA’s most misguided claims.

Claim 1: “Vaping does not reduce smoking”

This claim ignores the overwhelming scientific evidence that vaping is an effective quitting aid. Rigorous Cochrane reviews of randomised controlled trials have found vaping to be more effective than nicotine patches and gum and at least as effective as varenicline (Champix). Findings from real-world studies including observational studies, population studies, improvements in national smoking rates and studies of accidental quitting support this.

To deny the effectiveness of vaping as a quitting tool in the face of such robust evidence is reckless and harmful. Smokers who are struggling to quit need options that work, and vaping has proven to be the most effective to date. By dismissing vaping’s effectiveness, the AMA is doing a disservice to public health.

Evidence here

Claim 2: “The idea that vaping is a safer alternative is a highly dangerous narrative pushed by tobacco companies”

This is not an argument pushed by the tobacco industry—it is a statement of fact supported by a wide range of reputable, independent public health organisations, such as Public Health England, the Royal College of Physicians and NASEM, based on comprehensive reviews of the evidence.

The AMA’s claim is a deliberate attempt to discredit the science behind vaping by linking it to Big Tobacco, a common tactic used by anti-vaping advocates to incite fear and mistrust. This only serves to confuse the public and delay harm reduction efforts.

Evidence here

Claim 3: Vaping is “linked to acute lung injury and popcorn lung”

There is no evidence that vaping nicotine causes either of these conditions. This is another desperate and dishonest attempt to stoke fear and misinformation.

Evidence here and here

Claim 4: “Vaping has become a gateway to smoking”

This is one of the most persistent myths about vaping, yet the research shows the exact opposite. Vaping is diverting young people away from smoking overall and is accelerating the decline in youth smoking rates. Once again, the AMA is ignoring the real-world evidence and clinging to disproven fears.

The association between vaping and smoking is not causal and is based on the  ”common liability” of some young people to both vape and smoke. AMA is making the fundamental error of confusing association with causation.

Evidence here

Claim 5: Restrictions will “mitigate, not encourage, illicit trade”

The AMA dismisses concerns that further restrictions on vaping will lead to the growth of the black market, calling it an “industry ploy.” This claim is not only factually incorrect, but it also ignores the current situation in Australia. As criminologist Dr James Martin explained to the Victorian Parliamentary Inquiry recently:

“The black markets for illicit tobacco and vaping products in Victoria and around Australia are large and growing…The massive black market for these products is the direct result of increased government restrictions”

The solution for this black market is not more harsh restrictions, but rather to replace it with a legal, regulated one.

Evidence here

Claim 6: “GPs are very happy to help” with vaping

Finally, the AMA claims that general practitioners (GPs) are ready and willing to help patients with vaping. This is far from the truth. While some GPs are supportive of vaping as a harm reduction tool, the majority are either ill-informed or reluctant to prescribe or recommend nicotine vaping products.

Many smokers report frustration when approaching their GPs for help with vaping, often being turned away or given inaccurate information. This reality contrasts sharply with the AMA’s rosy depiction of GPs as champions of vaping support.

Evidence here

Conclusion

The Tasmanian branch of the AMA has done a disservice to public health with its misguided and factually inaccurate statements on vaping. Its media release not only dismisses the robust evidence supporting vaping as the most effective quitting aid but also spreads fear and misinformation about its safety and role in smoking cessation. Instead of engaging in evidence-based dialogue, the AMA has chosen to perpetuate outdated myths and ignore the harm reduction potential of vaping.

It’s time for the AMA to acknowledge the overwhelming body of scientific evidence and support vaping as a vital tool for reducing smoking-related harm in Australia.

References

Vapings dangerous myths. Media release. AMA Tasmania 16 September 2024

Senator Tammy Tyrrell. Nanny state needs to take a breath. The Mercury 1 May 2024

ONCE AGAIN, AUSTRALIAN RESEARCHERS have jumped on the bandwagon, making alarmist claims that vaping causes young people to start smoking. But let’s be clear: this study proves no such thing.

The researchers behind the Generation Vape study followed up 14-17-year-olds who had tried vaping and found they were five times more likely to also try smoking (even just “a few puffs”) at a later date.

This association is unsurprising, but it does not prove that vaping caused subsequent smoking as claimed

It’s long been recognised that some young people are simply predisposed to experiment with nicotine, whether through cigarettes, vaping, or other means. Surely the authors know this.

Causality requires more than surface-level associations. In this case, it would take more robust, sophisticated longitudinal studies to even begin establishing a causal relationship. Nonetheless, the authors claim their findings “indicate that vaping markedly increases the risk of subsequent smoking initiation.” They went a step further in their media release, declaring that vaping poses a real threat to increasing youth smoking rates, calling for tighter regulations.

Typically, these flawed conclusions had widespread media coverage in Australia and internationally

A far more likely explanation: common liability

A far more plausible explanation for the observed association is “common liability.” (Vanyukov 2012) In short, young people who try both vaping and smoking are simply different from their peers. They are predisposed to experiment with nicotine, driven by many underlying smoking predictors like peer pressure, parental smoking, and socio-economic status.

While this study adjusted for four smoking predictors (risk factors), it ignored a host of others. Crucial influences that increase the risk of smoking like school performance, genetic predisposition, personality type and mental health factors such as anxiety and depression were left out.

Studies that adjust for a broader range of risk factors (confounders) tell a very different story

Two such studies, which accounted for 14 and 22 risk factors, found that the link between vaping and later smoking vanished entirely. (Sun 2023; Kim 2019) A further study accounted for 34 risk factors which eliminated almost all (87%) of the association between vaping and smoking. (Lee 2019)

Where are all the smokers?

If vaping truly acted as a gateway to smoking, we’d expect to see a dramatic rise in youth smoking since the introduction of vaping in Australia.

Yet, the opposite is true – youth smoking has almost disappeared

In the most recent 2022-2023 ASSAD survey, just 0.3% of Australian students aged 12-17 reported daily smoking. Only 2.1% had smoked within the last week. Similarly, the NDSHS 2022-23 survey showed that only 3.5% of 14-17-year-olds had smoked in the past 30 days.

In fact, youth smoking rates have been falling faster than anticipated since vaping entered the scene. (Delnevo and Villanti 2021; Pesola 2021 Levy 2019; Meza 2021; NHS Digital UK 2022; ASH NZ 2022),) Studies suggest that youth vaping may actually be displacing smoking rather than encouraging it. (Foxon 2020, Selya 2021, Sokol 2021)

Experimentation vs. sustained smoking

One particularly misleading aspect of this study is its definition of “smokers.” A young person who takes “a few puffs” of a cigarette is classified as a smoker, but this is hardly equivalent to habitual smoking. Much adolescent cigarette use is fleeting, a brief experiment rather than the start of a smoking habit.

A recent analysis found that very few young people who tried smoking developed a regular smoking habit two years later, regardless of whether they had vaped beforehand. (Sun 2023) Another analysis showed that roughly two-thirds of youth who had tried smoking never progressed to regular use. (Friedman 2019)

Conclusion

This paper has sparked unnecessary alarm with its misleading claim of causality, feeding into the growing moral panic about youth vaping. By confusing correlation with causation, the authors have made a fundamental error. It’s hard to believe this wasn’t a deliberate decision.

Unfortunately, the recommendations from this paper—calling for stricter regulations on vaping—could ultimately do more harm than good. If these restrictions affect adult smokers, the public health consequences could be severe. We must prioritise evidence-based policy decisions, not reactions driven by alarmist studies that overstate the risks.

References

Egger S et al. The association between vaping and subsequent initiation of cigarette smoking in young Australians from age 12 to 17 years. ANZJPH 2024

Is vaping a gateway to smoking?. Blog

TO CIRCUMVENT AUSTRALIA’S HARSH RESTRICTIONS on nicotine, some people have been importing or purchasing vapes containing a nicotine-alternative, 6-methylnicotine. Is this still a good idea?

What is 6-methylnicotine?

6-methylnicotine (6MT) is a chemical related to nicotine (brand names include Metatine and HYT). It has the same effects as nicotine but is much more potent. 6-methylnicotine has been around for over 50 years, but there has been little research into it.

6MT is available at high concentrations (typically 100mg/mL) for mixing, and also in ready-to-use vaping products.

Some research suggests it may be more cytotoxic than nicotine, meaning it may be harmful or toxic to cells in the body. However, confirmation of this is needed. It may be as safe as nicotine but there also may be unknown side-effects.

See tweets here: 7 May 2024

Why is it used?

People use 6-methylnicotine in vapes as a substitute for nicotine to bypass the Australian restrictions on nicotine. When tested, e-liquids with 6MT do not show up as having nicotine. As a result, it has been legal to use or import it without a prescription.

6MT is also used in the US to by pass the absurd FDA regulations.

Recent research

An Australian study published today in the Medical Journal of Australia analysed nine samples of 6MT. The main finding of concern was poor labelling with unexpected variations in the strength of the product. This variation could increase the risk of getting too much 6MT with potential adverse effects.

Unintended consequences

The use of 6MT is an example of how harsh regulatory restrictions can cause potential harm by forcing people to create workarounds, for example using alternatives of unknown safety.  Sometimes this can lead to harmful outcomes. It is not yet clear if 6MT is harmful, but the possibility is there.

Is it still worth using 6MT?

Under the new laws, it is now illegal to import all vapes whether they contain nicotine or not. It is also illegal to sell all vapes outside a pharmacy. So there is now no advantage in using 6MT. It is safest to use vapes with nicotine from a reliable source.

Reference

Jenkins C et al. 6-Methylnicotine: a new nicotine alternative identified in e-cigarette
liquids sold in Australia. Medical Journal of Australia 2024

THE NATIONAL HEART FOUNDATION (NHF) has recently intensified its attack on vaping, claiming that “e-cigarettes and vaping are damaging to cardiovascular health” and that vaping serves as a gateway to smoking. However, it fails to provide evidence of harm caused by vaping and misinterprets the gateway research.

The NHF’s assertions are prominently featured in its submission to the Victorian Parliamentary Inquiry into vaping (here) and in a recent media release (here).

No evidence provided

The NHF claims that vaping damages cardiovascular health, but provides ZERO evidence to support this claim

The NHF has made the basic scientific error of confusing association with causation. It references two studies in which vaping is associated with heart disease, but no evidence that vaping causes heart disease.

Heart attack 

The NHF refers to a review of four studies which found that e-cigarettes are “associated with a 33% increased risk of having a heart attack when compared to people that have never used e-cigarettes”.  (Sharma 2024) Importantly, this type of cross-sectional study (data is drawn from a single point in time) cannot prove causation.

As noted in the study itself, “All the included studies in the meta-analysis are cross-sectional studies, thus ruling out any interpretation on the causal association between the studied variables.” This correlation is more likely attributed to prior smoking rather than vaping itself.

Heart failure 

The NHF references another study which found that “people who used e-cigarettes at any point were 19% more likely to develop heart failure compared with people who had never used e-cigarettes.” This statement refers to a brief conference abstract that reviewed four studies. (Bene-Alhasan 2024) However, the abstract was not peer-reviewed and should not have been cited until more comprehensive details were available.

Once again, the study only indicates an association between vaping and heart failure without proving that vaping is the cause. Alternative explanations for the observed association must also be considered, such as past smoking habits and reverse causation—where individuals may take up vaping as a response to existing health concerns.

The gateway myth

The NHF claims that “e-cigarette use is the strongest risk factor for initiation of tobacco smoking among Victorian teenagers aged 14-17.” This assertion, based on a study by Scully, erroneously suggests that vaping causes young people to start smoking. (Scully 2023) In reality, Scully only found an association between e-cigarette use and susceptibility to smoking. The authors themselves acknowledged that, due to the cross-sectional nature of the research, “we are unable to draw any causal inferences about the observed associations.”

The NHF also cites that “the highest prevalence of e-cigarette use was found in the 18 to 24-year-old age bracket,” raising concerns about vaping among young adults. However, panic regarding vaping in this demographic is premature, as data from the National Drug Strategy Household Survey (NDSHS 2022-23) shows that smoking rates are declining at the fastest rate in this age group, likely due to the effect of vaping. Other studies have confirmed this finding in the US and UK. (Floxon 2022; Meza 2023; Tattan-Birch 2024)

Moreover, the NHF’s claim that “growing evidence suggests that vaping, especially by young people who have never smoked, increases the risk of initiation of tobacco smoking” overlooks crucial evidence indicating that vaping first (before smoking) may actually reduce the likelihood of young people transitioning to smoking. (Shahab 2020; Mus 2023; Legleye 2020)

Recent research has debunked the gateway theory. (Selya 2024) Although some young people who try vaping may later smoke, this progression is likely due to a predisposition for risk-taking behaviour, rather than vaping itself being a gateway. (Vanyukov 2012) Importantly, population studies indicate that smoking rates are declining faster as youth vaping rates increase, suggesting that vaping is diverting young people away from smoking altogether. (Sokol 2021; Selya 2021; Walker 2020)

What does the evidence say?

There is currently no definitive evidence that vaping increases the risk of cardiovascular harm. Long-term epidemiological studies are needed to provide more conclusive answers.

However, the potential harm is likely to be small in most cases and significantly less than that caused by cigarette smoking. The risk is greatest in heavy or long-term vapers and those with pre-existing cardiovascular conditions.

In contrast, the evidence is clear that switching from smoking to vaping substantially reduces the risk of cardiovascular disease. See my review of the evidence here.

Conclusion

We should expect nothing less than the highest scientific standards from Australia’s leading heart charity. However, the National Heart Foundation’s recent statements on vaping fail to show the claimed harm from vaping and misinterpret the available evidence.

As evidence increasingly supports the role of vaping in reducing smoking rates, it is crucial for health organisations to base their recommendations on sound science rather than fear-based narratives. A more nuanced approach that considers the evidence and the potential harm reduction benefits of vaping is essential for public health discourse.

Resources

National Heart Foundation submission to Victorian Parliamentary Inquiry into vaping. 5 April 2024

Proposed vaping legislation in Tasmania. NHF media release. 30 August 2024

Does vaping cause cardiovascular disease? Blog

THE REPORT FROM THE VICTORIAN PARLIAMENTARY INQUIRY into vaping was handed down today. It was a huge disappointment for vapers, and anyone committed to evidence-based policy. 

Astonishingly, the report concludes that vaping is no safer than smoking (Demaio, p27) ignoring the overwhelming empirical evidence that vaping is a far less harmful alternative for adult smokers

Instead of acknowledging vaping’s potential to help smokers quit, the report fixates on exaggerated concerns about youth vaping. By doubling down on the current, ineffective regulations, the inquiry has missed an opportunity to make a meaningful positive impact.

Health effects: misinformation and misleading claims

The committee’s assertion that “there is no scientific evidence to show that e-cigarette use is healthier than smoking tobacco” is absurd and reflects a profound misunderstanding of the evidence. This conclusion appears to be based on misleading and inaccurate information presented to the committee and accepted by it, including:

The “gateway myth” revisited

The report perpetuates the debunked gateway theory, claiming that vaping leads to smoking. The Committee’s misleading assertion that vapers are “three times more likely to become tobacco smokers than non-users” (Demaio p11; Banks, p26) ignores the wealth of evidence showing that vaping is actually diverting young people away from smoking.

Vaping as a quit aid: a missed opportunity

Despite vaping being the most popular and effective quitting aid for adult smokers, the report fails to mention this. While the Committee acknowledges that smoking rates are declining, it refuses to recognise the role vaping plays in this trend. Instead, it portrays vaping as a threat to tobacco control, missing a critical opportunity to leverage vaping to improve public health.

Youth vaping: moral panic and misdirection

The Committee has succumbed to the moral panic surrounding youth vaping, consistently referring to adolescents as “children”, referring to ‘current’ vaping instead of frequent vaping, and exaggerating the small harms. This panic is driving calls for even harsher restrictions on vaping, which will likely be ineffective and counterproductive.

Flawed regulation: ignoring the real problem

The report does acknowledge that current regulations and enforcement are failing. The rampant black market, run by violent criminals is devastating legal businesses while enforcement agencies are underfunded and overstretched. The Committee’s suggested solutions—licensing tobacconists, supporting vaping cessation, and restructuring the regulatory framework—are unlikely to address the root issues.

The only way to truly combat the black market is to replace it with a regulated, legal one

Licensing and support for vapers are steps in the right direction, but history shows that increased enforcement and penalties will not stem the tide of black-market sales.

Conclusion: a victory for ideology, a loss for public health

This report represents another victory for puritanical ideologues pushing an abstinence-only agenda, at the expense of public health. The Committee has overlooked a golden opportunity to improve public health by helping adult smokers quit through vaping.

Furthermore, by failing to consider the regulation of vapes as adult consumer products with strict age verification, the report ensures that youth will continue to access vapes through the black market. A rational regulatory approach—one that balances access for adults with protections for youth—would have addressed both concerns effectively. Unfortunately, this was not considered.

Links

Vaping and tobacco controls report. Victorian Parliament Public Accounts and Estimates Committee. August 2024

Inquiry website

My submission

IF YOU ARE LOOKING for comprehensive, easy-to-read and fully referenced information on vaping, please visit the FAQs page on my website. This page is constantly updated with the latest evidence-based information as it is published.

Most of the information applies to all countries, but there is some specific information for Australia, particularly under regulation.

The information is organised under 64 questions. Any suggestions for further topics, how to improve the list or any corrections are very welcome.

Here is the list of topics with links directly to each answer.

The basics

Safety and health

Quitting Smoking

Youth vaping

Young adult vaping

Other issues

The tobacco industry

Regulation of vaping

THANK YOU TO ALTERNATIVE MAGAZINE for publishing this interview with me. It covers some of my work and my views on tobacco harm reduction. You can download the pdf of this interview here.

First and foremost, we’d like to say a huge congratulations for winning the Michael Russell Award 2024 at the Global Forum on Nicotine in Poland. What were your thoughts and feelings upon being presented this award and how important are events such as the GFN in spreading awareness about THR?

It was a great honour, but with a large dose of irony. I am treated as a pariah in Australia as my views are out-of-step with the mainstream narrative, so it is nice to be recognised overseas.

Tobacco harm reduction faces relentless opposition in Australia for ideological and political reasons and is opposed by almost all government organisations, medical associations and health charities. Vaping is framed as a threat rather than an opportunity and there is a moral panic about youth vaping.

The scientific evidence is ignored or distorted and that message is amplified by the mainstream media. As a result, Australia’s smoking rates are declining slowly compared to other countries, and this is costing lives.

The GFN is a wonderful opportunity to gather with like-minded people, to be inspired and recharged for another round of battle.

With a career in tobacco treatment spanning over four decades, what is one thing you have learnt or experienced that has stayed with you?

I used to think that good public health policy was based on the best available science. I now realise how naïve that was.

Policy on tobacco harm reduction (THR) is driven by everything but the science. Much of the opposition is based on ideological abstinence-only beliefs, politics, vested interests, financial considerations, and a range of other secondary issues.

Opponents often scaremonger, exaggerate risks, use emotional arguments, and ignore the positive evidence. This is amplified by the media which is typically alarmist and negative about vaping.

It is no wonder that the public is misinformed and that misperceptions about less harmful alternatives are the norm. For some things that doesn’t matter, but for smoking, misinformation is deadly if it discourages smokers from switching to safer products.

Tobacco harm reduction tools such as vapes are continuously under attack by global bodies and the media, what advice would you give to advocates and experts fighting on the front line?

Tobacco Control from organisations like the World Health Organisation has really lost its way. Our top priority should be to prevent death and disease from smoking, yet so often the focus seems to be on punishing tobacco companies, eliminating nicotine or protecting youth from nicotine. We seem to have forgotten about the 1.3 billion adult smokers who are at imminent and serious risk.

The evidence for tobacco harm reduction is now overwhelming and this should be the driver of policy. Nicotine is demonized. It is dependence-forming but is relatively benign in the doses used in THR products. We have to remind ourselves that smoke is the cause of 98% of tobacco-related deaths and eliminating smoke should be our main priority.

We still struggle to get the balance right between avoiding harm to youth and helping adult smokers quit. In fact, the risk to youth is exaggerated and the actual risks are small. For adult smokers, THR options are potentially lifesaving and should be given greater emphasis.

Your work teaching students, medical practitioners and other health professionals how to help smokers quit is incredibly impressive and important. How can more medical experts and doctors use education as an effective method to aid smokers in quitting

Smoking is a silent epidemic and seems to have fallen off the radar. In spite of decades of anti-smoking efforts, tobacco smoking is still the leading preventable cause of death and illness globally and the number of smokers is increasing.

We need more training in medical schools and an organised, well-resourced network to train health professionals about smoking. Training should include ongoing support, such as follow-up sessions and regular reminders. Health professionals have so many other priorities and smoking tends to get overlooked. One-off training sessions are quickly forgotten.

Many smokers simply can’t quit with conventional treatments and for these smokers, safer alternatives, such as vaping, nicotine pouches, heated tobacco products, and snus can be lifesaving. These treatments should be embraced by health professionals as routine options in helping smokers quit.

Health professionals are poorly informed about nicotine in particular and this needs urgent correction. Nicotine doesn’t cause cancer, heart or lung disease, yet many think otherwise. This misinformation undermines the use of NRT and safer nicotine alternatives to smoking.

How do we advance the cause of tobacco harm reduction?

I think the first priority is to correct the misinformation about THR. Much of the opposition is based on misunderstandings, ideology and myths, particularly around nicotine. That is the main reason I wrote my book, Stop Smoking Start Vaping.

We also need to keep the risks of THR in perspective. Yes, there are risks from vaping and other forms of THR – nothing is risk-free – but the benefits to public health overall are far greater than the small risks.

Finally, I would like to see vapers more active in this debate. Their passion and personal stories will often cut through when scientific arguments aren’t effective. Vapers are voters and they could be a powerful voice that could be very influential with policymakers who are elected officials.

Alternative Magazine

Alternative Magazine is a new, bi-monthly UK-based magazine focussed on the latest global news in alternative nicotine

Visit Alternative Magazine online here.

Download the August 2024 issue here.

WHILE VAPING MAY POSE A RISK of cardiovascular harm, such as heart attacks or strokes, there is currently no definitive evidence to confirm this. Long-term epidemiological studies are needed to provide more conclusive answers.

However, the potential harm is likely to be small in most cases and significantly less than that caused by cigarette smoking. The risk is greatest in heavy or long-term vapers and those with pre-existing cardiovascular conditions.

In contrast, the evidence is clear that switching from smoking to vaping substantially reduces the risk of cardiovascular disease

The evidence

Cross-sectional studies

Cross-sectional studies provide a snapshot of a population at a single point in time. While they can identify associations between vaping and health outcomes, they cannot determine whether vaping caused those outcomes.

Some cross-sectional studies have reported an association between vaping and a higher risk of cardiovascular issues compared to non-vapers. (Sharma; Alzaharani; Farfan; Vindyal) However, in many instances, participants who vaped had a history of smoking, and the increased harm may be attributed to their previous smoking habits. In some studies, cardiovascular events occurred before the onset of vaping.

Other cross-sectional studies have not identified any increased risk. One study of 450,000 subjects found that people who vaped but had never smoked had no increased risk. (Osei) Another study of 60,000 subjects found no increased incidence of heart disease in vapers compared to non-vapers. (Farsalinos)

Longitudinal studies

Longitudinal studies follow subjects over time. They are more robust and provide more reliable information.

A study of 24,000 subjects found that vapers who had never smoked had the same risk as non-vapers after five years follow-up. (Berlowitz) Another study found that vapers did not have an increased incidence of heart attack or stroke compared to non-vapers and non-smokers after five years. (Hirschtstick)

Cross-sectional and longitudinal studies

An analysis of 20 studies (14 cross-sectional and 6 longitudinal) involving nearly 9 million people did not find an increased incidence of cardiovascular disease in people who exclusively vaped compared to those who had never vaped or smoked. (Chen) The authors point out that this study does not prove that vaping is risk-free to the cardiovascular system – longer studies may be needed to identify harms.

Dual  use

Numerous studies have found that dual use (smoking and vaping) significantly increases the risk of cardiovascular disease. (Chen; Berlowitz)

Does switching to vaping improve heart health?

The harm to the cardiovascular system from smoking far outweighs any potential risks from vaping (Peruzzi; Ding; Sharma)

Switching from smoking to vaping has been shown to reduce cardiovascular risk. Research has documented improvements in cardiovascular health in the short term (Caruso), within one month (George), and also at three and six months. (Klonizakis)

Studies have demonstrated significant improvements in blood pressure control among smokers with hypertension who switch to vaping, with benefits observed at a 12-month follow-up. (Farsalinos; Polosa) Additionally, both heart rate and blood pressure tend to decrease after switching from smoking to vaping. (OHID p956, 963)

Biological Plausibility: How might vaping cause harm?

While most of the toxic chemicals found in cigarette smoke are absent from e-cigarette vapour, some toxicants are present which could impact cardiovascular health. These include acrolein, oxidizing chemicals, volatile organic compounds (such as acrolein and benzene), and trace metals. However, these substances are present at much lower levels in vapor than in smoke. (OHID)

Studies in cells, animals and humans have found that vapour can affect cardiovascular health in several ways, the most potent being oxidising stress (harm to blood vessels from free radicals). Other mechanisms of harm include inflammation, sympathetic activation (increased pulse rate and blood pressure), platelet activation (increased stickiness in platelets leading to blood clots), harm to blood fats and endothelial dysfunction (damage to the lining of the arteries).

The risk to to human health from these findings is possible but uncertain. (Benowitz) Importantly, these effects are less pronounced compared to those caused by smoking. (Middlekauff; Ikonomidis)

What about the effect of nicotine?

Nicotine has well-documented effects on the cardiovascular system and could pose a risk for people with existing cardiovascular conditions. (Benowitz) However, these risks are much lower than those associated with smoking.

Nicotine increases heart rate and blood pressure, makes the heart work harder, and constricts blood vessels. It can also trigger arrhythmia (irregular heartbeat), cause insulin resistance (leading to elevated blood glucose levels) and may result in lipid (blood fat) abnormalities. Additionally, nicotine might damage the lining of the arteries. (Benowitz)

However, in the short term, nicotine use appears to pose minimal risk. A review of 42 clinical trials using nicotine products for up to 12 weeks found no significant increase in cardiovascular events. (Kim)

Furthermore, long-term users of Swedish snus (a product that delivers high doses of nicotine) do not have higher rates of heart attack or stroke compared to non-users. (Hansson)

Conclusions

There is strong evidence that smokers who switch to exclusive vaping substantially reduce their risk of cardiovascular disease.

There is no good evidence that exclusive vaping increases cardiovascular disease, although longer studies are needed to confirm this. Nevertheless, it is best not to vape if you are not a smoker or former smoker.

Dual use (smoking and vaping) significantly increases cardiovascular risk.

LAST WEEK, THE NSW PARLIAMENTARY INQUIRY into vaping regulation released its long-awaited report. The result was predictable and disappointing and has failed the people of NSW.

From the outset, the report adopts an alarmist tone, boldly claiming that “Vaping is one of the biggest public health challenges our country currently faces” and “threatens to undermine years of progress in tobacco control.” Such statements are not only exaggerated but reveal the report’s overall bias and lack of nuance.

The Committee’s findings were heavily influenced by a barrage of misinformation and selective evidence from organisations like Lung Foundation Australia and the Australian Medical Association – groups that have consistently opposed vaping despite mounting evidence of its  potential as a harm reduction tool.

The report is lost in a moral panic about youth vaping and recklessly dismisses the lifesaving opportunity to help adult smokers quit. The overall impact on public health of this report will be negative

Moral panic over youth vaping

1. Frequency of vaping

The report’s primary focus is an exaggerated fear about the frequency of vaping by young people. However, most vaping by young people who have never smoked is experimental, occasional and short-term and is of little public health importance. Half of all youth who vape do so only once or twice.

Only regular vaping has the potential to cause harm, but this is uncommon, especially in non-smokers. The 2023 ASSAD survey, for instance, found that only 3% of 12-17-year-olds vape daily.

2. Harm from vaping

The report overstates the harm from youth vaping which it describes as “a significant public health issue”. In contrast, our recent review of the evidence concluded that “Youth vaping carries relatively minor health risks”. Here are some examples of flawed claims

Exaggerated risks and misleading claims

Much of the information provided to the Committee was exaggerated and misleading. For instance, the serious lung disease EVALI was raised, despite the clear evidence that EVALI was caused by black-market THC products, not nicotine vaping. Similarly, there is no evidence that vaping causes scarred lungs or seizures.

One academic even went so far as to claim that “there is strong evidence that use of e-cigarettes has multiple health harms and no health benefits.” She warned the Committee about the presence of harmful chemicals without mentioning that most were in very small doses, well below harmful levels.

The neglected needs of smokers

 The most significant oversight is the report’s failure to properly consider the needs of adult smokers

Vaping is a lifesaving substitute for smokers who are otherwise unable to quit. Numerous studies have shown that switching to vaping dramatically reduces exposure to toxicants and leads to substantial health improvements.

Many experts giving evidence ignored the high-quality evidence that vaping is the most effective quitting aid available, with one health charity claiming that the evidence for vaping as a quitting aid is “patchy at best.” An academic asserted that smokers who vape to quit are twice as likely to relapse –  a grossly misleading claim.

While the Committee grudgingly acknowledged that vaping “may help some people quit smoking when delivered in a controlled way and with advice from a primary healthcare provider,” they failed to recognize that only a tiny fraction of smokers are willing to follow this medical pathway.

The wrong approach to regulation

The Committee’s main recommendation to eliminate illicit vapes by a crackdown is naive and is bound to fail. History has shown that harsh bans and enforcement of popular illicit drugs do not reduce supply and are rarely successful.

The illicit market is firmly established and run by criminal networks, and the only way to eliminate it is to replace it with a legal and regulated one

A far more effective solution is for vapes to be sold as adult-only consumer products from licensed retail outlets, with strict age verification, like tobacco and alcohol. Age-of-sale breaches can be minimised by the use of CCTV, large fines, and loss of licence.

Conclusion: a missed opportunity

The NSW Parliamentary Committee had a chance to embrace a progressive, evidence-based harm reduction approach to vaping that could have improved public health overall. Instead, it succumbed to moral panic about youth vaping. The recommendations perpetuate a failed model, leaving the health of countless smokers at risk. It’s time for a rethink—before it’s too late.

Documents

Report. E-cigarette regulation and compliance in New South Wales. Committee on Law and Safety. August 2024

Mendelsohn CP. NSW Parliament, Inquiry into E-cigarette regulation and compliance. Submission 24 October 2023

My evidence at the hearing, 12 April 2024

AN ANALYSIS OF AUSTRALIAN NEWS STORIES has exposed the media’s role in creating a moral panic about youth vaping. The resulting outrage and distorted public opinion leads to knee-jerk, heavy-handed responses by regulators, without considering the unintended consequences or alternative options.

In reviewing media stories over a 6-month period, the researchers from the University of Queensland found that media reports were often sensationalised and inflammatory.

They presented vaping as an exaggerated threat to society, creating social anxiety and public concern, leading to a moral panic

The report found the media was biased and favoured the views of the same health experts and politicians who are critical of vapes and who supported restrictions. The views of pro-vaping experts were covered infrequently. When included, their biases were highlighted and their opinions discredited. As a result, the media coverage is narrow and neglects the full range of issues around vaping.

Australian media reporting on NVPs has included sometimes outlandish claims, such as that they contain ‘flesh-eating horse tranquilliser’ or toxic levels of radioactive polonium, and that vaping can lead to a ‘lifetime of gangster crime’.

It was no surprise that there was “significant divergence between the available evidence and public understanding’ and that many people wrongly think vaping is as harmful as smoking.

How the media ‘frames’ stories

How the media presents or ‘frames’ a story is very influential. Framing involves selecting and highlighting certain aspects of a story to promote a particular interpretation.

The media tends to present or frame youth vaping in emotional and sensational ways to amplify the public perception of risk

Two of the most common ways of framing vaping are:

1. “Vaping is a poisonous epidemic”

In these stories, vaping is presented as an uncontrolled epidemic of young people using a highly toxic substance leading to a ‘public health disaster’ and a ‘youth vaping crisis’. This desperate situation demands an intensive and rapid response and pressures regulators to act urgently to ‘crack down’ or ‘stamp out’ vaping.

An example of this is “’I’ve lost my children to vaping’: the tragic stories behind the soaring rates of youth addiction” by Melissa Davey in the Guardian.

2. “A failure of control”

Some stories present vaping as a loss of control over retailers, marketers, and youth by the government, police, schoolteachers, and parents. This leads to attempts to control the situation, eg with vape detectors, locking school bathrooms, cracking down on retailers and criminalising vaping.

An example of this is “Nationals leader makes big admission on Australian vaping laws as he pushes alternative policy” at news.com.au. This story emphasises loss of control as the primary issue requiring a government ‘clampdown”, without giving any actual evidence. Possible unintended effects and alternative responses are not considered.

A more helpful approach is to frame youth vaping as a health condition requiring treatment and support, as for other harmful drugs. This could lead to better education, and harm reduction strategies. However, this approach is infrequently used.

“Think of the children”

Issues that threaten the health and safety of children resonate with parents and carers and are easy click-bait for headlines. They lead to panic and urgent demands for solutions. Often the solutions are heavy-handed, and ignore the needs of other stakeholders. Possible secondary or unintended consequences are overlooked.

This hysterical approach to vaping in the media does not recognize the complex and nuanced nature of vaping. ‘Think of the children’ creates a state of panic. Other concerns become secondary. The result is often poor policies that do not reflect the empirical evidence and have serious unintended consequences.

Conclusion

How the media reports a news story has a major influence on public perceptions which lead to policy change. Journalists have a moral and social responsibility to consider the impact of their work and the effects on society.

Although less ‘newsworthy’, reports on youth vaping need more balance to allow a more nuanced and broader debate. Stories should be less sensational and more factual.

Well, we can dream can’t we?

Article

Brookfield S et al. A frame analysis of the Australian media’s construction of the youth vaping crisis. International Journal of Drug Policy 2024

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