Last updated 6 December 2023
Tobacco Harm Reduction is a strategy to reduce the harm for smokers who are unable or unwilling to quit. It involves replacing high-risk combustible tobacco products such as cigarettes with lower-risk, non-combustible nicotine alternatives, like vaping.
Video: Introduction to Tobacco Harm Reduction, March 2022 (10 mins)
The aim of harm reduction is to reduce (not necessarily eliminate) the harms from smoking, in particular cancer, heart and lung disease. The aim is not to stop nicotine as nicotine causes little harm. Almost all the harm from smoking is from the thousands of toxic chemicals and carcinogens (cancer-causing chemicals) from burning tobacco. Reduced-risk products are not risk-free, but they are far safer than smoking.
Reduced-risk nicotine products fall on a ‘continuum of risk’. They include vaping (using an e-cigarette), Swedish snus (small pouches of special tobacco placed under the upper lip), nicotine pouches (similar to snus but without tobacco) and heated tobacco products (which heat tobacco without burning it).
The aim of tobacco harm reduction is for nicotine users is to shift from deadly combustible products on the right of this diagram to safer products on the left.
The harm continuum of nicotine products (safer products on the left)
Safer nicotine products can supplement traditional tobacco control strategies which target complete quitting.
Tobacco harm reduction is no different to other harm reduction strategies which are generally very effective and widely accepted. These include methadone for heroin users, clean needle exchange programs and even car seat belts.
Tobacco harm reduction is one of the three pillars of Australia’s National Tobacco Strategy. One objective of the NTS is to “reduce harm associated with continuing use of tobacco and nicotine products” (p11).
Australia is legally obligated to support tobacco harm reduction as a signatory to the World Health Organisation Framework Convention on Tobacco Control. The FCTC provides an obligation on governments to not only allow reduced-risk products but actively promote them as part of implementing their tobacco control policies. Currently Australia is in breach of its international obligations as no harm reduction strategies are supported in practice.
Vaping is a less harmful alternative for adult smokers who are unable to quit smoking on their own or with other methods. Vaping delivers nicotine and mimics the familiar hand-to-mouth action, habit and sensations of smoking.
Nicotine vapes (e-cigarettes, vaporisers, ENDS) heat a liquid nicotine solution into an aerosol which is inhaled and exhaled as a visible mist. This is known as ‘vaping’.
All vapes consist of a battery (usually rechargeable), a tank or pod to hold the e-liquid and a coil or heating element to heat the liquid to create the vapour.
As there is no tobacco and no combustion, almost all the toxic chemicals in smoke are absent from vapour. Those that are still present are in far lower doses than in tobacco smoke.
Some smokers use vaping for a short time to quit tobacco smoking and then cease vaping. Others continue vaping long-term to prevent relapse to smoking. Some smokers experiment with vaping without intending to quit but then ‘accidentally’ quit.
Vaping should not be used by non-smokers including young people who don’t smoke.
In Australia in 2019, smokers gave the following reasons for taking up vaping (could select more than one response) according to the 2019 National Drug Strategy Household Survey:
In Great Britain, ASH found similar results in 2023. The 4 main reasons for vaping were
According to the latest Roy Morgan survey in September 2023, 1.6 million Australian adults (18+) now vape, or around 7.9% of the adult population. Vaping is defined as vaping once or more in the last month. Currently 11.7% of Australians smoke (age 14+)
The number of vapers is rapidly rising. It has increased four-fold since 2019 when 1.9% of adults vaped, and has doubled since 1 October 2021 when the failed prescription-only vaping regulations were introduced. However, only 8% of vapers have a prescription and 92% vape illegally, buying products on the black market.
The highest vaping rates are in Queensland (8.4%), NSW (8.2%) and the Northern Territory (8.1%):
Australia now has one of the highest vaping rates in the world. In other western countries, the current vaping rates are:
You can vape legally in Australia with a nicotine prescription from a doctor.
Currently only 8% of Australian vapers have a nicotine prescription. The prescription model is a significant barrier for adult smokers wishing to legally access regulated nicotine vaping products to quit smoking or to reduce smoking-related harm.
Most doctors are reluctant to prescribe nicotine. As of April 2023, there were only 1963 doctors authorised to prescribe nicotine out of >100,000 doctors in Australia However only about 500 are publicly listed. The RACGP recommends that prescriptions are for 3 months only, although they can be up to 12 months supply.
The prescription model has led to a lucrative, thriving black market run by organised crime groups, selling unregulated, mislabelled, high nicotine content disposable vapes to adults and children.
There are severe penalties (up to $45,000 and up to two years jail) for using or possessing liquid nicotine unless it is prescribed by a doctor to help you quit or cut down smoking.
|ACT||$32,000 max or prison or both||2 years||Medicines, Poisons and Therapeutic Goods Act 2008, 4.1.3, 36|
|Western Australia||$45,000||Medicines and Poisons Act 2014, 2.16.2 and 115|
|Victoria||$1,817||Drugs, Poisons and Controlled Substances Regulations 2017|
|South Australia||$10,000 max||Controlled Substances Act 1984, 4.22|
|Northern Territory||$15,700 max or prison||12 months||Medicines, Poisons and Therapeutic Goods Act , 2.2, Div 3, 44.2|
|Queensland||$27,570 max||Medicines and Poisons Act 2019 , 188.8.131.52|
|New South Wales||$2,200 max or prison or both||6 months||Poisons and Therapeutic Goods Act 1966, No 31, 16|
|Tasmania||$8,650 or prison||Up to 2 years||Poisons Act 1971, Part 3, Division 1, Clause 36|
State and Territory laws regulate issues such as sale, use in public places, age limits on sale, display and promotion of vapes.
To purchase nicotine legally, you need a prescription from a registered Australian doctor. There are currently 2 ways to legally access nicotine e-liquid
1. Importation from overseas
If you have a prescription, you can import up to 3 months’ supply of nicotine e-liquid at a time from overseas suppliers for personal use to quit smoking or prevent relapse under the Personal Importation Scheme. Most vapers order supplies from New Zealand or China.
It is important to send a copy of your prescription to the supplier to return with your order. If a prescription is not provided your order may be destroyed by the Border Force and you may face a fine up to $222,000 under the Customs Act 1901.
The TGA has established new standards for nicotine e-liquid [Therapeutic Goods (Standard for Nicotine Vaping Products) (TGO) Order 2021] commencing 1 October 2021. Products imported under the Personal Importation Scheme,
However, the Health Minister has announced in May 2023 that the Personal Importation Scheme will soon be cancelled.
2. Commercial products from Australian pharmacies
Since May 2021, Australian chemist shops and online pharmacies can sell commercial nicotine e-liquid products if you have a prescription and your doctor is an Authorised Provider. This refers to nicotine e-liquid in bottles, pods and disposables.
You will need to inform your doctor which product, brand and flavour you require and find out if an Australian pharmacy can provide it. The volume supplied per script is not limited, but is determined by the doctor.
However, there are only a very small number of community and online pharmacies which stock nicotine vaping products.
There are additional standards for products supplied by pharmacies, including a full ingredient list, labelling, packaging regulations, safety warning statements and child-resistant containers. Nicotine concentrations up to 100mg/mL can be sold by pharmacies if approved by your doctor.
Vaping is not risk-free but it is far less harmful than smoking which kills up to two in three long-term users.
Almost all the harm from smoking is caused by the 7,000 chemicals in smoke (including 70 cancer-causing agents) released from burning tobacco.
In contrast, vapes heat a liquid into an aerosol, without tobacco, combustion or smoke. The toxic constituents in smoke are either absent in vapour or, if present, are mostly at levels significantly below 5% (mostly below 1%) of doses from smoking and far below safety limits for occupational exposure. and are at generally at much lower levels than in cigarette smoke. Studies have found on average around 100-150 chemicals in vapour (eg here and here).
A comprehensive systematic review in September 2022 for England’s Office for Health Improvements and Disparities concluded that
“Vaping poses only a small fraction of the risks of smoking and is “at least 95% less harmful” than smoking”
According to the UK Royal College of Physicians,
“Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.”
A review by the US National Academies of Sciences, Engineering and Medicine concluded:
“While e-cigarettes are not without health risks, they are likely to be far less harmful than combustible tobacco cigarettes.”
The advice of the United Kingdom National Health Service is
“Nicotine vaping is not risk-free, but it is substantially less harmful than smoking”
According to the UK National Centre for Smoking Cessation and Training,
“Anyone who switches from smoking to vaping is instantly improving their current and future health”
Numerous studies have also shown substantial reductions in biomarkers of exposure (toxins in the blood, saliva or urine of users) and biomarkers of potential harm (signs of damage to the body) in tobacco smokers who have switched to vaping.
Individuals who use nicotine vapes to quit smoking completely will gain significant health benefits. Clinical trials and surveys of smokers who completely switched to e-cigarettes have shown improvements in asthma, chronic obstructive pulmonary disease (COPD), blood pressure, muco-ciliary clearance, respiratory infections, lung function, respiratory symptoms, cardiovascular markers and gum disease.
Based on the level of carcinogens and their potency, the lifetime cancer risk from vaping has been estimated as less than 0.5% of the risk from smoking.
For a review of the evidence on vaping safety please watch my presentation to the National Drug and Alcohol Research Centre at the University of New South Wales [17 February 2022]:
A written summary of the presentation is also available here.
The unwanted effects most often reported from vaping are throat or mouth irritation, headache, cough and feeling sick. These tend to reduce over time as people continue vaping.
Is vaping safe?
Much of the debate about vaping is framed in terms of whether vaping is safe. This is the wrong question and sets a high bar that we do not apply to other behaviours, such as drinking alcohol, eating fast food, or playing sport.
Nothing is completely safe. We all take risks every day, weighing the risks against the benefits. We decide if the risks are within our ‘risk appetite’ for the benefits we get.
Yes. This estimate is based on comprehensive, independent reviews of the scientific evidence.
The most rigorous and comprehensive systematic review of the health effects of vaping nicotine commissioned by the England government (Office of Health Information and Disparities) in 2022 concluded
Vaping is “at least 95% less harmful” than smoking, based on their finding that “vaping poses only a small fraction of the risks of smoking”
“Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure”
Of course, the exact figure doesn’t really matter, but saying the risk of vaping is probably less than 5% of smoking helps to communicate a ballpark for the level of risk so smokers can make an informed choice. Just saying vaping is ‘less harmful’ is too vague. That could be 30%, 60%, or maybe even 99% less harmful.
The ”95% safer” figure is based on the following evidence
Vaping is not risk-free. However, as a substitute for smoking, the risk must be compared to the alternative, i.e., continuing to smoke. Based on scientific principles and what we already know (which is substantial), The Royal College of Physicians estimates the long-term risk is likely to be no more than 5% of the risk of smoking.
According to Professor Ann McNeil, author of the UK government commissioned reviews on the harms of vaping,
“It is wrong to say we have no idea what the future risks from vaping will be. On the contrary levels of exposure to cancer-causing and other toxicants are drastically lower in people who vape compared with those who smoke, which indicates that any risks to health are likely to be a fraction of those posed by smoking”
In the absence of long-term data, modelling studies are a well-accepted way of estimating the population impact of an intervention. Numerous modelling studies estimate that vaping nicotine has a significant net public health benefit under all realistic assumptions and would do so even if it generated 20% of the harm of smoking.
There were an estimated 82 million people vaping in dozens of countries in 2021. Some ex-smokers have used vapes for over a decade, and to date, reports of serious adverse effects are very rare.
The requirement for policy to wait for evidence of long-term safety is not applied to other medical or consumer product, for example COVID vaccines. Nicotine vaping devices have been used by millions of consumers for far longer than many approved medicines or consumer products.
There is a theoretical possibility that long-term vaping may increase the risks of lung cancer, emphysema, cardiovascular and other smoking-related diseases. However, these risks are likely to be significantly lower than the risks of smoking and low in absolute terms.
Like all new medicines and treatments, post-market surveillance of vaping (ongoing monitoring after going on the market) should continue to monitor safety and detect any new side-effects. As with any new product, it is possible that some harms may emerge over time.
If cigarettes were invented today, we would know very quickly that they were very, very harmful.
We know much more today about chemistry, toxicology, physiology and the causes of disease than when cigarettes were introduced over a century ago. We have a much greater understanding of the toxic effects of most chemicals and can assess them against occupational and environmental health and safety standards. The scientific method, analytical techniques and equipment are also far superior to that available in the past.
This claim is a tactic by vaping opponents to cast doubt on the safety of vaping. However, extensive and rigorous research of vapes has concluded beyond reasonable doubt that vapes carry only a small fraction of the risk of cigarettes and are a far safer substitute for smoking.
Switching from smoking to vaping dramatically reduces your risk of cancer. And, in spite of what many people think, nicotine does NOT cause cancer.
Presentation on the relative risk of cancer from smoking and vaping,
Medical Grand Rounds, Prince of Wales Hospital, Sydney, 22 November 2023
The overall cancer risk from vaping nicotine is estimated to be <0.5% (less than one in two hundred) of the risk from smoking. The lung cancer risk has been estimated to be 50,000 times less than from cigarette smoking. The lifetime lung cancer risk from second-hand vapour is estimated to be 50,000 times less than from second-hand smoke.
This is because the cancer-causing chemicals (carcinogens) in tobacco smoke are dramatically reduced in vapour. According to the International Agency for Research on Cancer and the US Surgeon General, the main cancer-causing toxins in tobacco smoke are:
When smokers switch to vaping all of these carcinogens are substantially reduced, when measured in the body fluids. In many cases they are at the same level as a non-smoker.
Vaping is strongly supported by the leading UK cancer charity Cancer Research UK, which states:
“There is no good evidence that vaping causes cancer. Because vaping is far less harmful than smoking, your health could benefit from switching from smoking to vaping. And you will reduce your risk of getting cancer”
A review by the US National Academies of Sciences Engineering and Medicine concluded:
“There is little evidence that e-cigarettes pose significant cancer risk”
“The cancer risk for people who vape is considerably lower than for those who smoke”
Cancer from smoking
Tobacco smoke contains 69 known carcinogens and causes at least 15 types of cancer.
Further reading: Switching from smoking to vaping dramatically reduces cancer risk
Unlike secondhand smoke, there is no evidence that passive vaping is harmful to bystanders.
According to expert health organisations:
Research shows that vaping releases extremely low levels of chemicals into the surrounding air which pose very little risk to health:
Furthermore, the liquid aerosol droplets from vapour evaporate and disperse in seconds, much more quickly than the solid particles in smoke, reducing risk further.
Based on the carcinogens in second-hand vapour and the estimated doses, the cancer risk for passive smokers was estimated to be five orders of magnitude (50,000x) greater than for passive vapers.
Nicotine is a relatively benign drug. Although it causes dependence, it presents very little risk to the user and even has some significant beneficial effects.
Because of its association with smoking, many people incorrectly believe it is the harmful ingredient in tobacco smoke. However many independent expert bodies disagree:
The vast majority of harm from smoking comes from tar, carbon monoxide, toxic gases and solid particles released by burning tobacco, not from the nicotine.
Nicotine has mild effects such as temporarily increasing the pulse and blood pressure and narrowing the blood vessels. It can impair wound healing and raise blood glucose levels.
A word on the definition of ‘addiction’
The urge to vape is not strictly characterised as “addiction”. According to Addiction Ontology, the definition of addiction is a compulsion to engage in a behaviour known to cause serious net harm.
Nicotine has only minor health effects and the urge to vape is best described as dependence. Dependence means having the urge to use a drug to avoid physical symptoms of withdrawal when it is ceased.
The dependence of nicotine alone is also overrated. There are other ingredients in tobacco smoke which make nicotine more habit-forming (monoamine oxidase inhibitors). Cigarettes also deliver nicotine very quickly which increases its dependence potential.
However, outside of tobacco smoke, nicotine is far less dependence-forming. For example, nicotine gum and patches have very low risk of dependence but are used long-term by some ex-smokers to prevent relapse. The behavioural, sensory and social aspects of smoking also enhance dependence.
It is important to note that nicotine is approved for use as a medicine in Australia from the age of twelve.
Beneficial effects of nicotine
Nicotine has a range of benefits, including hedonistic (pleasure), functional and therapeutic effects:
Source: Clive Bates, ECig Summit 2023
Many people regard nicotine (when delivered with minimal harm) as a socially acceptable recreational stimulant, like caffeine and alcohol.
There is no evidence that nicotine vaping causes seizures. The fact that a seizure occurred while vaping does not prove that vaping was the cause.
Association or causation?
Both vaping and seizures are common
As a result, it is likely that some people who vape will have a seizure from time to time. However, this is an association of two behaviours, and is not causal.
The NHMRC incorrectly claims that there is “high certainty” evidence that vaping leads to seizures. This claim was subsequently debunked by 11 leading international experts in a critique in Addiction:
“A small number of case studies have reported seizures in people using nicotine e-cigarettes, but these cases do not establish causation and hence do not qualify as ‘high-certainty’ evidence. Many of these cases had a pre-existing seizure disorder, and some had used other drugs. If nicotine e-cigarette use was a cause of seizures, an association between cigarette smoking and seizures would also be expected—but none has been reported”
In the US, 35 cases of seizures ‘associated with vaping’ were reported to the FDA from 2010-2019. Soon after, the FDA acknowledged that “A causal relationship between e-cigarette use and seizure has not been established“. Some of these episodes were in people with epilepsy, others caused by illicit drug use.
Severe nicotine poisoning
Claims of seizures from vaping nicotine may be confused with seizures from severe nicotine poisoning. A nicotine overdose from ingesting nicotine liquid can cause seizures and this may have led some people to think that nicotine vaping may also be implicated.
No. This condition was not caused by nicotine vaping.
In 2019, there was an outbreak of a serious lung injury EVALI (E-cigarette, or Vaping, product use-Associated Lung Injury) in the US in people who had recently vaped. This condition has now been clearly associated with vaping black-market cannabis (THC) oils contaminated with vitamin E acetate (VEA), purchased from street dealers.
Not a single case has been linked to commercial nicotine vaping to stop or reduce smoking. VEA cannot be dissolved in nicotine e-liquid and has never been detected in nicotine e-liquid. Noo other potential cause in nicotine vapes has been identified.
When VEA was removed from the illicit supply chain, EVALI disappeared in early 2020. No further cases have been reported in the US despite the continuing widespread use of nicotine vaping and no significant e-cigarette product changes.
Some fourteen percent of cases denied using THC vapes and some commentators have incorrectly claimed that nicotine vapes must have been the cause. However some of those who denied using THC were later found to have done so after family interviews or testing. Also, THC was illegal in many states at the time. False denials were more common in states where THC was illegal.
The death of an Australian man in 2021 was incorrectly attributed to EVALI. The man had been a heavy smoker for 40 years and switched to vaping 10 years before his death. It is far more likely that the man died from progressive lung damage caused by 40 years of heavy smoking.
No. There is no evidence that vaping nicotine causes this condition and there has not been a single case linked to vaping.
‘Popcorn lung’ (bronchiolitis obliterans) is a serious, but rare lung disease first detected in popcorn factory workers. It was linked to very high levels of ‘diacetyl’ which is used to create a buttery flavour.
Some earlier e-liquids contained diacetyl, however the levels found in vapour were hundreds of times lower than in cigarette smoke and there has never been a case of bronchiolitis obliterans due to smoking or vaping. Diacetyl is now rarely used and is banned in Australia in e-liquids.
According to leading health organisations
However Australia’s peak health and medical research body, the NHMRC falsely claims that vaping causes popcorn lung in its 2020 CEO statement on vaping and has refused to withdraw this claim, in spite of being advised of the evidence in our review in Addiction:
There is no evidence that vaping causes spontaneous pneumothorax.
A spontaneous pneumothorax is the sudden collapse of a lung without any apparent cause. It occurs when a congenital bleb or ‘bulla’ on the surface of the lung ruptures. Air is released from the lung into the chest cavity (pleural space) and the lung collapses.
Spontaneous pneumothorax occurs mainly in healthy young people without underlying lung disease, and can be sometimes triggered by smoking, strenuous exercise e.g., heavy lifting or severe coughing. It is most common in the 15-34-year-age group, especially in tall, thin young men. About 90% of cases in this age group are spontaneous. ‘Spontaneous’ means there is no underlying cause.
“Secondary” pneumothorax is caused by underlying lung disease. The most common cause is emphysema but also pneumonia, lung cancers, asthma, pulmonary fibrosis, and cystic fibrosis. Secondary pneumothorax is less common and occurs mainly in older people (55+).
Pneumothorax is common. For example, in England it occurs in 24 men and 10 women out of every 100,000 people each year. In fact, I personally was admitted to hospital with a spontaneous pneumothorax at the age of 20, and neither smoked or vaped.
In Australia, with 1.6 million adult vapers, most being under 40, there would be over 200 cases of spontaneous pneumothorax each year in young people who vape. This is based on 17 cases per 100,000 people per year, of which 90% are spontaneous.
The occurrence of vaping and this condition is an association. There is absolutely no reason to suggest that vaping causes spontaneous pneumothorax.
Many studies have found that adolescents, young adults and adults with depression are more likely to try vaping. (Lechner; Saeed; Gorfinkel; Javed). However, despite claims by some anti-vaping advocates, there is no evidence that vaping causes depression.
In fact, nicotine relieves depression and many people vape nicotine to make themselves feel better (known as “self-medication”). Nicotine acts in the “reward centre” of the brain to release the hormone dopamine, which creates pleasure. It also releases other chemicals in the brain, relieving anxiety and improving mood.
Adolescents often report vaping for stress relief. In the 2021 Canadian Tobacco and Nicotine Survey, the most commonly reported reason for vaping was to relax and relieve tension. A report by the NSW Office of the Advocate for Children and Young People in 2023 found that many young people use vaping as a coping mechanism “to manage their distress”. Vaping helped them deal with stress from home and school.
Higher levels of depression are associated with a faster escalation of e-cigarette use.
The beneficial effects of nicotine also partly explain why smoking rates are much higher in people with anxiety disorders and depression. However, smoking is deadly and smoking does far more harm overall than good.
One downside is that vapers who become dependent on nicotine can develop withdrawal symptoms when they cease vaping. These symptoms can include anxiety, loss of concentration, low mood and insomnia. In most cases these symptoms resolve over a couple of weeks. They are short-term and can be unpleasant, but are not harmful or serious.
It is best not to vape or smoke in pregnancy, however vaping is certain to be safer than smoking for the mother and foetus and is an effective quitting aid in pregnancy.
Safety in pregnancy
Unlike smoking, studies of vaping in pregnancy (here, here, here and here) have found little or no effect on birthweight, nor any increase in the risk of adverse birth outcomes. A randomised trial found that the safety of vaping was similar to nicotine patches and women who vaped were less likely to have babies with low birthweight (<2,500g).
Women who smoke who switch to vaping in pregnancy should aim to stop smoking completely for the best results.
Nicotine has been linked to harmful effects on the fetus in animal studies. However, there is no evidence that these findings apply to humans. Nicotine may not be completely safe for the pregnant mother and foetus, but it is always safer than smoking.
Nicotine replacement products such as patches, gums and lozenges are approved for use in pregnancy in Australia. Human studies have not shown any clear harms from their use, such as stillbirth, premature birth, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities or neonatal death.
Although it is not risk-free, vaping has a role as a substitute for pregnant women who are unable to quit smoking with other methods. It should not be used by women who do not smoke.
A randomised controlled trial of 1,140 pregnant smokers found that vaping was twice as effective for quitting as nicotine patches (6.8% vs 3.6%). A cohort study of 1,329 pregnant women found that women who vaped were more than twice as likely as other those using NRT to report abstinence late in pregnancy (50.8% vs 19.4%). Vaping may also help to prevent relapse to smoking after birth.
Women who vape are more likely to breastfeed than women who smoke and also continue breastfeeding longer.
The use of vaping in pregnancy is endorsed by an important expert group in the UK, the Smoking in Pregnancy Challenge Group, a partnership between the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and the Royal College of Paediatrics and Child Health.
The Challenge Group provides the following advice to midwives:
“Very little research exists regarding the safety of using e-cigarettes (vaping) during pregnancy, however evidence from adult smokers in general suggests that they are likely to be significantly less harmful to a pregnant woman and her baby than continuing to smoke.”
Advice from the Challenge Group
The UK Royal College of Midwives 2019 Position Statement on quitting in pregnancy states:
“E-cigarettes contain some toxins, but at far lower levels than found in tobacco smoke. If a pregnant woman who has been smoking chooses to use an e-cigarette (vaping) and it helps her to quit smoking and stay smokefree, she should be supported to do so.”
The UK National Centre for Smoking Cessation and Training says, “if a person who is pregnant chooses to use a vape, and if that helps them to quit smoking and stay smokefree, they should be supported to do so.”
1. Use of electronic cigarettes before, during and after pregnancy. A guide for maternity and other healthcare professionals. Smoking in Pregnancy Challenge Group 2020
2. Position Statement. Support to Quit Smoking in Pregnancy. The Royal College of Midwives. 2019
Vaping is significantly less addictive than smoking. Smokers who switch to vaping find it easier to quit vaping (than smoking) when they are ready to try. [Refs: Shiffman 2020; Foulds 2015; Fagerstrom 2018; Hughes 2019; Liu 2018]
Almost all former smokers who vape were already dependent on nicotine from past smoking but have transferred their nicotine dependence to a much safer product.
A comprehensive report commissioned by the UK Government in 2022 concluded that:
“the risk and severity of [nicotine dependence from vaping] is lower than for cigarette smoking”
Addiction by young people
Nicotine dependence from vaping is rare in young people who have never previously smoked. In the US, less than 4% of young never-smokers who vaped reported symptoms of addiction to vaping.
A study by 15 past Presidents of the Society for Research on Nicotine and Tobacco concluded:
“Vaping likely addicts some young people to nicotine. However, the evidence does not suggest it is addicting very large numbers. Jarvis et al. concluded that “Data . . . do not provide support for claims of a new epidemic of nicotine addiction stemming from use of e-cigarettes.” Jackson et al. recently reported that the e-cigarette–driven increase in nicotine product use among high-school students is not associated with an increase in population-level dependence. Among tobacco-naïve youths, in addition to low vaping prevalence (9.1% in the past 30 days in 2020) and frequency (2.3% vaping ≥20 days in the past 30 days), small percentages exhibited signs of nicotine dependence.90
Frequent use is much more common among current or former smoking youths than among never-smokers. Many former smokers were already addicted to nicotine before initiating vaping. With high-school students’ smoking declining at an increasing rate since youths began using e-cigarettes, some may vape to reduce or quit smoking.”
“More addictive than heroin?”
It is wrong to say “nicotine is more addictive than heroin”. The dependence-forming characteristics of nicotine depend on how it is delivered i.e., how fast it reaches the brain and whether there are other chemicals that increase its effect.
That is why dependence on nicotine patches is very uncommon. Less than 2% of patch users continue long-term.
A word on the definition of ‘addiction’
The urge to vape is not strictly characterised as “addiction”. According to Addiction Ontology, the definition of addiction is a compulsion to engage in a behaviour known to cause serious net harm.
Nicotine has only minor health effects and the urge to vape is best described as dependence. Dependence means having the urge to use a drug to avoid physical symptoms of withdrawal when it is ceased.
Many people do not regard dependence on nicotine from vaping as a problem as it provides many beneficial and enjoyable effects.
Switching from smoking to vaping is simply changing the source of nicotine from a deadly delivery system (a cigarette) to a far less harmful, potentially lifesaving alternative.
With vaping, there is no burning and therefore no tar, carbon monoxide and other harmful constituents that are inhaled from tobacco smoke. Vaper is a far safer and less addictive source of nicotine.
Some former smokers continue vaping long-term to avoid relapse to smoking. However for many, vaping is a temporary transition stage and many go on to quit vaping as well as smoking.
Wrong. Even frequent vaping is far safer than smoking and each puff is far less harmful.
Smokers and vapers puff to get the right level of nicotine their brain needs. A cigarette has to be consumed in one sitting, usually in 10-12 puffs, to deliver the nicotine hit. Vapers often ‘graze’, i.e., regularly take a few puffs on their vape as needed to maintain their nicotine levels through the day.
Vapers generally get less nicotine than smokers and it is usually delivered more slowly. More importantly, the nicotine is not accompanied by the thousands of toxic chemicals in smoke from burning tobacco.
You should use your vape as often as you need to get sufficient nicotine to prevent cravings and avoid relapse to smoking.
Accidental ingestion of nicotine is usually followed by intense vomiting and most cases resolve without treatment. Serious harm is rare. Accidental poisoning from nicotine e-liquid is rare especially when compared to poisoning from other chemicals and medicines. However, if a child swallows nicotine e-liquid, medical advice should be sought immediately.
Poisons Information Centres document ‘exposures’ to nicotine e-liquid which are often incorrectly reported by the media as ‘poisoning’. However, the Australian government says “Poisoning occurs when someone is sufficiently exposed to a substance that can cause illness, injury or death”.
‘Exposures’ are simply phone calls about actual or potential exposure or a request for information. Calls could include an enquiry from a worried parent that a child had touched a vape or put a vape in the mouth.
In 2022, the NSW Poisons Information Centre (PIC) received 213 calls about ‘exposure’ to nicotine e-liquid by children under the age of four. No serious outcomes were reported in the media. In comparison there were 927 calls about hand sanitiser, 834 calls about dishwasher detergent and 788 calls about toiler cleaner in this age group.
The Victorian Poisons Information Centre reported low rates of exposure to liquid nicotine in 2018 and 2019. The number of cases referred for treatment was 14 in 2018 and 15 in 2019. The claim by the Health Minister (19 June 2020) that nicotine poisoning had doubled during this time period is incorrect.
There has been one death in Australia from accidental nicotine liquid poisoning. In May 2018, an 18-month old child died after drinking from an open (non-childproof) bottle of imported concentrated nicotine (100mg/mL) when the mother was mixing the nicotine with locally purchased flavours. This tragic case underlines the importance of allowing the sale of low-concentrations of nicotine liquid, so it is available in child-proof containers with warning labels.
Three other accidental child deaths have been reported globally since 2013: one each in Israel, Korea and the US.
According to a review by Public Health England, the risks of ingestion of e-liquids appear comparable to similar potentially poisonous household substances.
Any poisoning risk should be considered in the context of 21,000 annual deaths from smoking in Australia. Many of these could be prevented by the wider use of vaping nicotine.
Exposure to poisons is widespread in society and is associated with many products from which society benefits, such as bleach and laundry detergents. These are managed by common-sense, warning labels and child resistant containers – not by bans.
Rechargeable lithium ion batteries in vaporisers can malfunction (“thermal runaway”) resulting in thermal and chemical burns and traumatic injuries. These incidents get a lot of media attention, but fortunately are very rare and most can be prevented.
Malfunctions of this type do not occur in the popular beginner models, ie sealed pod devices and pen-style models in which the battery is built-in and not removable. These devices are regulated and have an integrated circuit (chipset) to maintain electrical safety and protect the device from overheating. It cuts out the power if there is a malfunction or if the fire button is pressed for too long.
Nearly all ‘exploding e-cigarette’ stories you hear about on the news aren’t from regulated, properly handled vaping products. They are mostly from loose spare batteries being carried around in a pocket or purse where they come into contact with metal objects like keys or coins and discharge accidentally.
‘Mechanical mods’ used by some experienced users they do not have built-in electrical protection and must be used with great care. Sometimes incidents also occur with devices which have been tampered with.
Tobacco cigarettes remain the biggest cause of fatal house fires. According to the London Fire Brigade “Switching from smoking tobacco to vaping can greatly reduce the risk of dying in a fire”.
Most incidents could be prevented by user education eg
Plastic case for a 18650 battery
Vaping nicotine is a more effective quitting aid than nicotine replacement therapy (patches, gums, lozenges) and is probably the most effective quitting aid available. Vaping has helped millions of smokers quit who were unable to quit with other methods.
Studies show that vaping is effective in the controlled setting of randomised controlled trials, in natural real-world studies and with or without support.
Randomised controlled trials
The best scientific evidence that a treatment works is from randomised controlled trials (RCTs), in which subjects are randomly allocated the treatment (in this case vaping) or something else in a carefully controlled setting and the outcomes compared. The gold standard is Cochrane reviews which pool and analyse results (‘meta-analyse’) from the best RCTs to give even more reliable results:
A similar review by the UK National Institute for Health Research analysed 363 RCTs of smoking treatments and concluded that vaping was the most effective single therapy, followed by varenicline (Champix) and nicotine replacement therapy (NRT).
RCTs underestimate the effectiveness of vaping. RCTs are limited to short time frames, typically 6 months. Real-world studies show that many smokers quit early but others switch successfully over time, some taking a year or more to adjust to vaping, eg Goldenson 2021. These quitters are not captured in RCT results.
Triangulation with other research
Combining different types of research with different strengths and weaknesses (triangulation) provides a more accurate picture than just RCTs alone. These studies all point to the same conclusion, strengthening the evidence that vaping is an effective quitting aid. They also show that vaping works in the real-world setting, not just in a controlled trial setting.
1. Observational studies
Observational studies examine whether vaping works by observing its impact in real-world settings. The findings are less reliable than RCTs but still give valuable information. The better quality observational studies show that vaping increases quitting (eg Goldenson 2021; Adriaens 2021; Kotz 2022).
2. Population studies
Multiple large population studies have found that smokers who vape to quit have significantly higher quit rates and quit success than smokers who do not vape, for example in the United States and in the United Kingdom. A study in Australia, Canada, England, United States found that smokers who initiated daily vaping were more likely to make a quit attempts and were three times more likely to have quit 12-24 months later. Non-daily vaping was not effective in increasing quit rates. Daily vapers are 3–8 times more likely to quit than smokers who do not vape.
An Australian population study by Chambers found that smokers who attempted to quit with vaping were twice as likely to have quit smoking for more than a month, 12 months later than those who did not try vaping (excluding those who vaped only once or twice). Higher quit rates are expected in a more supportive regulatory environment.
3. Declines in national smoking rates
Many western countries which provide legal access to vaping have experienced rapid declines in national smoking rates (see below). Vaping is not the only factor at play but is likely to be a major contributor.
4. England Stop-Smoking-Services
Analysis of quit attempts by the Stop Smoking Service in England shows that smokers have greater success in quitting by vaping with professional support compared to any other quitting method (64.9% vs 58.6%). (OHID 2022)
5. Accidental quitters
Vaping is unique as a quitting aid in that many smokers with no intention to quit, who try vaping, go on to quit without any support. Accidental quitters are surprisingly common and are not captured in RCTs. Studies include Kasza 2021; Foulds 2022; Carpenter 2023.
Anecdotes are the weakest type of scientific evidence. However in 2021, there were an estimated 82 million vapers globally and many more had quit smoking and vaping completely. At these levels, anecdotes can’t be ignored.
Smoking rates have stagnated over the past decade in Australia while falling 2-3 times faster in other countries where safer alternatives such as nicotine vaping, snus, nicotine pouches and heated tobacco products are widely available.
The adult smoking rate in Australia declined by only 1.7% per year since 2013, despite comprehensive tobacco control strategies, plain packaging and the highest cigarette prices in the world.
In New Zealand, the adult smoking rate fell by an unprecedented 33% from 2020-22 after vaping was legalised and regulated in August 2022 by the New Zealand parliament. During the same period, the smoking rate in Australia increased by 4.5%.
Because of their effectiveness and popularity, vapes have the potential for a substantial positive public health impact (a function of reach × efficacy), given that vapes are both more effective and have a greater reach than other approved cessation methods.
Vapes function as substitutes for cigarettes. Smoking rates decline faster as vapes became more widely used with the largest declines occurring among young adults, the age group with the highest vaping uptake.
Studies show that vapes function as economic substitutes for cigarettes. For instance, higher cigarette prices are associated with lower cigarette purchases but higher vaping purchases. Likewise, there is some evidence that higher e-cigarette prices are associated with higher cigarette purchases.
There is evidence that restrictions imposed on vape sales has the harmful unintended effect of driving tobacco users back to cigarettes, which are far more harmful to health.
Vaping nicotine is now the most popular quitting aid in Australia and in many countries where it is readily available.
In 2019, 22% of Australian smokers used vaping to help them quit (8%) or reduce (14%) smoking. The next most popular quitting aid was nicotine replacement therapy (17%), followed by smoking cessation pills (6%), quit smoking apps (5%) and Quitline (2%).
Because of its combined popularity and effectiveness, the public health impact of vaping is even greater.
It is recommended that smokers should try to stop vaping once they have successfully quit smoking. However, for many former smokers, relapse to smoking is a constant risk. Research suggests that vaping may play an important role in preventing relapse. Vaping can act as a substitute for smoking behaviour to help cope with urges to smoke.
Smokers vary in the length of time they continue to vape after switching from smoking. The number vaping gradually declines over time, although some vapers need to vape long-term to prevent relapse to smoking.
An analysis of 19 studies in 2022 found that 70% of smokers who quit with vaping were still vaping after 6 months. In Great Britain, 55% of current vapers had been vaping for over 3 years, according to the annual ASH UK report in 2023. Of course, many former smokers who quit with vaping are now neither smoking or vaping.
Remember, “abstinence from nicotine is not necessarily a priority, the most urgent priority is to switch away from smoking tobacco”. (UK NCSCT)
You should only try to quit vaping when you are confident that you will not relapse to smoking as the small health risk from continuing to vape is minor compared to the harm from relapsing to smoking.
Quitting vaping is generally much easier than quitting smoking as vaping is less addictive. Some people can stop vaping abruptly, using techniques to manage urges, such as distraction and a commitment to the ‘not-a-puff’ rule.
If you are more dependent on vaping, you can gradually reduce the nicotine content of your vape and try to use it less frequently. Reducing nicotine levels may require an “open” vape system so you can fine tune your dose reductions. You can gradually reduce the time between vaping and set rules for when and where you do and do not vape to gradually reduce use. However if there is any risk of relapse to smoking you should continue vaping.
Some people benefit from switching to nicotine replacement therapy, such as patches or gums, as a step to quitting. There is some evidence that a course of varenicline tablets (Champix) can also help you stop vaping. This needs to be prescribed by your doctor.
After quitting, it is a good idea to keep a vape or faster-acting NRT (eg gum or lozenge) at hand for ‘emergency’ situations when a sudden trigger causes an urge to smoke.
Supporting clients who want to stop vaping. National Centre for Smoking Cessation and Training, UK. 2022
Wahhab M. Clinicians guide to supporting adolescents and young adults quit vapes. Sydney Childrens Hospital Network 2023
A Guide to Support Rangatahi (children) to Quit Vaping. NZ Asthma and Resp Foundation 2023
Only one in twenty 14-17-year-olds in Australia vapes frequently and half of these had already tried smoking, according to Australian research.
This is a far cry from the alarmist media headlines of a youth vaping ‘epidemic’ and a ‘new generation addicted to nicotine’.
From a health point of view, the main concern is for never-smoking teens who vape frequently as this is the group most at risk from new and potentially harmful inhaled chemicals.
However, less than 2% of Australians 14-17-year-olds vape nicotine ‘frequently’ but have never smoked
Media reports usually refer to lifetime (ever-vaping) or past-12 month vaping. These measures exaggerate the risk as most teen vaping is experimental and short term. Many vape only once or twice, or every now and then. This group is at little or no risk of harm.
Many young people who vape were former or current smokers who turned to vaping as a safer alternative or as a quitting aid, according to the National Drug Strategy Household Survey. Smokers who switch to vaping are likely to have improved health.
A study by Watts in 2022 of 721 youth aged aged 14-17-years in NSW found that 16% had vaped in the past 30 days. However, more than half only vaped 1-5 days in the month. Of the total sample only 5% were vaping frequently (defined as vaping on 6 days or more in the past 30 days).
The study reported that 54% of of teens who vaped had not tried smoking before they tried vaping, Therefore only about 2.5% of teens who vaped frequently had never smoked.
Another survey by Gardner of 4,204 youth aged 14-17 years published in 2023 found similar results. The study surveyed youth in NSW, Victoria and Queensland and found that 10.1% had vaped in the last 30 days. However, only 5.7% were frequent vapers, ie had vaped 6 times or more in the last 30 days.
The smoking status of vapers was not identified, but assuming the same proportion had not tried smoking as in the Watts study (54%), the rate of frequent vaping by never-smokers would be 2.8%.
Furthermore, many young vapers do not use nicotine. Watts found that only 37% were using nicotine, although 27% did not know if they were using it or not. Not using nicotine reduces the risk of developing nicotine dependence and lessens the concerns about youth vaping.
Frequent vaping by young never smokers is generally <2% in other western countries. (reference)
For example, in England in 2021 only 1% of 11-15-year-olds who had never smoked cigarettes vaped regularly (once or more weekly).
Mendelsohn CP, Hall W. What are the harms of vaping in young people who have never smoked? Int J Drug Policy 2023
Blog post. Frequent vaping by teen non-smokers is very uncommon in Australia, August 2023
There is now good evidence that vaping is NOT a gateway to youth smoking. In fact, vaping is REDUCING smoking rates overall by diverting young people away from smoking.
There are 5 strands of scientific evidence supporting this finding.
1. Common risk factors for vaping and smoking
Studies show that young people who experiment with vaping are three times more likely to also try smoking. However, young people who experiment with vaping are different to kids who don’t vape. Kids who try vaping are more likely to use other drugs, have friends who vape or smoke, have mental illness, parents who smoke, come from lower socio-economic backgrounds, have lower education etc. These ‘shared risk factors’ put them at risk of experimenting with both vaping and smoking.
Studies that allow for these differences between groups have found that the increased risk of smoking in teens who vape (compared to teens who don’t vape) dramatically reduces or disappears. For example, Kim 2019, adjusted for 14 shared risk factors and concluded that:
“The apparent relationship between e-cigarette use and current conventional smoking is fully explained by shared risk factors, thus failing to support claims that e-cigarettes have a causal effect on concurrent conventional smoking among youth”
2. Accelerated decline in youth smoking
The gateway theory predicts that vaping will increase smoking rates in young people. However, we are seeing the opposite of this. In countries where vaping is readily available such as the UK, US and New Zealand, the decline in youth smoking rates has accelerated (Levy 2019; Meza 2021; NHS Digital UK 2022; ASH NZ 2022).
For example, since vaping became popular in the US in 2013, smoking by high schoolers has fallen 10% faster than the previous decline.
2 recent studies from the US and UK confirmed the absence of a gateway effect:
3. Vaping diverts young people from smoking
Many studies have found that vaping and smoking are substitutes and that vaping is diverting young people AWAY FROM smoking.
4. Restrictions on vaping increase smoking
Other research studies (natural experiments) have found that youth smoking rates increase when access to vaping is restricted. This has been demonstrated for
These findings confirm that vapes and smokes are substitutes. Reducing access to vaping increases the uptake of deadly smoking.
5. Vaping first (before smoking) reduces smoking uptake
There is growing evidence that teens who vape first (before smoking) are less likely to smoke later, compared to those who smoke first (Shahab 2021; Legleye S 2021; Mus 2023) Other studies have found no evidence that vaping first increases smoking uptake (Chyderiotis 2020; Stanton 2023)
Despite the flood of alarming stories in the media, vaping carries relatively minor health risk for young people who have never smoked.
This 5-minute video outlines the key issues:
Most vaping by young non-smokers is infrequent and short-term, so they are exposed to low levels of chemicals and therefore low risk. A recent review of adolescents and young adults concluded
“Most e-cigarette usage is infrequent and unlikely to increase a person’s risk of negative health consequences”
Some young people have reported cough or wheeze from vaping, however
Vaping nicotine does NOT cause the serious lung disease E-cigarette or Vaping Associated Lung Injury (EVALI) or spontaneous pneumothorax (lung collapse) – see above.
High doses of nicotine can harm the adolescent brain in animal studies but there is no evidence of harm in humans. Even smoking has not been found to impair IQ, educational achievement or cognitive abilities later in life, so it is very unlikely that vaping will.
There is no evidence that vaping nicotine causes seizures. There is a rare risk of burns and injuries from lithium-battery explosions, but none have been reported from disposables, the most popular type of device used by young people.
Nicotine dependence in never-smokers
Vaping can cause nicotine dependence in some young people who have never smoked. However, this is only in a small minority of cases. Nicotine withdrawal can cause short-term symptoms such as irritability, restlessness, anxiety, difficulty concentrating and depression. Nicotine otherwise causes little harm in the doses commonly used in vaping. Nicotine does not cause cancer or lung disease and it has only a minor role in cardiovascular disease.
In Australia, less than 2% of non-smoking 14-17-year-olds vape nicotine “frequently” enough to be at-risk of developing nicotine-dependence.
An analysis of the 2018 US National Youth Tobacco Survey found that <4% of young people who had vaped in the past 30 days but had never smoked had signs of nicotine dependence. This is to be expected as the dominant pattern of use is occasional and short-term.
Nicotine dependence is mostly concentrated in young people who have are past or current smokers.
Risk for former smokers
Vaping is not harmless, but is far less harmful than smoking. Young smokers who switch to vaping are likely to see health benefits.
The precise long-term effects of vaping nicotine will not be fully known for decades but are highly likely to be far less than from smoking. Ongoing monitoring and long-term studies are essential to detect any problems that may arise in the future, particularly from sustained frequent vaping.
Mendelsohn CP, Hall W. What are the harms of vaping in young people who have never smoked? International Journal of Drug Policy 2023
Mendelsohn CP, Wodak A, Hall W. How should nicotine vaping be regulated in Australia? Drug and Alcohol Review. April 2023. DOI: 10.1111/dar.13663
Kids should not smoke or vape, but the benefits of vaping outweigh the risks at a population level. Rather than just focus on the harms of vaping, we need to do a formal risk-benefit analysis of youth vaping to assess its overall impact.
The harms of vaping are summarized above. The key points are
Vaping is not risk-free, but the benefits of youth vaping outweigh the modest risks at a population level, especially due to its impact in reducing smoking rates.
This is not to endorse youth vaping. Kids should not vape or smoke, but some kids will do one or both anyway. However, policy should not be driven by emotion or moral judgements. Evidence-based policy should consider the overall impact of vaping.
More here: Youth vaping: a risk-benefit analysis
There is no evidence that nicotine causes harmful effects on the human adolescent brain.
Nicotine has been linked to harmful effects on the adolescent brain animal studies which mostly use chronic, high-dose exposure. However, given species and dosing differences, the extrapolation of these findings to humans is speculative. The rodent brain is not a reliable proxy for the human brain.
Also, there is no long-term evidence of impaired brain function in the hundreds of millions of adults who smoked as adolescents and then stopped.
Studies of young people who smoked have not found any difference in IQ, educational achievement or cognitive abilities in adulthood between those who have smoked in the past and those who have never smoked.
Nicotine in NRT is approved for use from the age of 12 in Australia.
High levels of youth vaping are largely a result of failed regulations.
Under current Australian law, adult vapers are required to have a doctor’s prescription for nicotine to vape legally, but very few are willing to get one. This has created a thriving black market run by organised crime groups, which supplies dodgy, unregulated vapes freely to teens through rogue convenience stores and tobacconists or via social media.
Eliminating the black market is the key to reducing youth vaping. The only way to eliminate the black market is to replace it with a legal, regulated one.
A tightly regulated, risk-proportionate consumer model with strict age verification would make regulated vaping products more available for adults who smoke, reduce illicit sales and make vapes less accessible and less appealing to young people.
Measures to reduce youth access and appeal include
It is strongly recommended that non-smokers should not start vaping. However, vaping is largely confined to smokers and ex-smokers. Use by adults who have never smoked is rare.
In Australia in 2019, only 0.7% of never-smokers aged 14 and over were ‘current’ vapers (vaped at least once in the last 12 months). In a study in 2023, 1.2% of current Australian adult vapers had never smoked.
Some never-smoking vapers may have taken up smoking instead if vaping was not available.
Never-smokers who vape, also vape less frequently. For example, in Great Britain, only 8.8% of never smokers who have ever tried vaping report vaping daily. Never-smokers who vape are also less likely to use nicotine.
International surveys have found that vaping by adult non-smokers is generally around 1% or less, for example Great Britain 1.1%; New Zealand no regular use; United States 0.3%; European Union current daily use by never smokers 0.08%; Germany 0.3%; Iceland 0.4%; and Greece 0.2%.
There is no evidence that vaping is renormalising smoking.
Vaping critics fear that widespread vaping could make smoking appear more socially acceptable again and undermine decades of successful tobacco control efforts. However, a review of studies on renormalisation found no evidence that this is happening.
According to Public Health England , ‘There is no evidence that ENDS are undermining the long-term decline in cigarette smoking among adults and youth and may in fact be contributing to it’.
This was also confirmed in another study of adolescents in Great Britain during a period of rapid growth of vaping. Another recent review by the National Institute of Health and Care Research came to the same conclustion – youth attitudes to smoking became more negative over the time when vaping was increasing, the opposite of what would be expected from renormalisation.
The main sign that renormalising is occurring would be stagnating or rising smoking rates. In fact, the opposite is occurring. Smoking rates have declined at a faster rate in the UK and US since vaping became widely available.
About one in two vapers also currently smokes (dual use). This is often a temporary transition phase and is usually less harmful than exclusive smoking. However, dual users should try to quit smoking completely as soon as possible.
Some smokers quit smoking soon after they start vaping. Others take longer and smoke and vape for a period while trying to transition to exclusive vaping.
Dual users are a mixed group. Some are predominantly smokers who vape occasionally. Others mostly vape, but smoke occasionally.
Is dual use harmful?
Dual users usually reduce their cigarette intake, often to very low levels because they are getting some of their nicotine from vaping. Dual users have lower levels of toxins in the body compared to exclusive smokers and many studies show improvements in health, such as blood pressure and asthma. However, when dual users do not reduce their cigarette intake, toxin levels are not reduced compared to smoking.
The only potential harm from dual use is if it reduces interest in quitting. However, this does not appear to be the case. Smokers who vape are more interested in quitting than those who do not and are more likely to make quit attempts.
One reason for continuing dual use is the widespread misinformation about the risks of vaping. Many people incorrectly believe that vaping is as harmful as, or even more harmful than smoking. If you believe that, why would you bother trying to stop smoking?
Quitting dual use
Dual users are more interested in quitting and are more likely to quit smoking than other smokers, especially if vaping daily. However, smokers who become dual users are often more nicotine-dependent and many will not be able to quit smoking in a given attempt. Studies have typically found that 20-45% of dual users quit smoking over the next one to two years.
A randomised controlled trial of varenicline (Champix) found it was effective in helping long-term (>12 months) dual users quit smoking. Between 4 and 12 weeks, 50% quit with varenicline and 17% with placebo.
How common is dual use?
Dual use tends to decrease over time as more dual users quit smoking. In Great Britain, only 37% of current vapers were also smoking in 2023 and in the United States the dual use rate was 35-39% in two national surveys in 2019.
Vaping is substantially cheaper than smoking and can lead to large financial savings.
Australia has the highest priced cigarettes in the world. The average cost of smoking in Australia is $11,850 per year (13 cigarettes per day; a 20-pack of the leading brand costs $40). Vaping costs $500-2,000 per year depending on the type of device used, a saving of over $10,000 per year.
This is especially important for low-income and disadvantaged populations such as people with mental illness, substance use disorders, Indigenous people, prisoners, LGBTIQ+ communities and people who use drugs whose families suffer considerable financial stress, and have less money for other essential needs like food, housing, healthcare, and education.
Disadvantaged populations have twice the smoking rate of the wealthy, smoke twice as many cigarettes and have lower quit rates. Smoking is responsible for half the difference in life expectancy between the most and least advantaged in society,
Smoking is also a social justice issue and vaping could help reduce health and financial inequalities.
The growing popularity of vaping products has raised concerns about their environmental impact, especially from disposable products. Vaping products have a far lower impact on the environment than cigarettes because most users do not vape long-term, however they are a growing source of litter, environmental harm and fires.
Recycling of vape products is important because it
Currently most disposable vapes are sold illegally on social media and at retail outlets. Recycling is not an option for these illegal sales, which are mostly disposable products. A recycling program is only workable when nicotine vaping products are made legal, adult consumer products sold from licensed retail outlets
A national recycling program
A vape recycling program is best managed by expanding the existing National Television and Computer Recycling Scheme under the auspices of the Australian Government Department of Climate Change, Energy, the Environment and Water.
The first step required is to make nicotine vaping products legally available for sale through licensed retail outlets, such as vape shops, conveniences stores, pharmacies and tobacconists. The recycling model can only be applied to the legal market.
Recycling of vape products would be mandatory for all licensed vaping product retailers. Monitoring would be required with fines and loss of licence for failing to comply with recycling rules.
How it works
The recycling process is set out in this flowchart:
Recyclable extracts are used to manufacture other products. Non-recyclable components are disposed of in landfill.
All retail outlets selling nicotine vaping products would be licensed and have mandatory recycling boxes for used devices. Recycling boxes would be available at other locations as well.
Consumers would return used products when purchasing supplies. Consumers would need to be educated and a financial incentive could be provided, such as a small discount on future purchases.
Recycled products would be collected by recycling companies. Components would be recycled and reused.
Some vaping sceptics argue that there are things we don’t know about vaping, so it is better to wait until we have more information, and this could take several decades. ‘Better to be safe than sorry’. This is known as the ‘precautionary principle’.
However the precautionary principle is misused when applied to vaping in this way. When correctly applied, the precautionary principle requires a full assessment of both the potential risks and benefits of both adopting and rejecting a new product.
In the case of vaping nicotine, the risks of NOT adopting vaping are much greater because cigarettes are substantially more harmful. Banning nicotine vaping denies smokers the opportunity to quit or switch to a much less harmful product.
This requirement for long-term evidence is not applied to other products. If we applied this standard in other areas, no new medicines would be introduced until we had safety data from 20-30 years of use.
Over the past 15 years there has not been a single confirmed death from nicotine vaping anywhere in the world and serious adverse effects are extremely rare. The alternative behaviour, tobacco smoking, kills 8 million people world-wide per year.
In Australia there are about 21,000 deaths each year from smoking related conditions.
The Royal Australian and New Zealand College of Psychiatrists states in its 2018 Position Statement on vaping:
“Further research is required to ascertain the effectiveness of e-cigarettes and vaporisers as tools for smoking cessation and whether they may provide a novel route into smoking initiation. This does not justify withholding what is, on the current evidence, a lower-risk product from existing smokers while such data is collected.”
Vaping is not a ploy by the evil tobacco industry to “hook a new generation of Australian children on nicotine” as claimed by some anti-vaping activists and the Health Minister Mark Butler. This is a convenient narrative by vaping opponents to undermine vaping by poisoning it by association with Big Tobacco.
None of the disposable vapes sold in Australia on the black market and used by young people are made by tobacco companies. All of these are imported illegally from China.
In any case, vaping is diverting young people away from deadly smoking. As youth vaping rates increase, smoking rates in countries like New Zealand, the UK and US are falling faster than ever (see above)
The reality is that vaping is a huge disruptive threat to the tobacco industry and is a direct competitor to its highly profitable tobacco sales, much like digital cameras were to Kodak and electric cars are to petrol vehicle manufacturers.
The tobacco industry began investing in vaping in 2012 in response to the clear threat. It has been trying to catch up ever since and currently controls only around 12% of the global vapour market, according to research company ECigIntellience (June 2023).
The tobacco industry is transforming
In response to the rise in vaping, the major multinationals are moving away from combustibles to much safer nicotine alternatives (like vaping, HTPs, nicotine pouches), some faster than others. PMI has gone furthest so far, spending USD 10.5 billion since 2008 in research, development, and commercialization of safer alternatives to smoking. It now earns 35% of net revenue from reduced risk products, aiming for over two-thirds by 2030 and to finally become “smoke-free”. This transition to safer products is a huge positive for public health and should be encouraged rather than obstructed.
Some skepticism is justified. Tobacco companies have lied about the harms of smoking for decades. They continue to oppose tobacco control policies and promote the sale of cigarettes. However, the transformation would be faster if activists like Professor Chapman ceased resisting it. By opposing industry transformation, he is inadvertently supporting the very thing he should be trying to eradicate – combustible cigarette sales.
But lets not kid ourselves. The push by the tobacco industry is not driven primarily by public health concerns but is a response to commercial realities created by consumer preferences. However, in this case the goals of the industry are aligned with those of public health. It’s a win-win for everyone: the industry, shareholders, consumers, and public health.
Does it matter who makes reduced risk products?
The focus of tobacco control is to prevent smokers dying from cancer, lung and heart disease. Safer alternatives to smoking will save lives, regardless of who manufactures them.
Furthermore, allowing reduced-risk options for nicotine provides an exit strategy for the industry. It may enable tobacco companies to escape from manufacturing only the most dangerous nicotine delivery system – combustible cigarettes.
Prohibition doesn’t work
Bhutan, a small country in the Himalayas, banned the sale, purchase and possession of tobacco in 2004. This led to massive tobacco smuggling, black market sales, soaring prices, a loss of taxation and an increase in smoking by both young people and adults. The ban was revoked in 2022. Attempts to ban the sale of a legal product would also inevitably lead to legal action by tobacco companies.
In South Africa, the government banned tobacco sales during the COVID pandemic. The legal supply was soon replaced with a thriving black market and substantial loss of government revenue.
Prohibition of other drugs also doesn’t make the drug disappear, it simply changes how it is supplied. In the 2023 National Illicit Drug Reporting System (IDRS) Interviews, 91% of Australian intravenous drug users reported that it was ‘easy’ or ‘very easy’ to access heroin (Figure 5). Heroin has been banned in Australia since 1953.
Nor can tobacco companies just stop production
It is naive (or disingenuous) to insist that tobacco companies stop making cigarettes. Public companies have a legal obligation to shareholders to maintain value and profits.
A Board making such a decision would be sacked and others would take its place. Even if the company closed shop, its competitors would take over and nothing would change.
In any case, there are still over a billion smokers who rely on cigarettes. If tobacco companies transition from deadly cigarettes to safer non-combustible nicotine alternatives, many will switch to getting nicotine from these less harmful alternatives.
E-liquid does not have much taste on its own, so it is flavoured with food-grade additives. Flavours are integral to the success of vaping as a quitting aid and as a safer alternative to smoking. Blanket flavour bans to reduce youth vaping will increase both youth and adult smoking.
Bans on flavours may increase youth smoking. A ban on flavoured tobacco and vaping products in San Francisco in 2020 resulted in a more than doubling of smoking by high school students.
Other studies have found that bans have no effect on youth vaping and users simply switch to other available options or devices.
Flavours are not the primary reason for youth experimentation with vaping in Australia, the US or the UK. The main reasons kids give for vaping are curiosity, peer pressure and stress relief, followed by liking the flavours. Young people enjoy flavours but they only appear to play a small role.
Non-tobacco flavours preferred by young people are very similar to those preferred by adults. The most popular flavours used by adults and youth are fruit, dessert, and other sweet flavours. As a result, flavour bans to protect youth are likely to be harmful for adult smokers and vapers.
Impact on adults
Flavours are an integral part of the appeal of vaping for adult smokers and play an important role in the initiation of vaping for current smokers. Many smokers start vaping with tobacco flavours, but most migrate to non-tobacco flavours over time.
Flavoured e-liquids also are associated with a greater chance of making a quit smoking attempt, higher quit rates compared to non-flavoured e-liquids, smoking reduction and reduced relapse. (Glasser 2020; Li 2021; Mok 2022)
Restricting flavours leads to more smoking overall. For example, a recent large US study across 7 states and 375 localities, found that for every vape pod not sold due to flavor restrictions, there were an additional 15 cigarettes sold.
Without flavours, some adult vapers would switch back to smoking, a far more harmful alternative.
Flavour bans would also lead to increased black-market supplies and home mixing. In one study, 50% of vapers said they would find a way to buy their preferred flavour if it was banned.
Flavours are used in nicotine replacement products for this reason. Nicorette gum is available in Australia in fruit, mint, spearmint and icy mint flavours and research shows that flavoured nicotine gum enhances appeal and improves compliance.
Flavour chemicals are food-grave and are approved for ingestion, but so far not for inhalation. According to Public Health England, “To date, there is no clear evidence that specific flavourings pose health risks but there are suggestions that inhalation of some could be a source of preventable risks”. These flavourings include diacetyl, cinnamaldehyde and benzaldehyde and should be avoided.
Unintended consequences of a flavour ban
The Health Minister Mark Butler has announced that the importation of disposable vapes will be banned from 1 January 2024. However, black-market disposables are already banned and a further ban is likely to have little effect on long-term supply and use.
An estimated 90-100 million illicit disposable devices are imported each year by organised crime gangs from China and are freely sold from retail outlets, social media and online to adults and young people.
A ban will increase deadly smoking
Many of Australia’s 1.6 million adult vapers rely on vaping to stay smoke-free, and some disposable users will return to smoking if their preferred product is not available – a catastrophic consequence for public health. If a ban is successful, it will remove an effective and popular adult quitting aid from the market and would increase smoking,
Disposable vapes are a popular transition device for adult smokers. They are relatively inexpensive and easy to use and can make the transition from smoking a smoother process. They are also popular for smokers with severe mental illness, homelessness, learning disabilities, hospital inpatients and older smokers who struggle with more complex devices.
Other adult smokers who may wish to try disposables to quit in the future, will have reduced access.
A ban will be ineffective
As we have already discovered, bans don’t reduce access or supply, They simply transfer control to the black market suppliers who sell untaxed, dodgy products happily to young people.
According to Professor Nicole Lee from the National Drug Research Institute at Curtin University, “Banning or restricting vaping could actually do more harm than good. Banning drugs doesn’t stop people using them. Prohibition does have a number of unintended consequences, including driving drugs underground and creating a black market or increasing harms as people switch to other drugs, which are often more dangerous.”
Deakin University criminologist Dr James Martin agrees. He believes a crackdown could further fuel the black-market. “When there’s demand that strong there will always be supply that will emerge.”
The Border Force can’t help
The Australian Border Force (ABF) is simply not equipped to intercept the high volume of illicit disposables already entering the country. According to ABF chief, Michael Outram, “banning vapes at the border won’t be enough to stamp out a rampant black market”. The ABF was already only managing to detect only a quarter of illicit drugs making their way into Australia, “even on a good day”.
Each year, 8 million shipping containers are imported into Australia and only 101,500 containers (1.3%) are scanned. No additional funding has been allocated to the ABF to detect vapes, and their main priority is dangerous illicit drugs and firearms.
What about the environment?
Over 90% of vape litter is from black-market disposable products over which there is currently no control. Vape litter will continue if disposables are banned, but are still used widely. However, if vaping products are made legal, adult consumer products, a national, manufacturer-funded recycling program can be introduced. Almost all of the parts of modern legal disposables can be recycled.
What needs to be done?
Banning a product because it is sometimes consumed by people who are already banned from buying it is a poor basis for legislation. The solution is to address the cause of the problem, the current restrictive, prescription-only regulation of vaping products. Getting a prescription is onerous and inconvenient, and the black market has stepped up to provide a simple and cheap alternative.
The only way to eliminate a black-market is to replace it with a legally regulated one.
Nicotine vaping products should be reclassified as adult consumer goods like cigarettes, to bring Australia into line with all other western countries, such as the UK, NZ, US and Canada. Nicotine vapes could then be sold from licensed retail outlets with strict age verification at the time of purchase with harsh penalties and loss of licence for under-age sales, strict compliance measures and spot checks.
Under this model, the black-market would become less profitable, illicit sales of disposables would diminish over time. Teens would have reduced access to vapes and adult smokers could readily access regulated products to help them quit and stay quit, including with high quality disposables.
Why Australia should not ban disposable vapes. Blog July 2023
A Vapid Solution. Why banning disposable e-cigarettes would be a failure of law-enforcement. Institute of Economic Affairs UK, Sept 2023
There is no justification for banning public vaping on health grounds. Secondhand vapour is an issue of public nuisance, like loud conversations on mobile phones or strong perfumes.
Exposure can be reduced by educating vapers about vaping etiquette and to be considerate of the people around them. Vapers should not blow large clouds in crowded areas or vape around children. Authorities can erect signs reminding vapers to only blow small clouds and be considerate of others.
Vaping is a ‘victimless crime’ and causes no known harm to others. Regulators should consider the harm principle, which is that “The only purpose for which power can be rightfully exercised over any member of a civilised cohttps://colinmendelsohn.com.au/vaping/#is-vaping-harmful-to-bystandersmmunity, against his will, is to prevent harm to others.”
A blanket ban on all public vaping sends the misleading message that vaping is just as harmful as smoking. This could deter smokers from switching to vaping. The opportunity to vape in places where smoking is prohibited is an incentive to switch to the healthier behaviour. Vapers may be more likely to relapse if they are forced to vape in smoking areas with smokers.
However, restrictions are appropriate in some circumstances, such as at schools and hospitals. It is also reasonable to disallow vaping in private homes to reduce the risk of young people starting vaping.
Public Health England recommends that vapour policy be set by owners, employers and managers for local premises according to their circumstances, rather than a blanket ban.
Potential disadvantages of vaping inside are that it might encourage people to start vaping, increase dependence and discourage vapers from quitting
Pharmaceutical-like plain packaging has been proposed in Australia to reduce the appeal of vapes to young people. However, this may result in increased smoking in young people and adults.
Plain packaging is appropriate for deadly cigarettes. However using it for vaping products falsely implies a similar high risk, and may discourage adult smokers from switching. Harm perceptions about vaping are already exaggerated. Most people incorrectly think vaping is at least as harmful as smoking or more harmful. Plain packaging may reinforce this misperception and deter some smokers from switching to the far safer alternative.
In young people, there is some evidence that plain packaging may reduce interest in vaping (Simonavicius; Taylor). However, vaping is diverting young people away from smoking and is helping some young smokers quit. Plain packaging may undermine that progress and may increase smoking rates as vaping and smoking are substitutes.
A better solution is make packaging simple, without bright colours or images with youth appeal (as for Juul below). Flavour names that specifically appeal to young people such as ‘dragon vomit’ should be banned and only simple flavour descriptors such as caramel or blueberry used.
Six percent nicotine (6%) is a realistic upper limit for nicotine vaping liquids.
Vaping products need to deliver sufficient nicotine to compete with and replace cigarettes. Excessively low limits on nicotine concentration will make them ineffective for some users.
Higher levels are more effective
Higher nicotine concentrations are more effective initially for quitting, especially for more dependent smokers (eg here, here, here). A nicotine concentration of at least 5-6% (50-60 mg/mL) is needed to match a cigarette, and should be the upper limit in my opinion. (eg here, here, here)
After having quit, vapers tend to reduce their nicotine concentration over time.
The nicotine limit of 2% proposed for Australia is too low to act as a satisfying alternative for a cigarette, especially for more dependent smokers. The selection of this level by the EU in 2014 was arbitrary and not based on any scientific argument. Even Simon Chapman agrees that a 50mg/mL upper limit is a reasonable compromise and is needed for adequate effect.
Low nicotine levels will make compact pod and disposable products less effective. These devices have low-power batteries and low aerosol volumes and require higher nicotine levels, in the range of 2-6%. These are transition models for many smokers as they are easy and convenient to use and have a low initial outlay. They are especially useful for people with mental illness, for institutional use, the elderly, the homeless and the technically challenged.
Reducing the nicotine concentration will make vaping less satisfying and some users will return to smoking. Others will source high nicotine supplies from the black market. This has long been a problem for nicotine replacement products which fail to delivery adequate nicotine levels and craving relief and therefore have low success rates.
Higher levels are safer
Low powered devices using higher nicotine concentrations are also safer because they have lower operating temperatures, and produce fewer toxicants from thermal breakdown of the e-liquid components.
Excessively low levels of nicotine will also lead some vapers to home-mixing, purchasing high nicotine liquids (10-20%) for mixing with other ingredients. These concentrated solutions are potentially toxic, especially for small children and have led to deaths from overdose.
What about adolescents?
There is a genuine concern about higher nicotine levels for adolescents. Higher nicotine concentrations potentially increase the risk of dependence. However, dependence by never-smokers who vape is very low.
Never-smokers who vape high levels of nicotine may initially experience nausea and dizziness. These side-effects are unpleasant but not serious.
Maintaining a low nicotine limit out of exaggerated concern for illegal use by adolescents is poor policy and will reduce the success of vaping as a quitting aid for adults.
Any regulatory measures to control youth vaping should focus on reducing access and appeal to young people. The preferred model is a strictly regulated adult consumer market with sale through licensed retail outlets with strict age verification.
The regulations were intended to prevent youth vaping and to allow access for adult smokers as a smoking cessation aid. After 12 months, they have clearly achieved neither of those goals. In fact, they have had the opposite effect and have been a resounding failure.
They have made it much harder for adult smokers and vapers to legally access nicotine vaping products and have created a thriving black market which sells dodgy products to teens. Youth vaping has skyrocketed.
An ideal regulatory approach should strike a balance between making high quality nicotine vaping products readily available as a quitting aid or long-term less harmful substitute for adult smokers while reducing access and appeal to young people.
Nicotine e-liquid is classified as consumer products in other western countries, such as the UK, EU, New Zealand, Canada and US, ie as a safer alternative to another deadly consumer product, tobacco cigarettes. In Australia nicotine e-liquid is inappropriately classified as a poison or a medicine.
Nicotine vapes should be strictly regulated and sold as adult consumer products from licensed retail outlets (like cigarettes and alcohol) with strict age verification and harsh penalties and loss of licence for underage sales.
Regulation of vaping should be proportionate to its risk (the principle of proportionality). Vaping is at least 95% less harmful than smoking and should not be regulated like deadly tobacco products. Vaping does not involve tobacco, combustion or smoke and imposing harsh regulations that apply to tobacco is not appropriate.
Regulations on vaping should never be more restrictive than those for smoking. Vaping products should be at least as easy to access as cigarettes. The hardware, vaporisers, are currently regulated under consumer law.
Regulation of e-liquids should also ensure that high quality and safe products are available and includes:
The standards specify a range of labelling, packaging, ingredient, nicotine concentration and record-keeping requirements for nicotine e-liquids. The standards regulate nicotine as a medicine and include the following requirements:
For personal importation
Requirements for pharmacy products
Taxation on vaping products should be kept to a minimum to encourage smokers to switch to the safer product.
There is a good case for high tobacco taxes on cigarettes to discourage their use and reduce smoking rates. However, vapes are a less harmful substitute for smoking and there is no justification for high taxes on health grounds. Low taxes on vaping will provide an incentive to smokers to switch and will improve public health.
Vaping nicotine should be taxed according to risk. Vaping is at least 95% less harmful than smoking and the tax level should reflect that low risk. The tax rate for vapes in the UK and New Zealand is 15-20%, in line with the GST or VAT.
Furthermore, smoking is increasingly concentrated in low-income and disadvantaged groups and this is the population at greatest risk. A significant tax differential between vaping and smoking should be maintained to incentivise switching to the less harmful alternative, especially for this population.
Increased taxation of vapes has led to increased smoking by youth (here and here), young adults, adults. and prenatal and pregnant women. This suggests that vapes and cigarettes are economic substitutes.
One modelling study found that every 10% increase in e-cigarette prices was associated with a drop in adult e-cigarettes use by up to 11.5% and was associated with a significant increase in smoking.
Because the benefit to society is so high, regulators should look to other sources of income to replace tobacco taxes. Raising vape taxes to replace tobacco excise is as illogical as saying that someone who switches from driving a car to riding a bicycle should expect new taxes on biking to replace the lost petrol taxes.
Vaping products are consumer products and should be regulated by the Australian Competition and Consumer Commission (ACCC) which provide strong protection for consumers.
The ACCC ensures that products are safe, fit for purpose, of merchantable quality and comply with all legal requirements under the Competition and Consumer Act 2010.
Australian state and territory laws complement ACCC regulation of vaping products. They address the sale and supply of nicotine liquid, the sale of vaporisers, minimum age of sale, sale in vending machines, use in smoke-free areas, advertising and display. However, state laws are not uniform and a consistent national approach is needed.
Vapes should not be regulated as they are at present by Australia’s medicines regulator, the Therapeutic Goods Administration (TGA). The TGA is responsible for regulating medicines and medical devices which make therapeutic (medicinal) claims, such as ‘this product can help you quit smoking’. Nicotine vapes are consumer products used almost exclusively as a less harmful substitute by smokers who can’t or won’t quit smoking or consuming nicotine.
No western country requires vaping products to undergo medicines regulation or a prescription. It makes no sense to require the highest standards of research and quality for nicotine vapes when they are replacing a far more harmful product, lethal cigarettes, which are virtually unregulated.
One practical outcome of TGA regulation would be the decimation of the vaping market. Every device and e-liquid and every future modification would require a detailed, costly and onerous application that only tobacco companies could afford. Most small to medium companies and vape shops would be driven out of business. The result would be that tobacco companies take over the vaping market.
Additional vaping resources