Note: Where available, the PDF/Word icon below is provided to view the complete and fully formatted document
Report on the Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia
3. 3. Smoking and Vaping: Health Considerations

Overview

3.1
The increasing use of electronic cigarettes (E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes) is a relatively recent phenomenon and this creates a challenge for researchers and policy makers seeking to evaluate the public health impact of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes. Potential health risks from the use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes include impacts on: lung health, adolescent brain development, and maternal and fetal health during pregnancy.[1]
3.2
In addition, there may be health impacts from the use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes that are yet to become apparent. The potential health impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use, the possibility of additional and as yet unknown effects, and the health risks relative to the known impacts of smoking are all factors that require balanced consideration by policy makers.
3.3
E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes have been described as a potential smoking cessation aid to assist those smokers who have been unable to quit using other methods.[2] While some studies have found evidence suggesting that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may help smokers to quit,[3] other studies have found that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were ineffective as a smoking cessation aid.[4]
3.4
Another key issue for public health policy makers is whether E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes could create a new pathway into smoking for young people.[5] There are conflicting views on whether the evidence suggests there is an association between E <NonBreakingHyphen> </NonBreakingHyphen> cigarette availability and the increased likelihood of young people trying and taking up smoking.[6]

E-cigarettes and Smoking

3.5
In Australia, any product that claims to assist smokers to quit smoking must be approved by the Therapeutic Goods Administration (TGA) prior to sale. To date, ‘no E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes have yet been approved by the TGA as smoking cessation aids’.[7]

Consumer Perspective

3.6
The New Nicotine Alliance Australia (NNAA), an organisation representing E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users, stated that ‘the big difference between E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and other nicotine replacement options is that the E <NonBreakingHyphen> </NonBreakingHyphen> cigarette simulates smoking’. The NNAA added that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were also able to provide nicotine to the user faster than nicotine replacement therapies (NRT).[8]
3.7
The Committee received many submissions from individuals who recounted their personal stories of using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes. In most cases, these submissions were from people who had successfully used E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to quit smoking tobacco. Mr Ben Grotegoed, in an account mirrored by other participants, described his experience of unsuccessfully trying to quit smoking using other methods before turning to E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes. Mr Grotegoed stated:
I’ve tried [nicotine] patches and gum and spray all with varying degrees of success. However nothing I’ve tried has kept me off the dreaded smokes for any longer than a month or two. About three years ago I took up vaping … I can count the number of cigarettes I’ve had in the three years [since] on one hand.[9]
3.8
The personal accounts of the individual vapers who provided submissions to the inquiry are considered in more detail in Chapter 4.

Public Health Perspective

3.9
The Department of Health stated that available evidence on the use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to help people to quit smoking ‘does not allow any firm conclusions to be drawn as to whether E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may help most smokers quit smoking or prevent them from doing so.’[10]
3.10
This view was shared by many Australian public health bodies. The Royal Australasian College of Physicians (RACP) stated that ‘the evidence base is unable to support or refute the role E-cigarettes play in smoking cessation.’[11] The Thoracic Society of Australia and New Zealand (TSANZ) agreed, stating that ‘we would advise caution with respect to the idea that electronic cigarettes promote smoking cessation. They may actually do so; the problem is we just don’t know.’[12]
3.11
The Australian Medical Association (AMA) described the ‘efficacy and safety of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes as cessation aids [as] an area of rapidly emerging evidence’ and stated that ‘it is not unusual for two contradictory articles on E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to be released in one week.’[13]
3.12
State government agencies in New South Wales,[14] Queensland,[15] South Australia,[16] Tasmania,[17] Victoria,[18] and Western Australia[19] also agreed that there was insufficient evidence to support the use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes as smoking cessation devices. These government agencies also supported the role of the TGA and the National Health and Medical Research Council (NHMRC) as the appropriate bodies to assess the evidence relating to E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and smoking cessation.
3.13
The Department of Health also drew attention to the World Health Organization’s statement that the ‘scientific evidence regarding the effectiveness of [E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes] as a smoking cessation aid is scant and of low certainty, making it difficult to draw credible inferences.’[20]

Research on E-cigarettes and Smoking Cessation

The Cochrane Review

3.14
Many inquiry participants referred to a study on the effectiveness of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes as smoking cessation aids undertaken by Cochrane. Cochrane undertakes ‘systematic reviews of primary research in human health care and health policy’.[21]
3.15
The Cochrane Review (the Review) considered 24 studies looking at the effectiveness of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes at assisting people to quit smoking. Of these studies, 22 did not follow participants for a long period of time or did not ‘directly compare the effectiveness of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes with other possible smoking cessation aids’.[22] The two remaining studies were Randomised Controlled Trials (RCTs) that followed participants for at least six months and were considered to ‘provide the best evidence’.[23]
3.16
The two RCTs found that people using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes containing nicotine were more successful in quitting smoking than people using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes without nicotine.[24] The Review was not able to determine whether E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were more effective in helping people to quit smoking than nicotine patches.[25] Overall the Review rated the confidence in the result as low due to the small number of studies.[26] The Review added that more studies of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and smoking cessation were needed, some of which were already underway.[27]
3.17
Associate Professor Coral Gartner and Professor Wayne Hall stated that the two RCTs considered by the Review used first generation cigalike[28] E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes that ‘are known to be less effective at delivering nicotine than the modern tank devices that are now predominantly used by vapers.’[29]
3.18
Professor Martin McKee suggested that in one of the RCTs ‘it is likely that that the effectiveness of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes was overstated’ due to the inconsistencies between how E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users and NRT users were provided with the materials to take part in the trial.[30]

National Academy of Science Review

3.19
The United State of America’s (USA) National Academy of Sciences (NAS) considered the effectiveness of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes in assisting people to quit smoking. The review was undertaken on behalf of the USA Food and Drug Administration and published in January 2018. The NAS Review classified the evidence relating to the effectiveness of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes in assisting people to quit smoking as limited evidence[31].This classificationsuggests there is sufficient evidence to conclude that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may be effective as smoking cessation aids but that this conclusion is subject to significant uncertainty.[32]
3.20
The 2018 NAS Review identified three RCTs and stated that the results of these trials suggest that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes have a ‘possible though not definitively positive association with quitting smoking’.[33] Two of the RCTs found nicotine E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to be a more effective smoking cessation aid than non <NonBreakingHyphen> </NonBreakingHyphen> nicotine E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and the 2018 NAS Review also stated that the ‘substantial body of RCT evidence demonstrating the efficacy of nicotine replacement products … provided plausibility for the role of nicotine in enhancing the likelihood of smoking cessation.’[34]
3.21
The 2018 NAS Review stated that the only RCT comparing E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes with NRTs had found no statistically significant difference in the quit rates between E <NonBreakingHyphen> </NonBreakingHyphen> cigarette and NRT users.[35] The 2018 NAS Review stated that there was insufficient evidence to determine whether E-cigarettes were more or less effective than NRTs as a smoking cessation aid.[36]
3.22
The 2018 NAS Review drew attention to the discrepancy between the results from the RCTs and the results of meta-analyses of observational studies published prior to 2016. Two of these meta-analyses (El Dib, and Kalkhoran and Glantz; discussed below) found a negative association between E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and quitting smoking. The 2018 NAS Review stated that this discrepancy contributed ‘to the uncertainty about the overall effect of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes on cessation’.[37]
3.23
The 2018 NAS Review highlighted that studies published prior to 2016 may have included E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users who either vaped infrequently or continued smoking while using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes (dual users). Due to the possibility that this may have affected the results of these studies, as well as the rapid evolution of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette technology, the 2018 NAS Review gave greater weight to studies published recently.[38]
3.24
The 2018 NAS Review found that in recently published studies there was an association between the frequency of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use and the likelihood of successfully quitting smoking. The 2018 NAS Review stated:
Based on … the strong, consistent body of evidence from higher <NonBreakingHyphen> </NonBreakingHyphen> quality studies published more recently that overcome measurement limitations of studies published in the past, [the NAS] concluded that there was moderate evidence[39] that more frequent use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes is associated with quitting smoking.[40]

Other Studies on E-cigarettes and Smoking Cessation

3.25
Emeritus Professor Simon Chapman, Professor Mike Daube, David Bareham, and Associate Professor Matthew Peters (Emeritus Professor Chapman) highlighted a review undertaken by El Dib which considered eight longitudinal cohort studies that followed smokers over a long period to assess the effectiveness of different methods of quitting smoking. Emeritus Professor Chapman stated that this review indicated that there was ‘a potential suppression of chances in successful quitting when people use [E-cigarettes].’[41] The El Dib review, however, also reported a number of limitations in the cohort studies and stated they provided ‘very low <NonBreakingHyphen> </NonBreakingHyphen> certainty evidence from which no credible inferences can be drawn.’[42]
3.26
Overall, looking at both RCTs and longitudinal cohort studies, the El Dib review concluded that based on available evidence it was not possible to ‘verify nor exclude the hypothesis’ that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were more effective than other nicotine replacement strategies. The review also stated there was a need for more ‘well designed trials in this field’.[43]
3.27
Professor Martin McKee and the RACP highlighted a meta-analysis of 20 studies by Kalkhoran and Glantz which, ‘while subject to caveats’ found that E-cigarette users had a 28 per cent lower rate of quitting than those that did not use E-cigarettes.[44] Associate Professor Mendelsohn was, however, critical of the ‘poor methodology’ of the Kalkhoran and Glantz review stating it included studies that were too different to be compared, did not consider different types of E-cigarettes or different frequency of use, and used selective inclusion and reporting of studies.[45]
3.28
Associate Professor Gartner and Professor Hall drew attention to a population based study in the USA.[46] This study looked at the results from a 2014-2015 national survey of tobacco use and found that E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users attempted to quit smoking, and succeeded at quitting smoking at higher rates than other smokers. The study also found that there was a statistically significant increase in the overall rate of smokers quitting smoking between 2010-2011 and 2014-2015 (from 4.5 per cent to 5.6 per cent).[47]
3.29
Another population study of 5863 English smokers who had attempted to quit smoking in the past year without using professional support found that those who had used E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were more likely to quit than those who used NRT or no quitting aids.[48]
3.30
Emeritus Professor Chapman highlighted that as cross-sectional population surveys only collect data from a single moment in time they are unable to show causality and therefore they could not prove that E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use had caused a change in smoking rates.[49]

Smoking Among At-Risk Groups

3.31
Professor Ron Borland highlighted that smoking rates remain high among at-risk groups even in countries like Australia who have ‘done virtually everything on the tobacco control agenda that targets smokers and the social conditions influencing use.’[50] Professor Borland added ‘it is not clear how much further progress can be made [to reduce smoking among at <NonBreakingHyphen> </NonBreakingHyphen> risk groups] without large new initiatives designed to make it easier to give up smoking.’[51]
3.32
Emeritus Professor Ian Webster stated that there were ‘rusted on’ smokers who had been unable to quit and among this group there was an over <NonBreakingHyphen> </NonBreakingHyphen> representation of:
… Aboriginal and Torres Strait Islanders, people with enduring mental illnesses, people with established chronic diseases, persons with alcohol and other drug dependence, homeless people and people from socially deprived backgrounds.[52]
3.33
Professor Borland commented that people in at-risk groups were just as likely as other smokers to attempt to quit but were less likely to be successful in their quit attempts.[53] Professor Borland explained:
… a major factor in the increasing divergence in smoking rates between those living relatively privileged lives and those whose lives are psychologically or socially impoverished is almost entirely due to greater difficulty staying quit. The most likely explanation for this is that the rewarding aspects of smoking are relatively more important to these people than others, perhaps because of the lower levels of alternative rewards … the use of a nicotine substitute that provides much of the psychological effects obtained from smoking, is more likely to result in increased quit success.[54]
3.34
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) stated that 70 per cent of people with schizophrenia and 61 per cent of people with bipolar disorder smoke.[55] The RANZCP added that ‘people living with mental illness are not only more likely to smoke, but they also tend to smoke more heavily than people without mental disorders.’[56]
3.35
Professor Con Stough and Associate Professor Luke Downey stated that ‘a processing deficit (called the P50) observed in patients with schizophrenia may be significantly ameliorated by nicotine and is one of the reasons why smoking rates are so high in patients with schizophrenia.’[57]
3.36
The RANZCP stated that the rate of smoking among people with mental disorders has not gone down and that in cases where there are ‘factors that are impacting on someone’s ability or willingness to quit smoking, [that is] where harm reduction can have a role.’[58] The RANZCP also indicated that it would support a ‘comprehensive approach [that] should include the proportional regulation of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and vaporisers.’[59]
3.37
The RANZCP added that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes had the potential to provide an option for people who were financially struggling due to the cost of cigarettes, stating that:
With continued increases in the tobacco excise, keeping E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and vaporisers at a low cost would not only encourage uptake of these devices over more harmful products, but would also present financial benefits for vulnerable groups of people which may present flow-on benefits for public health.[60]

Substituting E-cigarettes for Tobacco

3.38
Some vapers[61] choose to use E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes over the long term without the intention of stopping, effectively using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to quit smoking without quitting nicotine use. For example, Dr Attila Danko of the NNAA stated that ‘nicotine is important for me to function, to be happy, to enjoy life and trying to reduce it and stop it is about as important to me as trying to reduce and stop caffeine … it is not important at all to me.’[62]
3.39
The NNAA stated that quit smoking rates are stalling as remaining smokers are ‘a hard core of smokers that either gain so much benefit and enjoyment out of smoking or else are so deeply addicted that we do need this disruptive technology.’[63] The NNAA described E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes as a plausible tobacco substitute for smokers because it replicated the sensation of smoking. The NNAA explained:
Almost all smokers have given up for long enough in the past for the hold of addiction to be broken, but most smokers get tempted back to smoking time and time again. Why? Because we enjoyed it. We gained pleasure from it. Vaping works because it recognises and acknowledges that people gain pleasure from smoking, and replaces it with something not only far safer, but more pleasurable.[64]
3.40
Associate Professor Mendelsohn observed that substituting E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes for smoking has been found to have significant short term health benefits, including improved lung function, reduced asthma symptoms, reduced blood pressure and improved cardiovascular health.[65] Associate Professor Mendelsohn added that ‘it is common sense to me that that would lead onto long term benefits but, of course, we do not have that data.’[66]
3.41
The 2018 NAS Review found that there was conclusive evidence[67] that the complete substitution of tobacco cigarettes with E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes reduced users’ exposure to toxicants and carcinogens. In addition, the 2018 NAS Review found that there was substantial evidence[68] that this reduced short term negative health impacts for several of the body’s organ systems.[69]
3.42
Associate Professor Gartner and Professor Hall stated that, for smokers who have difficulty quitting, moving to a less harmful source of nicotine may be much easier than quitting entirely. Associate Professor Gartner and Professor Hall added that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may also:
… assist some smokers to become smoke-free who would never quit smoking in the absence of an acceptable substitute. It is arguably unethical and unjust to deny smokers who have great difficulty ending their nicotine addiction from using less harmful alternatives while we continue to allow them ready access to the most harmful nicotine products (combustible tobacco cigarettes).[70]
3.43
Emeritus Professor Webster stated that for smokers who have been unable to quit using other available methods there was a case for the use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes as a nicotine substitute ‘deployed as part of a wider support program to help the patient cease smoking.’ Professor Webster added that:
… nicotine substitution has been accepted internationally, over many years, as an appropriate addition to the therapeutic repertoire for dependent smokers to cease smoking. [E-cigarettes with] nicotine solution at low dose levels [are] a biologically plausible and reasonable extension of this approach.[71]

Dual Smoking and Vaping

3.44
Some smokers may begin using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes while continuing to smoke cigarettes; this is referred to as ‘dual using’. The NHMRC stated that ‘experts disagree about whether E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may help smokers to quit, or whether they will become “dual users” of both E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and tobacco cigarettes.’[72]
3.45
The Department of Health stated that while dual use of tobacco and E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may:
… reduce daily consumption of cigarettes, available evidence suggests that the health benefits of this reduced consumption may be minimal at best. Several large cohort studies have shown little evidence of reduced mortality in smokers who reduce cigarette consumption, and no association between smoking reduction and a decline in all-cancer risk.[73]
3.46
Associate Professor Mendelsohn suggested that when smokers reduce their cigarette consumption without E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes they ‘unconsciously smoke more intensely to maintain their nicotine levels’, thus undermining potential health benefits. In contrast, dual users, who receive nicotine from E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, do not smoke more intensely and can experience health benefits when reducing cigarette consumption, including improvements in chronic obstructive pulmonary disease symptoms, blood pressure, asthma and lung function.[74]
3.47
In contrast, Emeritus Professor Chapman cautioned that using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to reduce consumption of tobacco cigarettes without completely quitting was unlikely to result in health benefits. Emeritus Professor Chapman drew attention to a Norwegian study that followed 51 210 people for over 20 years and found that smokers who reduced their cigarette consumption by more than 50 per cent did not reduce their risk of premature death.[75]
3.48
The Queensland Department of Health advised that two thirds of adults in Queensland who were using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were also smoking tobacco cigarettes. Dual use was most common among people aged between 30 to 44 years.[76] The Queensland Department of Health was concerned that dual use could result in smokers maintaining their tobacco smoking.[77]
3.49
Emeritus Professor Chapman stated that in 2014 the proportion of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users who continued smoking tobacco cigarettes was 93 per cent in the USA, 83 per cent in France, and 60 per cent in the United Kingdom of Great Britain (UK).[78] Emeritus Professor Chapman highlighted that the proportion of smokers in the UK who have tried to quit smoking had dropped from 42.5 per cent in 2007 to 30.9 per cent in 2016 and suggested that dual users may find it more difficult to quit ‘as they do not actually view themselves as smokers’.[79]
3.50
The Australian Drug Law Reform Foundation stated that in many cases smokers would continue smoking while using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes during a transitional period before entirely quitting smoking. This transitional period could take ‘weeks or years’.[80] Associate Professor Mendelsohn agreed that ‘dual use is a normal part of quitting’ and that the rate of dual use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and tobacco was similar to that of NRT and tobacco.[81]
3.51
Associate Professor Gartner and Professor Hall drew attention to the limitations of cross-sectional surveys of dual use of smoking and vaping as these studies cannot discern the reason people are dual using. Associate Professor Gartner and Professor Hall commented that longitudinal studies have found that dual users do not make fewer quit attempts than other smokers and that the proportion of dual users who quit smoking increases over time.[82]
3.52
The 2018 NAS Review stated that on average dual users do not smoke fewer cigarettes than other smokers but it is possible that if a smoker reduces their cigarette intake then dual use may help them maintain this reduction.[83] The 2018 NAS Review added that there is no available evidence on whether dual users have different mortality or morbidity rates than other smokers.[84]

Potential ‘Gateway’ to Smoking

3.53
An issue of significant debate among inquiry participants was whether there was a ‘gateway effect’ where young people initially experiment with E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes which then increases their likelihood of also trying traditional cigarettes. The Department of Health identified the potential gateway effect as an issue of concern and stated:
… E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may provide a gateway to nicotine addiction or tobacco use (particularly among youth), and may renormalise smoking. Rather than encouraging smokers to quit smoking, E-cigarettes may expand the nicotine market by attracting new smokers (particularly youth) who may otherwise be unlikely to initiate smoking with conventional cigarettes.[85]
3.54
Tobacco control policies have, over many years, sought to stop tobacco smoking being a normal, mainstream activity (for example through restricting where people can smoke). Some participants were concerned that widespread E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use could ‘renormalise’ smoking. For example, the Queensland Department of Health stated that ‘electronic cigarettes have the potential to renormalise smoking in smoke-free environments and reverse important gains achieved in smoking reduction’.[86] Quit Victoria agreed and stated that ‘E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use has the potential to re-glamorise and renormalise smoking, particularly where use occurs around children and young people.’[87]
3.55
The National Heart Foundation of Australia (NHFA) stated that:
… it is fair to say that there is growing evidence of the gateway effect. That is of real concern to us — the number of papers being published that show an increased risk for young people if they try E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes. There is a greater risk of them then becoming smokers of traditional cigarettes.[88]
3.56
The Queensland Department of Health advised that a randomly sampled survey of Queensland adults had found that nine per cent of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users (representing approximately 10 000 people) reported never having smoked tobacco cigarettes. The Queensland Department of Health stated that ‘these statistics are particularly concerning, as these are the new users of devices that have the potential to be a gateway to tobacco smoking.’[89]
3.57
Associate Professor Gartner agreed that ‘there does seem to be … an association between experimenting with E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes amongst young people and then experimenting with tobacco cigarettes’ but suggested that many of the young people who transitioned from E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to smoking may have tried smoking even if E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were not available.[90] Associate Professor Mendelsohn summarised this point by saying ‘kids who try stuff try other stuff, so kids who are more rebellious, risk-taking, who have that sort of personality will try E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and they will also smoke.’[91]
3.58
Several participants highlighted a review of longitudinal studies looking at the association between E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use and smoking by adolescents and young adults.[92] The review found that even after adjusting for ‘demographical, psychosocial, and behavioural risk factors for cigarette smoking’, E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users were three times more likely to start smoking.[93]
3.59
Associate Professor Gartner commented that some of the studies that had shown the existence of a gateway effect were conducted in locations where there were no age restrictions on the sale of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and this may not be the case if there were restrictions on the availability of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes for young people.[94]
3.60
Emeritus Professor Chapman stated that, due to their flavourings, a lack of harshness on the throat, and the ability to be used inconspicuously, E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes have more appeal to youth than smoking. Emeritus Professor Chapman also stated that after initial experimentation with E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes young people could move on to tobacco smoking, stating that:
… just as a large proportion of adults who experiment with [E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes] do not continue using them, finding them unsatisfying so too it is likely that some young people may move on to cigarettes with [E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes] abandoned as training wheels.[95]
3.61
Dr Konstantinos Farsalinos stated regular E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use ‘is extremely rare among never-smoking adolescents’ and suggested that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes could be preventing adolescents who had a propensity to take up smoking from initiating smoking.[96] Dr Farsalinos added that the increase in the number of adolescents who had used E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes at least once ‘has coincided with the sharpest declines in youth smoking rates for many decades.’[97]
3.62
The All-Party Parliamentary Group for E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes in the UK Parliament (All-Party Group) suggested that, as E-cigarettes were less damaging than smoking, unless many more people were drawn into smoking than helped out of smoking by E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes there would be a net public health benefit.[98] The All-Party Group added that ‘the gateway in [to smoking] is much, much smaller than the motorway out [of smoking].[99]
3.63
The Royal College of Physicians of London (RCPL), in its report Nicotine without Smoke, concluded that while there was concern that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes could act as a gateway to smoking for young people there was ‘no evidence that [this] is occurring to any significant degree in the UK.’[100]
3.64
In contrast, the 2018 NAS Review stated that there was substantial evidence of an association between E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use and young people trying tobacco cigarettes.[101] The 2018 NAS Review highlighted many methodological challenges that make analysis of the gateway effect difficult. Nevertheless, the 2018 NAS Review stated that the ‘overwhelming consistency of results’ across different studies gave it confidence in the ‘robustness, validity, and causality of the association of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use’ and trying tobacco cigarettes.[102]
3.65
The 2018 NAS Review added that among youth and young adult E-cigarette users who ever use tobacco cigarettes, there is:
Moderate evidence that E-cigarette use increases the frequency and intensity of subsequent combustible tobacco cigarette smoking’; and
limited evidence that E-cigarette use increases, in the near term, the duration of subsequent combustible tobacco cigarette smoking.’ [103]

E-cigarette and Smoking Prevalence Rates

3.66
Associate Professor Mendelsohn stated that smoking rates among under 18 year olds in the UK and USA have declined more rapidly since E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes became available. For example, in the USA since 2010, smoking rates for Year 12 students have declined three times faster than previously.[104]
3.67
The 2018 NAS Review, however, stated that although youth smoking rates in the USA had continued to fall since the emergence of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, an analysis of ‘trends going back a decade found that the rate of reduction of smoking in [USA] youth has remained consistent and has not accelerated in recent years when E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes have become popular.’[105]
3.68
Public Health England stated that in 2016, 2.6 per cent of youth in the UK were using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes at least monthly, with a further 9.3 per cent who had experimented with E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes.[106] E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use was most common among youth who also smoked, but rare among non-smokers with 0.4 per cent of the youth population who had never smoked using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes at least monthly.[107]
3.69
The United Kingdom Vaping Industry Association (UKVIA) stated that E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use in the UK was growing, but that the rate of growth was decreasing. The UKVIA stated that the number of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users increased by 86 per cent in 2013, 62 per cent in 2014, 24 per cent in 2015, and four per cent in 2016.[108]
3.70
The RCPL linked the increasing use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes with declining rates of smoking in the UK, stating that E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use was ‘the major driver of the substantial fall in UK smoking prevalence over the past five years from 20.2 per cent in 2011 to 15.8 per cent in 2016’.[109]
3.71
Counterfactual Consulting highlighted that in the UK in 2016, the number of vapers who were ex-smokers (1.5 million) exceeded the number of vapers who were current smokers (1.1 million) for the first time. In the USA in 2015, there were 8.3 million vapers, 2.5 million of whom were ex-smokers.[110]
3.72
Professor Sinclair Davidson highlighted a 2017 simulation study using USA data, which found that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes resulted in a 21 per cent reduction in smoking related deaths and a 20 per cent reduction in life years lost. The study concluded that even if some non-smokers become smokers because of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use, ‘these public health effects are more than compensated by current smokers smoking less or quitting.’[111]
3.73
Cancer Research UK stated that despite the availability of E-cigarettes in the UK there has been ‘no increase in youth smoking of tobacco, which is another important measure in terms of establishing the gateway effect.’[112]

Health Considerations: E-cigarettes

E-cigarette Safety

3.74
Many public health agencies suggested that there is not enough evidence on the health impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to be able to determine the safety of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use. The Department of Health stated ‘there is currently insufficient evidence, either in Australia or internationally, to conclude whether E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes are effective in assisting people to quit smoking, or about the extent of their potential harms.’[113]
3.75
The NHMRC agreed and added that there:
… wasn’t enough evidence out there to actually be making definitive recommendations … for or against electronic cigarettes … what we are saying is that a precautionary approach must be taken, simply on the basis that there is not enough evidence to say whether they are safe or not.[114]
3.76
While there would be a risk in making E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes accessible before long term evidence of their health impacts is available, Associate Professor Mendelsohn cautioned that there is a counter risk in not allowing smokers to access a product that potentially could be beneficial, stating ‘there is a cost in waiting. People are dying every day from smoking and I think the evidence is strong enough to say we should give it a chance’.[115]
3.77
The 2018 NAS Review undertook modelling to estimate the population health impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette usage. The modelling considered both the positive impact of assisting people to quit smoking and the negative impact of the increased likelihood of young people taking up smoking. The 2018 NAS Review found that in short <NonBreakingHyphen> </NonBreakingHyphen> term projections the increased number of people quitting resulted in E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes delivering a net public benefit. Over the course of decades, however, young people who have taken up smoking begin to experience negative health impacts and this reduces the net public benefit. The 2018 NAS Review found that, under some scenarios, in the long term (for example 50 years into the future) the net public health impact of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes becomes negative.[116]

Long-Term Studies

3.78
A limitation on the availability of evidence is that E-cigarettes are a relatively new product. Emeritus Professor Chapman highlighted that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes have been in existence for a little over a decade and only in mass use for around five years and described it as ‘very, very early days’ for research into the health impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes.[117]
3.79
To illustrate, Emeritus Professor Chapman described the period following the first appearance of affordable cigarettes in the early twentieth century. At this time, smoking rates were rapidly increasing but for the ‘next 20 years, lung cancer remained an uncommon, even rare disease’ and it was not until the 1950s that definitive evidence was published linking smoking to lung cancer.[118] Emeritus Professor Chapman added:
If any scientist had declared in 1920 that cigarette smoking was all but harmless, history would have judged their call as dangerously incorrect. But this is the reckless call that many [E <NonBreakingHyphen> </NonBreakingHyphen> cigarette] advocates are making today, after just 10 years.[119]
3.80
The RACP stated that the long term effects of E-cigarettes are ‘currently unclear due to the limited number of studies undertaken in this area to date.’[120] The equivalent body in the UK, the RCPL agreed that the long term effects of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use may not ‘become clear until the products had been in use for several decades.’ The RCPL added that E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use may increase the risk of smoking related diseases but that ‘the magnitude of such risks is likely to be substantially lower than those of smoking’.[121]
3.81
The TSANZ also commented on the possibility that E-cigarettes could have health impacts that are not currently apparent, stating ‘chronic respiratory conditions can take many years to become symptomatic. It is therefore important studies track health impacts over the long term, by which we mean greater than 10 years.’[122]
3.82
Some inquiry participants suggested that obtaining long term data will prove challenging because of developments in device technology and E <NonBreakingHyphen> </NonBreakingHyphen> cigarette flavours available on the market.[123]

Evaluating Product Safety

3.83
The TSANZ and Lung Foundation Australia (LFA) described the standard of evidence it considered necessary to test the safety of E-cigarettes, stating ‘until such time as long term randomised controlled studies are conducted with a homogenous product class, it is not possible to determine the safety and efficacy of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and personal vaporisers.’[124]
3.84
Associate Professor Gartner and Professor Hall agreed that RCTs were suitable for testing the effectiveness of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes as a smoking cessation aid. Associate Professor Gartner and Professor Hall also suggested that using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes as a tobacco substitute as part of a harm reduction strategy could not be tested using RCTs. Associate Professor Gartner and Professor Hall stated that ‘there are many factors that may make vaping a successful harm reduction strategy that do not transfer effectively into a clinical trial setting’.[125]
3.85
Associate Professor Mendelsohn also questioned whether RCTs were an appropriate standard to assess E-cigarette safety. Associate Professor Mendelsohn explained new users experiment with different brands and strengths of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and stated ‘you cannot test that in a standard, randomised, controlled trial but in the real world we know there are millions of people using them to quit. I think we have to look to a different standard of evidence.’[126]

Research in Progress

3.86
The NHMRC advised that since 2011, it had committed nearly $6.5 million in funding for research projects involving E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes. The eight projects currently being funded by the NHMRC are looking into:
Using nicotine as a long-term tobacco substitute in comparison to using it as a short term smoking cessation aid (funded from 2011 to 2018).
Public health interventions, including less harmful nicotine products, to reduce tobacco related harm among socially disadvantaged populations and low probability quitters (2014 to 2018).
Using new media to translate prevention research findings in the areas of tobacco control and obesity into policy and practice (2015 to 2019).[127]
A RCT focussed on ‘enhancing pharmacological and behavioural support to reduce smoking relapse’ (2015 to 2020).
Understanding the impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes on smoking in Australia (2016 to 2021).
Using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to help people with schizophrenia reduce their tobacco smoking (2016 to 2020).
A randomised trial which will assess the effectiveness of adding E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to standard behavioural treatments for low-socioeconomic status smokers (2017 to 2021).
The health effects of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes (2017 to 2019).[128]

Relative Health Risk

3.87
In 2015, Public Health England released its report E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: An Evidence Update which stated that ‘best estimates show E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes are 95 per cent less harmful to your health than normal cigarettes, and when supported by a smoking cessation service, help most smokers to quit tobacco altogether.’[129]
3.88
The statement that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes are 95 per cent less harmful than tobacco cigarettes has been quoted widely,[130] including by many inquiry participants.[131] This figure appears to be drawn from a 2014 article by Nutt et al. in the journal European Addiction Research. The Nutt study assessed 12 nicotine containing products against 14 weighted criteria, each representing a type of harm potentially caused by nicotine, to develop an overall relative harm for each product. E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were assessed as having four per cent of the relative harm of tobacco cigarettes.[132]
3.89
The Nutt assessment was undertaken by an expert panel comprised of academics, public health representatives, and a consultant.[133] Nutt et al. stated that the limitations of the study included that it did not include ‘formal criterion for the recruitment of the experts’ and that there was a ‘lack of hard evidence for the harms of most products on most of the criteria.’[134]
3.90
The 95 per cent safer than tobacco cigarettes-statistic relating to E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes was criticised by a number of inquiry participants.[135] The Cancer Council Australia (CCA) and the NHFA stated that the figure was ‘unfounded and devoid of any scientific basis’.[136]
3.91
Professor Martin McKee raised concerns about the lack of evidence used and the background of the expert panellists in the Nutt et al. study and stated:
… while there is acceptance that electronic cigarettes are likely to be somewhat safer than real ones by virtue of not producing tar, within Europe this 95 per cent figure has little credence beyond England.[137]
3.92
In addition, Emeritus Professor Chapman stated that ‘several of the [expert panel] had no research track record or expertise in tobacco control and some had histories of financial connections with manufacturers of [E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes] and tobacco companies’.[138]
3.93
In contrast, Public Health England stated that claims that the authors of the Nutt el al. study or members of Public Health England were paid by tobacco companies are false and a number of media outlets had retracted or corrected claims linking the authors with tobacco companies.[139]
3.94
Mr Steve Woodward suggested that the important point was that there were less health risks associated with E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use than with smoking; regardless of the exact degree to which E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were safer than cigarettes. Mr Steve Woodward stated:
The contentious point appears to be by how much is E-cigarette vapour less toxic than conventional tobacco smoke - 10 per cent less, 50 per cent less, or 95 per cent less? [In any case], if fewer toxins are inhaled, less disease and premature death will result.’[140]
3.95
Cancer Research UK agreed that it was ‘important not to get too caught up in the 95 per cent figure’ and suggested that, regardless of the exact figure, there is a series of studies that have found that vaping is ‘significantly safer’ than smoking.[141]
3.96
The TSANZ questioned whether it was appropriate to use cigarettes, which ultimately kill many smokers, as a benchmark for assessing the health impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes.[142] The TSANZ added that even if not fatal, many respiratory conditions ‘really disable people’ and these effects should also be considered when assessing the impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes.[143]

Heath Impacts of E-liquids

Nicotine

3.97
Dr Konstantinos Farsalinos was of the view that nicotine ‘is not classified as a carcinogen, does not cause lung disease’ and highlighted that nicotine has been approved for long term use in NRT.[144] Associate Professor Mendelsohn stated that the ‘long term adverse effects of nicotine are likely to be minimal except in pregnancy’ and that there ‘is no evidence that nicotine causes cancer in humans’.[145]
3.98
Conversely, the Department of Health stated that nicotine is highly addictive and that it is ‘highly toxic and poses significant health risks including adverse cardiovascular, respiratory, and reproductive effects’.[146] The Department of Health also advised that nicotine is scheduled as a poison under the Poisons Standard.[147] The Department of Health added that evidence suggests that ‘nicotine is associated with DNA damage and other pathways of carcinogenesis.’[148]
3.99
The 2018 NAS Review stated that while it was ‘biologically plausible’ that nicotine could promote tumours there was no evidence that nicotine was a carcinogen and that therefore ‘nicotine exposure from E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use will likely pose minimal cancer risk to users’.[149] The 2018 NAS Review added, however, that nicotine increased cardiovascular risks for people with pre <NonBreakingHyphen> </NonBreakingHyphen> existing cardiovascular disease.[150]
3.100
The Centre for Adolescent Health (CAH) at the Royal Children’s Hospital highlighted the health risks to adolescents from nicotine exposure. The CAH stated that adolescents may become addicted to nicotine more rapidly than adults and that nicotine exposure during adolescence ‘may have a long-term negative impact on higher cognitive function.’[151] The CAH also drew attention to the potential maternal and fetal health risks from nicotine use during pregnancy, including contributing to ‘preterm delivery, still birth, neonatal apnoea, and sudden infant death syndrome’.[152]
3.101
The CCA and NHFA stated that nicotine can contribute to the ‘onset and growth of various forms of cancer’ and compromise the effectiveness of cancer treatment.[153] In addition, the CCA and NHFA stated that inhaling vaporised nicotine can contribute to the following conditions:
Acute myocardial ischemia which can contribute to Coronary Vascular Disease;
Respiratory disorders through effects on the lungs and central nervous system;
Risk of kidney disease due to loss of renoprotective mechanism; and
Immunosuppression including delayed wound healing and increased infection.[154]

Flavourings and Other Chemicals

3.102
The liquid used to create the vapour in E-cigarettes contains chemicals which are used to flavour the vapour. The Department of Health advised that in addition to flavouring chemicals, E <NonBreakingHyphen> </NonBreakingHyphen> cigarette vapour can include: formaldehyde, heavy metals, and particulate matter at ‘levels that have the potential to cause adverse health effects.’[155] The Department of Health stated that E-cigarette vapour contained known carcinogens and the health impacts of exposure to E <NonBreakingHyphen> </NonBreakingHyphen> cigarette vapour are not well understood.[156]
3.103
The TSANZ and LFA commented that although some of the flavouring used in E-liquids may be approved for oral ingestion they are not approved for inhalation. The TSANZ and LFA added that as the E-liquid is heated to form the vapour:
… the superheated environment alters [the flavourings into] toxins, and higher levels of toxins equal to or greater than those seen in cigarette smoking can be produced. In particular, the carcinogen formaldehyde and other aldehyde may be created in these superheated aerosols.[157]
3.104
Cancer Research UK referred to a study released in February 2017 by researchers at the University College London which tracked vapers, smokers, and dual-users over a period of 18 months. The study found that vapers had levels of toxicants in their urine and saliva ‘similar to those in [users of] conventional nicotine replacement therapies’ and much lower than the levels of smokers and dual users.[158]
3.105
In contrast, the CCA and NHFA highlighted a report stating that some carcinogens and other toxins present in tobacco smoke had also been detected in E <NonBreakingHyphen> </NonBreakingHyphen> cigarette vapour, ‘which raises the possibility that long-term use might increase the risk of lung cancer, cardiovascular, [chronic obstructive pulmonary disease (COPD)] and other smoking related diseases.’[159]
3.106
Associate Professor Mendelsohn stated that while potentially harmful chemicals do exist in E <NonBreakingHyphen> </NonBreakingHyphen> cigarette vapour, research had found that they were at levels nine to 450 times lower than in cigarette smoke.[160] The RCPL made the similar point that while long term E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use may increase the risk of lung cancer, COPD, and cardiovascular diseases the ‘magnitude of such risks is likely to be substantially lower than those of smoking, and extremely low in absolute terms.’ The RCPL added that these risks were ‘amenable to reduction through product technological and purity improvements.’[161]
3.107
The 2018 NAS Review stated that there was conclusive evidence that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes emit numerous potentially toxic substances and that the quantity and characteristics of these substances was highly variable between different E <NonBreakingHyphen> </NonBreakingHyphen> cigarette products.[162] These toxic substances included: ‘formaldehyde, acetaldehyde, and acrolein, which are known cancer-producing toxicants’.[163] Despite this, the 2018 NAS Review stated that there was substantial evidence that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes exposed users to significantly lower levels of potentially toxic substances than tobacco cigarettes.[164]
3.108
In addition, the 2018 NAS Review also stated that there was substantial evidence that E <NonBreakingHyphen> </NonBreakingHyphen> cigarette vapour contained metals and that there was limited evidence that (with the exception of cadmium) the quantity of these metals were higher in E <NonBreakingHyphen> </NonBreakingHyphen> cigarette vapour than in tobacco smoke. The 2018 NAS Review stated that these metals may come from the metal coil used to heat the E <NonBreakingHyphen> </NonBreakingHyphen> liquid. The 2018 NAS Review added, however, that there were no studies undertaken of the metals in E <NonBreakingHyphen> </NonBreakingHyphen> cigarette vapour using the most recent third generation of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette devices.[165]
3.109
The 2018 NAS Review stated that the presence of compounds such as formaldehyde and acrolein supported the biological plausibility that long <NonBreakingHyphen> </NonBreakingHyphen> term E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use could increase the risk of cancer. Nevertheless the sparseness of evidence precluded the 2018 NAS Review from ‘making any evidence-based conclusions about the potential association between E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use and the risk of cancer in human populations’.[166]
3.110
A recently published study followed nine young adult E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users, who had never smoked tobacco cigarettes, for a period of 3.5 years. The study examined whether there were any negative health impacts associated with E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use among this group, when compared to a control group of non-users. The study did not find ‘any health concerns’ related to E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes over the 3.5 year period, and concluded that:
While the sample size was small, the results of this study may provide some preliminary evidence that long-term use of [E-cigarettes] is unlikely to raise significant health concerns in relatively young users.[167]
3.111
The study cautioned, however, that ‘it cannot be excluded that some harm may occur at later stages.’[168]

Lung Health

3.112
The TSANZ and LFA advised that following E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use, as much as half of the thin surface fluid lining in the lungs is made up of deposits derived from vaping.[169] Emeritus Professor Chapman commented that the changes to the composition of the lung lining could alter the ability of the lung to absorb asthma medication, or increase the risk from cigarette smoke particles for people who both smoke and vape.[170]
3.113
Emeritus Professor Chapman commented that recent research was suggesting that ‘E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes are almost certainly going to have far less carcinogenic risk than cigarettes but they may well have significant cardiovascular and respiratory risk’.[171] The TSANZ and LFA added that the ‘early data’ from investigations into the effects of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes on immune cells in the lungs found that E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use was making these cells less able to detect pathogenic bacteria and contributing to ‘supressed immune cell function and immune response, potentially contributing to chronic lung inflammation’.[172]
3.114
The TSANZ and LFA also drew attention to the results from an animal study which found E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use during adolescence and early adulthood is ‘not harmless to the lungs’ as it may decrease function in the ‘areas of the lung where gas exchange occurs (parenchyma).’ A further animal study found that ‘maternal [E <NonBreakingHyphen> </NonBreakingHyphen> cigarette] use enhances and worsens allergic asthma in offspring’.[173]
3.115
In addition, the TSANZ and LFA highlighted a recent case of an individual who both smoked and vaped for a period of three months and in this time developed ‘new areas of interstitial lung damage’ which resolved following cessation of use of the E <NonBreakingHyphen> </NonBreakingHyphen> cigarette. The TSANZ and LFA advised that this is the first case linking E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use to ‘rapid lung damage.’[174]
3.116
The 2018 NAS Review found that there was no available evidence in relation to ‘whether or not E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes cause respiratory diseases’. The 2018 NAS Review found moderate evidence of an increase in coughing, wheezing, and asthma symptoms among adolescent E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users. For adult smokers who switch (completely or partially) to E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, the 2018 NAS Review found that there was limited evidence of improvements in lung function and respiratory symptoms and a reduction in COPD exacerbations.[175]

Other Potentially Harmful Impacts

3.117
The Australian Competition and Consumer Commission (ACCC) stated that it was concerned about two safety hazards from E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: firstly, injuries resulting from fires and battery explosions; and second, ‘injuries to children from ingesting nicotine E <NonBreakingHyphen> </NonBreakingHyphen> liquid.’[176]

Battery Explosions

3.118
The ACCC explained the potential safety risks from E <NonBreakingHyphen> </NonBreakingHyphen> cigarette batteries, stating:
E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes contain interchangeable parts, often including extra-low voltage lithium batteries. Failure of these parts has been linked to ignition of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, with a number of incidences of burns injuries reported overseas. Many have been linked to overcharging and overheating of batteries, causing the device to ignite or explode in close proximity to the user. The ACCC is yet to receive any reports of injuries from E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes igniting or exploding in Australia.[177]
3.119
Emeritus Professor Chapman commented that ‘there are now dozens of cases reported in medical journals of burns and other injury related to lithium-ion battery powered device malfunction.’[178] The AMA added that lithium batteries also ‘pose a serious health risk to small young children, who are inclined to swallow them’.[179]
3.120
Emeritus Professor Chapman also stated that explosions were more common in some other lithium battery powered devices, but added that ‘when mobile phones and computers explode, we see responsible industries suspend sales or enact global recalls, until they have rendered the product safe’.[180]
3.121
Associate Professor Gartner and Professor Hall stated that the number of explosions is ‘very small compared to the number of devices that are used globally’[181] and advised that some manufacturers have issued product recalls following explosions.[182] Associate Professor Gartner and Professor Hall added that:
Some manufacturers include safety features to prevent over-heating, fire and explosions. A reasonable approach would be to require all manufacturers to implement safety features that reduce these risks and regulate them like other consumer products that contain lithium ion batteries.[183]
3.122
The ACCC advised that it is advocating greater scrutiny of extra-low voltage lithium batteries by ‘state and territory electric safety regulators and this in time will improve battery quality and consumer safety.’[184]
3.123
Associate Professor Gartner and Professor Hall also compared the risk of burns from E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to the risk of fire caused by tobacco cigarettes, stating that in Adelaide cigarettes ‘were responsible for 47 house fires in a two month period’.[185] Associate Professor Gartner and Professor Hall also referred to an article by the London Fire Brigade that reported that in London, smoking was responsible for 255 times more fires than vaping.[186]

Nicotine Poisoning

3.124
The ACCC warned of the safety risks to children of E-liquid containing nicotine, stating:
If [E-liquid] contains high levels of nicotine and is ingested by a child, it could lead to serious illness or death. At least one death overseas has been linked to a child ingesting nicotine E-liquid. No injuries have been reported to the ACCC, but NSW Health has published anecdotal reports of harm to children.[187]
3.125
The ACCC also called for import controls to limit the illicit trade in nicotine E <NonBreakingHyphen> </NonBreakingHyphen> liquid and stated that it ‘expects that a reduction in the availability of illicit nicotine E <NonBreakingHyphen> </NonBreakingHyphen> liquids will mitigate the risk of ingestion by children.’[188]
3.126
The CAH at the Royal Children’s Hospital stated that nicotine is a ‘highly toxic substance’ and that:
In acute poisoning, death can occur within minutes due to the respiratory failure arising from paralysis of the respiratory muscles. Young children are most at risk from unintentional ingestion yet many E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and [E-liquid] products are not manufactured with even the most basic of safety features. The risk of unintentional ingestion is further increased as the packaging is often brightly coloured and therefore appealing to young children.[189]
3.127
The CAH added that in the USA between September 2010 and February 2014 reports of nicotine poisoning due to E <NonBreakingHyphen> </NonBreakingHyphen> liquids increased from one case per month to 215 cases per month. Over half of these cases involved children under the age of five years old.[190]
3.128
Public Health England stated that, in the UK, there were approximately 150 calls per year to the National Poisons Information Service regarding children being exposed to nicotine. Less than 10 of these cases involved severe poisoning and there have been no reported cases of fatal poisoning in children. Public Health England also advised that nicotine had been used in a number of attempted suicide cases.[191]
3.129
The Australian Vaping Advocacy, Trade and Research (AVATAR) explained that currently over 80 per cent of vaping store customers will purchase nicotine liquid online to add to the non-nicotine E-liquid purchased in-store. The AVATAR advised that vapers ‘generally have to import pretty high strength nicotine … a 10 per cent solution’.[192] Another E <NonBreakingHyphen> </NonBreakingHyphen> cigarette business, Bettavape, suggested that the importation of high strength nicotine ‘introduces too many unnecessary risks to the consumer and their family from the accidental ingestion or exposure to these higher concentration nicotine bases.’[193]
3.130
The AVATAR added that high strength liquid spilt on skin can cause nausea and dizziness and it could be lethal if ingested.[194] The AVATAR suggested that if vaping stores were able to sell E <NonBreakingHyphen> </NonBreakingHyphen> liquids containing nicotine it would stop vapers needing to mix liquids at home which would be a ‘far safer situation, and it would mean that the government had control over the quality of the nicotine that went in.’[195]

Concluding Comment

3.131
From a public health perspective there are four main questions that must be asked in relation to the health impacts of electronic cigarettes (E-cigarettes). They are:
Do E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes help reduce the number of people smoking tobacco cigarettes?
What are the health effects of the long term use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes?
Would the legal availability of E-cigarettes act as a gateway to nicotine use for non <NonBreakingHyphen> </NonBreakingHyphen> smokers?
Is the use of E-cigarettes less harmful than the use of tobacco products?
3.132
As E-cigarettes are a relatively new product, there is very limited evidence available to answer these questions. For policy makers this poses a potential dilemma as making regulatory changes to legalise nicotine E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes comes with significant risks. Conversely, not making E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes available deprives smokers of a potentially useful tool to help them quit.

Can E-cigarettes Reduce the Number of Smokers?

E-cigarettes as a Smoking Cessation Tool

3.133
The view of almost all Australian public health organisations that contributed to the inquiry is that there is currently insufficient evidence to prove that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes are an effective smoking cessation tool. In addition to public health bodies, this view was shared by the Department of Health and the State Governments of New South Wales, Queensland, South Australia, Tasmania, Victoria, and Western Australia. These organisations were generally of the view that Australia has a successful system for evaluating health claims and that the appropriate bodies to assess the research are the Therapeutic Goods Administration and the National Health and Medical Research Council.
3.134
Several studies, including two randomised controlled trials, found that nicotine containing E-cigarettes were effective in helping smokers quit, but other studies have found that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes can hamper the ability of smokers to quit. The United States of America’s (USA) National Academy of Sciences (NAS) concluded there was some evidence supporting the conclusion that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes help smokers to quit but that this evidence was limited and subject to significant uncertainty.
3.135
Overall, while E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may have the potential to be effective as an aid for smoking cessation there is a need for high quality research in this area, ideally including randomised controlled trials. There is also a need for more research using modern, tank-style, E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes as these deliver nicotine more efficiently to the user.
3.136
Another issue of concern is the dual use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes and tobacco. Current research suggests that using E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes to cut back on smoking without quitting entirely is likely to have little, if any, health benefit. It is not clear whether, for most smokers, dual use represents a transitional stage on the path to quitting or a permanent state that could delay attempts to completely quit smoking.
3.137
Smoking rates among people with mental disorders are high and are not declining. The Royal Australian and New Zealand College of Psychiatrists suggested that there could be financial and health benefits from making E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes legally available for people living with mental illness. While there are risks, such as long term dual use, the Committee considers this is worthy of further investigation.

E-cigarettes as a Gateway to Smoking for Young People

3.138
Many public health agencies are concerned that legalising nicotine could increase the number of young people who take up smoking. If a young person becomes addicted to nicotine through the use of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes it seems plausible that, at some point, they may move onto smoking tobacco cigarettes.
3.139
The 2018 NAS Review found that there was substantial evidence that young people who used E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes were more likely to move onto tobacco smoking. This is a very concerning finding. It should be pointed out that, despite this, smoking rates in the UK and the USA have continued to decline suggesting that tobacco control policies can continue to be effective in the presence of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes.

What are the Health Effects of E-cigarette Use?

3.140
E-cigarette vapour has been found to contain dangerous substances such as heavy metals and formaldehyde. E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use also appears to have negative impacts on lung health, and potentially contribute to respiratory and cardiovascular conditions. In addition, some inquiry participants were concerned that long term nicotine use could have a negative health effect on adolescent health and maternal and fetal health during pregnancy. In contrast, other participants considered the health effects of nicotine negligible and comparable to those of caffeine.
3.141
Overall knowledge about the long term health impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette use is limited. There are many thousands of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette flavours and there is little known about the long term effects of inhaling the chemicals used in these flavours. The possibility that some of these chemicals could have serious adverse health impacts is a cause for concern.
3.142
Consideration must be given to whether the health impacts of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes should be primarily assessed in their own right or relative to the known impacts of tobacco smoking. Given cigarettes kill almost two-thirds of their long term users, they appear far from a suitable benchmark for assessing safety. Nevertheless, if E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes prove to be able to help reduce the overall number of smokers it will become necessary to weigh the potential risks of vaping against the known impacts of smoking.
3.143
Widespread attention has been given to the figure reported by Public Health England that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes are 95 per cent safer than tobacco cigarettes. Public Health England indicated that this figure was only an estimate and many inquiry participants disputed its accuracy. There does appear to be agreement that E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes are probably safer than tobacco but the magnitude of the difference is still under debate.

Weighing the Potential Risks and Benefits

3.144
Some of the long term health impacts of nicotine E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes may not be known for a decade or more but their impact on smoking rates should become clear much sooner. If E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes can be shown to reduce the number of smokers, then the potential benefits this may bring could strengthen the case for the legalisation of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes.

Recommendation 1

3.145
The Committee recommends that the National Health and Medical Research Council fund an independent and comprehensive review of the evidence relating to the health impacts of electronic cigarettes (E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes). This review should be updated every two years to take into account the findings of new research into E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes. Topics covered by the review should include:
The effectiveness of E-cigarettes as an aid to help people quit smoking tobacco cigarettes;
The health effects of ingredients commonly used in E-cigarette liquids. Following the review, any ingredients found to have significant negative impacts on human health should be prohibited from use in E-cigarette liquids;
The likelihood that E-cigarettes will increase the number of young people using nicotine and the number of young people smoking;
The health impacts of long term E-cigarette use;
The relative health impacts of E-cigarettes as compared to tobacco products.

Recommendation 2

3.146
The Committee recommends that the Department of Health convenes an international meeting of health experts from similar economic jurisdictions to discuss different policy and legislative approaches to electronic cigarettes.

[1]     

Thoracic Society of Australia and New Zealand and Lung Foundation Australia (TSANZ and LFA), Submission 332, p. 9; Centre for Adolescent Health, Submission 256, p. 5.

[2]     

New Nicotine Alliance Australia (NNAA), Submission 222, pp 3-4.

[3]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282.1, p. 9.

[4]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, pp 11-12.

[5]     

Department of Health, Submission 297, p. 1.

[6]     

Mr Maurice Gerard Swanson, Chief Executive Officer, National Heart Foundation of Australia (WA Division), Official Committee Hansard, Canberra, 8 September 2017, p. 11; Royal College of Physicians of London, Submission 280, p. 2.

[7]     

Department of Health, Submission 297, p. 1.

[8]     

Dr Attila Danko, President, NNAA, Official Committee Hansard, Sydney, 12 July 2017, p. 6.

[9]     

Mr Ben Grotegoed, Submission 91, p. 1.

[10]     

Department of Health, Submission 297, p. 2.

[11]     

Royal Australasian College of Physicians (RACP), Submission 276, p. 2.

[12]     

Professor Bruce Thompson, Treasurer and Board Director, Finance, Risk and Audit Compliance, TSANZ, Official Committee Hansard, Melbourne, 5 October 2017, p. 1.

[13]     

Australian Medical Association, Submission 289, p. 4.

[14]     

New South Wales Health, Submission 333, p. 1.

[15]     

Queensland Department of Health, Submission 226, p. 4.

[16]     

South Australian Government, Submission 230, p. 2.

[17]     

Tasmanian Government, Submission 182, p. 2.

[18]     

Quit Victoria, Submission 328, p. 1.

[19]     

Government of Western Australia, Submission 292, p. 2.

[20]     

Department of Health, Submission 297, p. 3.

[21]     

Cochrane, ‘What is Cochrane evidence and how can it help you?’ www.cochrane.org/what-is-cochrane-evidence, Accessed 1 December 2017.

[22]     

Department of Health, Submission 297, p. 3.

[23]     

Cochrane, ‘Can electronic cigarettes help people stop smoking and are they safe to use for this purpose?’ www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose, Accessed 1 November 2017.

[24]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282, p. 2.

[25]     

Cochrane, ‘Can electronic cigarettes help people stop smoking and are they safe to use for this purpose?’ www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose, Accessed 1 November 2017.

[26]     

Associate Professor Colin Mendelsohn, Submission 258, p. 8.

[27]     

Cochrane, ‘Can electronic cigarettes help people stop smoking and are they safe to use for this purpose?’ www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose, Accessed 1 November 2017.

[28]     

Cigalikes are a type of E <NonBreakingHyphen> </NonBreakingHyphen> cigarette that physically resembles a tobacco cigarette and is often disposable or uses a disposable liquid container as opposed to the refillable containers for E <NonBreakingHyphen> </NonBreakingHyphen> liquids used by tank system E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes.

[29]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282, p. 2.

[30]     

Professor Martin McKee, Submission 291, p. 3.

[31]     

The 2018 NAS review defines limited evidence as: ‘supportive findings from fair-quality studies or mixed findings with most favouring one conclusion. A conclusion can be made, but there is significant uncertainty due to chance, bias, and confounding factors.’ National Academy of Science, Exhibit 24a: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: Conclusions by Level of Evidence, p. 2.

[32]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. S-7.

[33]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 17-15.

[34]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 17-15.

[35]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 17-15.

[36]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 17-15.

[37]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 17-16.

[38]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 17-16.

[39]     

The 2018 NAS Review defines moderate evidence as: ‘several supportive findings from fair-quality studies with few or no credible opposing findings. A general conclusion can be made, but limitations, including chance, bias, and confounding factors, cannot be ruled out with reasonable confidence.’ Exhibit 24a: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: Conclusions by Level of Evidence, p. 2.

[40]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 17-17.

[41]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 11.

[42]     

El Dib, R., Suzumura, E.A., Aki, E.A., Gomaa, H, Agarwal, A., Chang, Y., Prasad, M., Ashoorion, V., Heels-Ansdell, D., Maziak, W., Guyatt, G., ‘Electronic Nicotine Delivery Systems and/or Electronic Non-Nicotine Delivery Systems for Tobacco Smoking Cessation or Reduction: A Systematic Review and Meta-Analysis, BMJ Open, 2017, 7.

[43]     

El Dib, R., Suzumura, E.A., Aki, E.A., Gomaa, H, Agarwal, A., Chang, Y., Prasad, M., Ashoorion, V., Heels-Ansdell, D., Maziak, W., Guyatt, G., ‘Electronic Nicotine Delivery Systems and/or Electronic Non-Nicotine Delivery Systems for Tobacco Smoking Cessation or Reduction: A Systematic Review and Meta-Analysis, BMJ Open, 2017, 7.

[44]     

Professor Martin McKee, Submission 291, p. 3; RACP, Submission 276, p. 2.

[45]     

Associate Professor Colin Mendelsohn, Submission 258, p. 8.

[46]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282.1, p. 9.

[47]     

Zhu, S.H., Zhuang, Y.L, Wong, S., Cummins S.E., Tedeschi, G.J., ‘E-cigarette Use and Associated Changes in Population Smoking Cessation: Evidence from US Current Population Surveys’, The BMJ, 2017, 358.

[48]     

Public Health England, Exhibit 1: E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: An Evidence Update, p. 48.

[49]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 11.

[50]     

Professor Ron Borland, Submission 216, p. 7.

[51]     

Professor Ron Borland, Submission 216, p. 7.

[52]     

Emeritus Professor Ian Webster, Submission 65, p. 2.

[53]     

Professor Ron Borland, Submission 216, p. 8.

[54]     

Professor Ron Borland, Submission 216, p. 19.

[55]     

Royal Australian and New Zealand College of Psychiatrists (RANZCP), Submission 294, p. 1.

[56]     

RANZCP, Submission 294, p. 1.

[57]     

Professor Con Stough and Associate Professor Luke Downey, Submission 324, p. 2.

[58]     

Dr Shalini Arunogiri, Chair, Faculty of Addiction Psychiatry, RANZCP, Official Committee Hansard, Canberra, 8 September 2017, p. 16.

[59]     

RANZCP, Submission 294, p. 1.

[60]     

RANZCP, Submission 294, p. 4.

[61]     

Vapers is the commonly used term for E <NonBreakingHyphen> </NonBreakingHyphen> cigarette users.

[62]     

Dr Attila Danko, NNAA, Official Committee Hansard, Sydney, 12 July 2017, pp 6-7.

[63]     

NNAA, Submission 222, p. 3.

[64]     

NNAA, Submission 222, pp 3-4.

[65]     

Associate Professor Colin Mendelsohn, Private Capacity, Official Committee Hansard, Sydney, 12 July 2017, pp 10-11.

[66]     

Associate Professor Colin Mendelsohn, Official Committee Hansard, Sydney, 12 July 2017, p. 11.

[67]     

The 2018 NAS Review defines conclusive evidence as: ‘many supportive findings from good-quality controlled studies (including randomised and non-randomised controlled trials) with no credible opposing findings. A firm conclusion can be made, and the limitations to the evidence, including change, bias, and confounding factors, can be ruled out with reasonable confidence.’ Exhibit 24a: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: Conclusions by Level of Evidence, p. 2.

[68]     

The 2018 NAS Review defines substantial evidence as: ‘several supportive findings from good-quality observational studies or controlled trials with few or no credible opposing findings. A firm conclusion can be made, but minor limitations, including chance, bias, and confounding factors, cannot be ruled out with reasonable confidence.’ Exhibit 24a: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: Conclusions by Level of Evidence, p. 2.

[69]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. S-7 - S-8.

[70]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282, p. 10.

[71]     

Emeritus Professor Ian Webster, Submission 65, p. 3.

[72]     

National Health and Medical Research Council, Submission 167, p. 2.

[73]     

Department of Health, Submission 297, p. 4.

[74]     

Associate Professor Colin Mendelsohn, Submission 258, p. 9.

[75]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 31.

[76]     

Queensland Department of Health, Submission 226, p. 3.

[77]     

Queensland Department of Health, Submission 226, p. 8.

[78]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 13.

[79]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, pp 15, 17.

[80]     

Australian Drug Law Reform Foundation, Submission 317, p. 12.

[81]     

Associate Professor Colin Mendelsohn, Submission 258, p. 9.

[82]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282, pp 6-7.

[83]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 18-25.

[84]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 18-25.

[85]     

Department of Health, Submission 297, p. 1.

[86]     

Queensland Department of Health, Submission 226, p. 8.

[87]     

Quit Victoria, Submission 328, p. 2.

[88]     

Mr Maurice Gerard Swanson, National Heart Foundation of Australia (WA Division), Official Committee Hansard, Canberra, 8 September 2017, p. 11.

[89]     

Queensland Department of Health, Submission 226, p. 4.

[90]     

Associate Professor Coral Gartner, Private Capacity, Official Committee Hansard, Canberra, 8 September 2017, p. 19.

[91]     

Associate Professor Colin Mendelsohn, Official Committee Hansard, Sydney, 12 July 2017, p. 14.

[92]     

TSANZ and LFA, Submission 332, p. 7; Professor Martin McKee, Submission 291, p. 3.

[93]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 50.

[94]     

Associate Professor Coral Gartner, Official Committee Hansard, Canberra, 8 September 2017, pp 19 <NonBreakingHyphen> </NonBreakingHyphen> 20.

[95]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 51.

[96]     

Dr Konstantinos Farsalinos, Submission 303, p. 9.

[97]     

Dr Konstantinos Farsalinos, Submission 303, p. 10.

[98]     

Viscount Matthew Ridley, Secretary, All-Party Parliamentary Group for E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, Official Committee Hansard, Canberra, 18 October 2017, p. 3.

[99]     

Viscount Ridley, All-Party Parliamentary Group for E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, Official Committee Hansard, Canberra, 18 October 2017, p. 3.

[100]     

Royal College of Physicians of London, Submission 280, p. 2.

[101]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 16-30.

[102]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 16-31.

[103]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 16-32.

[104]     

Associate Professor Colin Mendelsohn, Official Committee Hansard, Sydney, 12 July 2017, p. 14.

[105]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 16-31.

[106]     

Public Health England, Submission 336.1, p. 14.

[107]     

Public Health England, Submission 336.1, p. 15; Mr Martin Dockrell, Tobacco Control Lead, Public Health England, Official Committee Hansard, Canberra 18 October 2017, p. 7.

[108]     

Mr James Hargrave, Public Affairs Manager, UK Vaping Industry Association, Official Committee Hansard, Canberra, 25 October 2017, p. 4.

[109]     

Royal College of Physicians of London, Submission 280, p. 2.

[110]     

Counterfactual Consulting, Submission 271, p. 4.

[111]     

Professor Sinclair Davidson, Submission 164, pp 10-11.

[112]     

Mr George Butterworth, Tobacco Policy Manager, Cancer Research UK, Official Committee Hansard, Canberra, 25 October 2017, p. 10.

[113]     

Department of Health, Submission 297, p. 1.

[114]     

Ms Samantha Robertson, Executive Director, National Health and Medical Research Council, Official Committee Hansard, Canberra, 8 September 2017, p. 6.

[115]     

Associate Professor Colin Mendelsohn, Official Committee Hansard, Sydney, 12 July 2017, p. 7.

[116]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 19-16.

[117]     

Emeritus Professor Simon Chapman, Private Capacity, Official Committee Hansard, Canberra, 8 September 2017, p. 15.

[118]     

Emeritus Professor Simon Chapman, Official Committee Hansard, Canberra, 8 September 2017, pp 24 <NonBreakingHyphen> </NonBreakingHyphen> 25.

[119]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, pp 24-25.

[120]     

RACP, Submission 276, p. 3.

[121]     

Royal College of Physicians of London, Submission 280, p. 3.

[122]     

Professor Bruce Thompson, TSANZ, Official Committee Hansard, Melbourne, 5 October 2017, p. 1.

[123]     

Dr Sandra Costigan, Principal Toxicologist Vaping Products, British American Tobacco, Official Committee Hansard, Sydney, 12 July 2017, pp 8-9; Australian Drug Law Reform Foundation, Submission 317, p. 3.

[124]     

TSANZ and LFA, Submission 332, p. 12.

[125]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282.1, p. 4.

[126]     

Associate Professor Colin Mendelsohn, Official Committee Hansard, Sydney, 12 July 2017, p. 3.

[127]     

Research Data Australia, ‘Harnessing New Media to Translate Prevention Research Evidence in to Practice and Policy’, https://researchdata.ands.org.au/harnessing-new-media-practice-policy/519253, Accessed 22 November 2017.

[128]     

National Health and Medical Research Council, Submission 167, pp 10-12.

[129]     

Public Health England, Exhibit 1: E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: An Evidence Update, 2015, p. 5.

[130]     

Government of Western Australia, Submission 292, p. 4.

[131]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282.1, p. 8; Associate Professor Colin Mendelsohn, Submission 258, p. 3; Dr Konstantinos Farsalinos, Submission 303, p. 2; Australian Vaping Advocacy, Trade and Research (AVATAR), Submission 274, p. 3; NNAA, Submission 222, p. 2; Professor Ricardo Polosa, Submission 288, p. 3; Counterfactual Consulting, Submission 271, p. 2; Australasian Association of Convenience Stores, Submission 93, p. 3; Professor Sinclair Davidson, Submission 164, p. 11; Australian Taxpayers’ Alliance and MyChoice, Submission 302, p. 6; Dr Catherine Silsbury, Submission 159, p. 3; Australian Drug Law Reform Foundation, Submission 317, p. 4; Mr Stuart Singleton, Submission 316, p. 7; Australian Retailers Association, Submission 290, p. 4.

[132]     

Nutt, D.J., Phillips, L.D., Balfour, D., Curren, H.V., Dockrell, M., Foulds, J., Fagerstrom, K., Letlape, K., Milton, A., Polosa, R., Ramsey, J., Sweanor, D., ‘Exhibit 2: Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach’, European Addiction Research, 2014, 20:218-225.

[133]     

The expert panel was convened by the International Scientific Committee on Drugs, a body created in 2010 by Professor David Nutt as an ‘independent science-led drugs charity’. The expert panel was comprised of 12 representatives from the United Kingdom, Canada, the United States of America, Sweden, South Africa, and Italy. Sources: International Scientific Panel of Drugs, ‘About’, www.drugscience.org.uk/about, Accessed 14 November 2017; Nutt et al., ‘Exhibit 2: Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach’, European Addiction Research, 2014, 20:218-225.

[134]     

Nutt et al., Exhibit 2: ‘Estimating the Harms of Nicotine-Containing Products Using the MCDA Approach, European Addiction Research, 2014, p. 224.

[135]     

Department of Health, Submission 297, p. 5; Western Australian Government, Submission 292, p. 4; National Health and Medical Research Council, Submission 167, p. 3.

[136]     

Cancer Council Australia and National Heart Foundation of Australia, Submission 295, p. 4.

[137]     

Professor Martin McKee, Submission 291, p. 4.

[138]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 25.

[139]     

Public Health England, Submission 336, p. 3.

[140]     

Mr Steve Woodward, Submission 296, p. 11.

[141]     

Mr George Butterworth, Cancer Research UK, Official Committee Hansard, Canberra, 25 October 2017, p. 8.

[142]     

Professor Bruce Thompson, TSANZ, Official Committee Hansard, Melbourne, 5 October 2017, p. 3.

[143]     

Professor Anne Holland, Board Director, Clinical Care and Resource, TSANZ, Official Committee Hansard, Melbourne, 5 October 2017, p. 3.

[144]     

Dr Konstantinos Farsalinos, Submission 303, p. 5.

[145]     

Associate Professor Colin Mendelsohn, Submission 258, p. 14.

[146]     

Department of Health, Submission 297, p. 5.

[147]     

Department of Health, Submission 297: Attachment A, p. 2.

[148]     

Department of Health, Submission 297, p. 5.

[149]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 4-43.

[150]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 4-43.

[151]     

Centre for Adolescent Health, Submission 256, p. 5.

[152]     

Centre for Adolescent Health, Submission 256, p. 5.

[153]     

Cancer Council Australia and National Heart Foundation of Australia, Submission 295, p. 5.

[154]     

Cancer Council Australia and National Heart Foundation of Australia, Submission 295, p. 5.

[155]     

Department of Health, Submission 297, p. 5.

[156]     

Department of Health, Submission 297, p. 5.

[157]     

TSANZ and LFA, Submission 332, p. 9.

[158]     

Mr George Butterworth, Cancer Research UK, Official Committee Hansard, Canberra, 25 October 2017, p. 8.

[159]     

Cancer Council Australia and National Heart Foundation of Australia, Submission 295, p. 5.

[160]     

Associate Professor Colin Mendelsohn, Submission 258, p. 13.

[161]     

Royal College of Physicians of London, Submission 280, p. 3.

[162]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 5-32.

[163]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 5-31.

[164]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 5-32.

[165]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, pp 5-36 - 5-37.

[166]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, p. 10-18.

[167]     

Polosa, R., Cibell, F., Caponnetto, P., Maglia, M., Prosperini, U., Russo, C., Tashkin, D., Exhibit 21: ‘Health Impact of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: A prospective 3.5 year study of regular daily users who have never smoked’, Scientific Reports, 17 November 2017, p. 7.

[168]     

Polosa, R., Cibell, F., Caponnetto, P., Magila, M., Prosperini, U., Russo, C., Tashkin, D., Exhibit 21: ‘Health Impact of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes: A prospective 3.5 year study of regular daily users who have never smoked’, Scientific Reports, 17 November 2017, p. 1.

[169]     

TSANZ and LFA, Submission 332, p. 3.

[170]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 29.

[171]     

Emeritus Professor Simon Chapman, Official Committee Hansard, Canberra, 8 September 2017, p. 15.

[172]     

TSANZ and LFA, Submission 332, p. 9.

[173]     

TSANZ and LFA, Submission 332, p. 9.

[174]     

TSANZ and LFA, Submission 332, p. 9.

[175]     

Stratton, K., Kwan, L.Y., Eaton D.L., Exhibit 24: Public Health Consequences of E <NonBreakingHyphen> </NonBreakingHyphen> cigarettes, National Academy of Sciences, pp 11-11 - 11-12.

[176]     

Australian Competition and Consumer Commission, Submission 224, p. 4.

[177]     

Australian Competition and Consumer Commission, Submission 224, p. 4.

[178]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 36.

[179]     

Dr Tony Bartone, Vice-President, Australian Medical Association, Official Committee Hansard, Melbourne, 5 October 2017, p. 9.

[180]     

Emeritus Professor Simon Chapman AO, Professor Mike Daube AO, David Bareham, and Associate Professor Matthew Peters, Submission 313, p. 38.

[181]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282, pp 5-6.

[182]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282.1, p. 8.

[183]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282, p. 6.

[184]     

Australian Competition and Consumer Commission, Submission 224, p. 4.

[185]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282.1, p. 9.

[186]     

Associate Professor Coral Gartner and Professor Wayne Hall, Submission 282.1, p. 9.

[187]     

Australian Competition and Consumer Commission, Submission 224, p. 4.

[188]     

Australian Competition and Consumer Commission, Submission 224, p. 4.

[189]     

Centre for Adolescent Health, Submission 256, p. 3.

[190]     

Centre for Adolescent Health, Submission 256, p. 3.

[191]     

Mr Martin Dockrell, Tobacco Control Lead, Public Health England, Official Committee Hansard, Canberra, 18 October 2017, p. 7.

[192]     

Mr Savvas Dimitriou, Chairperson, AVATAR, Official Committee Hansard, Melbourne, 5 October 2017, p. 36.

[193]     

Bettavape, Submission 267, p. 3.

[194]     

Mr Savvas Dimitriou, AVATAR, Official Committee Hansard, Melbourne, 5 October 2017, p. 36.

[195]     

Mr Savvas Dimitriou, AVATAR, Official Committee Hansard, Melbourne, 5 October 2017, p. 37.