Vaping ‘a Trojan horse and a Pandora’s box’

A new systematic review finds 25 studies showing never-smokers are three times more likely to take up the coffin nails after vaping.

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A new systematic review has delivered another blow to tobacco companies by finding “strong evidence that young never-smokers and non-smokers who use e-cigarettes are about three times as likely as non-users to start smoking tobacco and to become regular smokers”.

In a week when the National Party announced it wants to ease regulation of nicotine-containing vaping products ­– having accepted at least $275,000 in tobacco industry donations between 2015-16 and 2021-22 – ANU researchers delivered an unequivocal message.

Writing in the Medical Journal of Australia, Professor Emily Banks and colleagues said: “There is substantial evidence that nicotine e-cigarettes can cause dependence or addiction in non-smokers, and strong evidence that young non-smokers who use e-cigarettes are more likely than non-users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e-cigarettes used with clinical support are efficacious aids for smoking cessation.”

Health Minister Mark Butler was quick to shut down the Nationals, saying the party “have a blatant conflict of interest in this debate, they are still the only major party that excepts donations from tobacco companies”.

“The tobacco industry has found a new way to develop a generation of nicotine addicts and we will not stand for it,” Butler said.

Professor Banks and her colleagues have provided even more evidence to back the Minister up.

She told TMR that it was “important to get things in perspective”.

“Eight-nine percent of the population of Australia are not current daily smokers,” she said.

“About two-thirds to three-quarters of people who quit smoking successfully do so unaided. Then for those people who need support to quit, there are a range of products which are licensed by the TGA and found to be safe and effective.

“The people who are left, who have tried everything else, they could potentially benefit from vaping.”

Professor Banks said tobacco companies and vaping advocates were using the possible benefits to a small proportion of smokers to justify “something which is affecting the whole population, including the 89% who don’t smoke daily”.

“The vast majority of young people don’t smoke,” she said. “Our youth are leading the way with smoking cessation.

“E-cigarettes have been used like a cross between a Trojan horse and Pandora’s box. They’ve been brought to the community, saying this is really helpful for smokers to quit. And when you open it up, there’s bubblegum-flavoured vapes that are being promoted to 13-year-olds to use in the school toilets.

“That’s not what the community signed up for.”

Banks et al. found “strong evidence” from 25 studies showing that “young never-smokers and non-smokers who use e-cigarettes are about three times as likely as non-users to start smoking tobacco and to become regular smokers”.

“The relationship between e-cigarette use and smoking was deemed likely to be causal according to the Bradford-Hill criteria.”

Additionally the review found “limited evidence” that freebase nicotine e-cigarettes used with clinical support “are as efficacious as smoking cessation aids as approved nicotine replacement therapy or usual care/no intervention”.

“The published evidence indicates that use of nicotine e-cigarettes increases the risks of adverse health outcomes, including addiction, poisoning, toxicity from inhalation (including seizures), and lung injury (largely but not exclusively attributable to THC/vitamin E acetate-containing products),” Banks et al wrote.

“There is evidence for adverse effects on cardiovascular health measures (including blood pressure and heart rate) and lung function. We identified a range of health harms, and no benefits, for non-smokers who use e-cigarettes.

“For non-nicotine e-cigarettes, we found no benefits in terms of smoking cessation, harms related to devices, and uncertainty regarding health effects, indicating overall harm.”

Professor Banks called on medical professionals to “do a little thought experiment”.

“What would it look like if e-cigarettes were truly targeted to smokers who wanted to quit?” she asked.

“[Tobacco companies] would have applied to have them licensed. They have not been licensed by any medical authority worldwide.

“These companies are saying this is really great for quitting smoking, but they’ve never had it tested, they’ve never put it to the FDA, they’ve never tried to get it licensed.

“The Medicines and Healthcare Products Regulatory Agency in England has even said, ‘we want companies to submit to us’. They are actively calling for submissions and nobody’s submitted to them.”

She said licensing e-cigarettes for smokers who want to quit was not going to let tobacco companies “hook the next generation of customers”.

“It seems to me that the pro-vaping lobby thinks that they can dismiss evidence because they disagree with it,” Professor Banks said.

“But we have to actually look at what the data are really saying. We need a comprehensive approach. It certainly doesn’t work to make things freely available, and then tell young people not to do it. That’s one thing we definitely know doesn’t work.

“We need to be working on supply and demand. The market has been flooded by e-cigarette products, and they’re freely available. The first thing is we need to shut down that flood.

“There’s been this huge, concerted campaign by cigarette companies to flood the market to undermine the legislation. And then they say, look, it doesn’t work.

“We’ve got to enforce this.”

On ABC Melbourne this morning, Mr Butler reemphasised his plans to crack down on both the importation and sale of vaping products.

“We’re going to do that in co-operation with the states,” he said. “We talk about this as state and federal Health Ministers, and across-the-board Liberal and Labor alike, state Health Ministers are determined to work with us to crack down on this issue.”

Another Australian systematic released this week in the Journal of Oral and Maxillofacial Surgery found that vapes are at risk for “spontaneous combustion that can cause serious oral and maxillofacial injuries, particularly to the lower facial third and commonly requiring surgical management”.

“Safety of these devices should be improved through increased user education and regulation,” the authors wrote.