Three University of Auckland researchers discuss the outcomes of new New Zealand trials on vaping amid a global backlash against e-cigarettes

Discussion on the therapeutic benefits of nicotine-containing e-cigarettes to smokers worldwide who want to quit the killer habit is being overtaken by concerns over potential harms.

The global backlash against vaping includes the banning of e-cigarettes in India; the US plan to remove flavoured e-cigarettes from stores; a ban by CBS and WarnerMedia on vaping ads and, more locally, news that WOMAD NZ will not allow vapes at its festival in March next year.

These concerns have been fuelled by youth vaping and reports of vaping-related lung illness in the US.

But while the debate over vaping is raging, we have shown in our research with more than a thousand New Zealanders who smoke cigarettes and want to quit, that nicotine-containing e-cigarettes when used alone or with nicotine patches can help. In fact, we can categorically state that people who smoke should be encouraged to fully switch away from tobacco-related products to e-cigarettes, with the aim of eventually also stopping vaping.

How can we say this with confidence, in light of the global backlash against vaping?

We can say it because of our research. We have completed two (of only five in the world) large clinical trials (the gold standard in scientific research) testing the effectiveness and safety of using nicotine e-cigarettes alone or combined with nicotine patches.

All five trials have come to the same conclusion, that vaping can help some people quit smoking, with no associated serious harm. However, none of the five trials were large enough or run for long enough to assess the occurrence of uncommon side effects or side effects with a long lead-time. Therefore, the long‐term safety of e-cigarette use remains to be seen – which is why we support the New Zealand Government’s view that people who vape should eventually try and stop vaping (at a time when they feel sure they won’t relapse back to smoking tobacco).

Amid the bad press, we have put together some questions and answers using evidence from our own research on the role of e-cigarettes in smoking cessation, known facts about tobacco smoking and what we know so far about the US cases of vaping-related harm.

We must at this point draw a distinction between e-cigarettes and the new heat-not-burn tobacco products. They are two different products: e-cigarettes do not use tobacco; heat-not-burn products are devices that heat tobacco sticks without burning them. Most of the e-cigarettes available in New Zealand are from local companies; all heat-not-burn tobacco products are made, marketed and sold by the tobacco industry. In this piece, we only discuss e-cigarettes.

Is there a place for vaping in NZ?

E-cigarettes, ideally with nicotine and in combination with nicotine patches, most certainly have a place to help people quit smoking. As most of us know, tobacco is incredibly harmful – nicotine is the addictive chemical, but it’s the tar and around 4000 other harmful chemicals in tobacco smoke that cause cancer, heart disease, lung problems and other smoking-related illnesses.

The most important thing is to stop smoking tobacco. For many people, e-cigarettes offer a gateway out of tobacco. Once they have stopped smoking, ideally they should also consider stopping vaping given we don’t have an understanding of its long-term risk. However, for some people, vaping is the only thing stopping them relapsing back to smoking – and in those circumstances continuing to vape is the less harmful alternative.

In many people’s ideal world no one would smoke and no one would vape. But they do. We want to stop people dying from tobacco smoking, and vaping is a harm reduction tool that can help. Harm reduction tools are used in other health-related areas – for example, needle exchange programmes help reduce the risk of HIV or Hepatitis C in heroin users; sex education and condoms giveaways for youth help prevent pregnancy and sexually transmitted infections.

Let’s remind ourselves here of the tobacco smoking statistics – just over half a million people smoke in New Zealand and each year 5000 people die from smoking-related diseases. And because we’ve mentioned the US and India, let’s check the smoking statistics in those countries: India has 90 million smokers and 17,887 tobacco-related deaths each week; the US has 34 million tobacco smokers and 1300 tobacco-related deaths each week. Allowing the use of nicotine e-cigarettes (particularly if combined with nicotine patches) would help some of these people quit smoking, with no evidence of any immediate serious harm.

I have a family member who smokes, what should I say to them?

Chances are this person has tried many times to quit smoking. They’ve probably tried nicotine patches before, maybe nicotine gum or Champix. Possibly they’ve called the Quitline – but they are still smoking. The choices are: keep smoking, try to quit with no support, try to quit with the products you’ve already tried but failed with, or try vaping. Vaping does not suit everyone – but for many people it has been the only thing that worked. It’s not harmless, neither is a nicotine patch or Champix (many medicines can have side effects), but like these products, vaping is less harmful than continuing to smoke tobacco.

I have a family member who vapes – what should I say to them?

If they vape and are not smoking tobacco, congratulate them! If they vape and are still smoking tobacco, suggest they add in a nicotine patch or increase the nicotine strength of their e-cigarette, until they stop craving a cigarette.

But can we really say vaping is safe?

We are not saying vaping is safe – but it is safer than smoking tobacco. To our knowledge there has been no confirmed cases of clinical harm or reported deaths from vaping in New Zealand. This was the situation worldwide until recent reports from the US of 530 possible cases of severe acute lung illness and seven reported deaths possibly caused by vaping. (These are the figures at the time of writing, drawn from US Centers for Disease Control and Prevention.)

While this is very concerning, there are no reports of harm or deaths outside the US where approximately 10 million people vape – some for many years.

The recent cluster of US vapers with serious acute lung disease has all the hallmarks of a poisoning incident, and is most likely to have been caused by something in the e-cigarettes liquid they were vaping, possibly a thickening additive called Vitamin E acetate in conjunction with use of THC oils (tetrahydrocannabinol – the main psychoactive ingredient of cannabis) obtained from unlicensed sellers and manufacturers.

Fortunately, there is no evidence of this product on the New Zealand market. But the incident underlines the need for regulation and quality assurance in e-liquids and is a salutary reminder to vapers to only buy products from reputable retailers.

And what about anecdotal evidence that vaping is appealing to those who have never smoked, including large numbers of young people?

Although some youth are trying e-cigarettes (and we don’t know if nicotine is being used in the devices or not), current NZ data shows that very few (less than two in very 100 young people, or 2 percent) are using e-cigarettes on a daily basis (daily use would be an indication of nicotine-dependence). Furthermore, NZ data shows that the numbers of young people who never smoked before starting to vape are very small – only two per 1000 young people (or 0.2 percent).

Couldn’t e-cigarettes – especially with nicotine – become a gateway drug to tobacco cigarettes, especially for young people?

The majority of people who use tobacco start when they are teenagers or young adults. Consequently, strategies to prevent initiation of tobacco use are important, as are strategies to help youth and young adults quit tobacco use. It is possible that a young person may progress from using a nicotine e-cigarette to regular cigarette use. However, it is also possible that a young person who currently smokes tobacco may find an e-cigarette helps them quit. If e-cigarettes were a gateway to smoking, then we would expect to see an increase in the rates of smoking in NZ youth and young adults – but we are not. In fact, smoking rates in these groups are declining.

There have always been young people more inclined to risk-taking – these are the ones who are more inclined to smoke tobacco, drink alcohol, use cannabis etc, in their teens – are e-cigarettes just another appealing behaviour for our risk-takers, or is it a fad (here today, gone tomorrow)?

That said, we need to keep monitoring use of e-cigarettes by youth, as we have anecdotal evidence that over the last three months, use by this group has increased – but we don’t know if this use relates to vaping once (and never again) or vaping more regularly.

Does the tobacco industry own all the vaping products?

No, at the moment the majority of e-cigarettes sold in New Zealand are not tobacco company products. Most vaping shops here are independent businesses (often Māori-owned) that do not stock tobacco-company vaping products, often run by ex-smokers who are passionate about supporting people to switch away from tobacco.

However, if the product helps people switch from far more harmful tobacco cigarettes that kill two in every three users does it really matter which company is making the e-cigarettes? Ultimately, it’s the choice of the individual who smokes.

For more information about vaping, check out the New Zealand government’s vaping facts website.

Associate Professor Natalie Walker, National Institute for Health Innovation at University of Auckland’s Faculty of Medical and Health Science; Professor Chris Bullen, Director of National Institute for Health Innovation at University of Auckland’s Faculty of Medical and Health Sciences; Dr George Laking (Te Whakatōhea), Oncology, University of Auckland’s Faculty of Medical and Health Sciences.

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