Study highlights vaping harms – and evidence gaps

Jolyon Attwooll

7/04/2022 4:42:16 PM

A new systemic review says e-cigarettes can be a ‘gateway’ to greater tobacco use, but researchers say many unknowns remain.

Person holding an e-cigarette.
The study found there is a ‘paucity of evidence’ regarding e-cigarettes and clinical health outcomes.

The authors of a major analysis of available studies on vaping have concluded e-cigarettes are harmful for non-smokers – but believe much is yet to be established about their health impacts.
There were 189 studies used in a synthesis of available evidence carried out by researchers at the National Centre for Epidemiology and Population Health at the Australian National University.
‘E-cigarettes are harmful for non-smokers, especially youth, and when used for purposes other than smoking cessation,’ the authors conclude. 
‘There is strong evidence that non-smokers who use e-cigarettes are three times as likely to go on to smoke combustible tobacco cigarettes as non-smokers who do not use e-cigarettes, supportive of a “gateway” effect.’
The researchers also state much is yet to be understood on about the longer-term impacts of vaping.
‘A central finding of this systematic review is the paucity of evidence regarding e-cigarettes and clinical health outcomes,’ they write.
Most of the available detail focuses on more immediate health outcomes such as addictiveness and acute impacts, the study states, with the impact on other health conditions is still largely unclear.
‘No or insufficient evidence was available on health effects of e-cigarettes in relation to cardiovascular disease, cancer, respiratory conditions other than lung injury, mental health, development in children and adolescents, reproduction, sleep, wound healing, neurological conditions other than seizures, and endocrine, olfactory, optical, allergic and haematological conditions,’ a summary of the study reads.
‘This means their safety for these outcomes has not been established.’
Professor Nicholas Zwar, who chaired the Expert Advisory Group that compiled the RACGP’s smoking cessation guidelines, said the ANU study backed up the view that vaping could be bad news in particular for younger users – although acknowledged that debate is likely to continue.
‘Increasingly there’s evidence that if non-smokers use e-cigarettes, that predisposes [them] to take up tobacco smoking,’ Professor Zwar told newsGP.
‘Given the increasing use of nicotine e-cigarettes, and most of them do contain nicotine, in young people, I think that that’s a major concern.’
The different approaches to prescribing
For Dr Hester Wilson, Chair of RACGP Specific Interests Addiction Medicine, general practice is divided into three distinct camps on the use of e-cigarettes.
According to Dr Wilson’s assessment, there are GPs who view vaping as a type of tobacco industry ‘Trojan horse’ and will not prescribe e-cigarettes under any circumstances. They are at the other end of the spectrum to those who believe the Federal Government should allow consumers use them freely.  
Dr Wilson puts the majority of GPs, including herself, somewhere in between, believing that prescribing vaping products for clinical use in certain circumstances can minimise harm.
The ANU report does point to ‘limited evidence that freebase nicotine e-cigarettes are an effective aid for quitting smoking when used in the clinical setting’ – although mentions significant caveats.
These include that the use of e-cigarettes by smokers trying to quit ‘is likely to lead to greater long-term exposure to nicotine than the use of other smoking cessation measures’.
It also points to evidence, again ‘limited’, that ex-smokers using e-cigarettes are twice as likely to relapse as those that do not.
‘How do you put together a system that allows access for those individuals, but doesn’t allow open access that leads to another generation of young people starting to vape, and the unknown risks of that?’ she told newsGP
A recent RACGP submission to Department of Health consultation on a National Tobacco Strategy until 2030, also highlighted concerns of young people who vape moving onto a life-long tobacco habit.
‘We know that e-cigarettes are a particularly attractive option for young people, including school-age children,’ RACGP President Professor Karen Price said.
‘That is why we need targeted early intervention and education for school children, including the development and implementation of additional measures to further restrict the marketing and availability of all e-cigarettes, regardless of their nicotine content.’

Dr Hester Wilson says many GPs find the current regulatory situation a tricky balancing act.
According to the ANU study, around 53% of those who use vaping products also smoke tobacco.
While the ANU report states ‘the health impacts of dual smoking and e-cigarette use are not known,’ Dr Wilson says that for those who are heavily addicted, there may be a benefit.
‘I would suggest that, in that group of people that are highly dependent, dual use is actually harm minimisation,’ she said.
‘You’re maintaining your nicotine intake, but your intake of the other harmful chemicals in tobacco is going to be lower.
‘[However], that dual use means that people don’t give up and they have they continue having an increased risk through their tobacco use.’
Prescribing regulations
Dr Wilson also says many GPs find the current regulatory situation a tricky balancing act.
She highlights the difficulties created by the new laws introduced last year that limited nicotine vaping products to prescription-only – despite there being no approved products listed by the Therapeutic Goods Administration (TGA).
‘It’s a lot of work for the GP and for the patient to set that up. And it’s kind of easier for smokers just to buy under the counter, and cheaper,’ she said.
‘How do we support our members to be able to provide this?
‘There are so many unknowns, but there is an opportunity here to decrease risk of harm for those that are highly dependent, and to engage them in treatment with smoking cessation, which is really where we want to get to.’
Dr Wilson believes more work needs to be done to make the prescription process easier for general practice.
Professor Zwar also says it would help GPs if there was a fully tested and approved nicotine vaping product, that had gone through an assessment process through the TGA.
‘Nowhere in the world is there such a product,’ he said. ‘You could do that alongside having it as a consumer product. They’re not mutually exclusive.
‘But no sponsor has to date wanted to go down that road. And you could make your own assessments of the motives for that.’
While the TGA has cited some success in clamping down on illegal advertising, Professor Zwar does not think the availability of vaping products has been reduced.
‘One of the points of changing in the legislation was to enable the law to be consistent across the country and to enable Australian Border Force to seize nicotine vaping products that are being imported without a prescription,’ he said.
‘It should have made enforcement easier [but] for whatever reason, the enforcement is not happening adequately. The enforcement of the controls does not seem to be effective.’
He is also keen to add context to a statement in the ANU study that suggests ‘the large majority of people quitting smoking successfully do so unaided’.
‘That’s true,’ Professor Zwar said. ‘But the fact that 20,000 Australians die each year from tobacco-related disease suggests that quite a few people don’t do that soon enough.
‘There is a need to offer support to help people quit. Not everyone wants that support.
‘But we know that if people make use of assistance, in terms of advice from health professionals, a quitline or both, and if they’re nicotine dependent use some pharmacotherapy to treat their dependence, then they are much more likely to succeed.
‘I wouldn’t want to discourage people from seeking help.’
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