THE MJA article, Regulating e-cigarettes in Australia: implications for tobacco use by young people, by Wolfenden, Stocking and Yoong, raised concerns that e-cigarettes may act as a gateway to tobacco smoking. The authors argued that any move to regulate e-cigarettes in Australia must take this risk into account.

In response, Prof Colin Mendelsohn wrote an opinion piece (published in MJA Insight), arguing the contrary – that e-cigarettes are not a potential gateway to smoking for young people. Mendelsohn claimed that the potential benefits offered by e-cigarettes to smokers in Australia are substantial.

The evidence on e-cigarettes, and their role in cessation and the risk they pose to young people, is not conclusive. For this reason, the Australian Medical Association (AMA) supports a precautionary approach. We recognise that, where there is potential to do harm, caution must be exercised. This view is shared by a range of health and medical organisations: Cancer Council Australia, Cancer Australia, the Heart Foundation and the Thoracic Society of Australia and New Zealand, to name a few.

As doctors, we see the harms caused by tobacco smoking. Nicotine is addictive – a fact that the tobacco industry has capitalised on for decades. Two in three smokers will die as a result of tobacco smoking. The AMA recognises the supports needed for smokers in their efforts to quit, which may include using evidence-based cessation aids. Smokers often have multiple attempts before they kick the addictive habit.

If the evidence was clear that e-cigarettes were effective as cessation aids, the AMA would support these products being available for smokers engaging in a quit attempt. Unfortunately, the evidence continues to be mixed. From the mountain of research available, the AMA is aware of an increased risk of dual use – that is, smoking tobacco as well as using e-cigarettes.

During the recent Parliamentary Inquiry into e-cigarettes, advocates for e-cigarettes confirmed that, unlike other cessation aids, nicotine levels in e-cigarettes should not be reduced over time. Rather than the traditional approach to “quitting”, whereby the behaviour, and the addiction to nicotine, is stopped (either gradually or abruptly), e-cigarettes are intended to be used without changes to nicotine levels in the longer term. These products transition smokers to a new method of nicotine delivery, hence the growth in dual use.

This also means that e-cigarettes may delay a smoker’s decision to quit, and there remains the potential for smokers to “transition” between cigarettes and e-cigarettes indefinitely.

The National Health and Medical Research Council (NHMRC) has funded research to consider the role of e-cigarettes as cessation aids. The results of this research will be available over the next year or two.

The AMA takes the potential risk that e-cigarettes may act as a gateway to smoking very seriously.

Decades of world-leading tobacco control efforts risk being undermined if we renormalise the act of smoking.

Given the prevalence of dual use, the concern that young people who use e-cigarettes initially will eventually transition to smoking is valid.

The international experience with e-cigarettes confirms the need to proceed with caution. The US Surgeon General recently cautioned that e-cigarettes posed a risk to developing brains, respiratory health, and of use of other tobacco products, and has implemented a campaign to caution young people against their use. This may have been precipitated by increases in tobacco smoking rates in the US (the first time since 1973), which have been associated with an increased e-cigarette use.

There is also a Parliamentary inquiry being undertaken in the United Kingdom to consider retrospectively the need for regulation of e-cigarettes, given their extremely widespread use.

Not surprisingly, the public relations machines of Big Tobacco have sprung into action. In the UK and the US, a number of tobacco companies have publicly announced their intention to “quit tobacco” and stop selling cigarettes. These pronouncements also flag significant investments (£2.5 billion in the UK) into research and development. No expense is being spared in ensuring they can “transition” smokers to their new products.

I make no apology for being sceptical when Big Tobacco claims to have a solution to a problem that they have caused. Given the continued promotion of tobacco products in low-income countries, it seems unlikely that these companies will actually cease manufacturing cigarettes any time soon.

Australia is in a unique position. It is clear that the evidence on e-cigarettes is not yet compelling, and there is a very real potential that e-cigarettes can have unintended health consequences.

We are also lucky that the leading research body in Australia, the NHMRC, has funded research into e-cigarettes, which will begin to become available over the next 12–24 months.

If e-cigarettes do become more widely available in Australia, questions remain about the best approach to their regulation. Should they be available to all, or over-the-counter, or prescription only? Given that e-cigarettes can cost upwards of $100 per unit, should we be pursuing a user-pays approach, or should access be subsidised, inevitably leading to Big Tobacco receiving taxpayer funds?

It is my view, and the view of the AMA more broadly, that we must proceed with caution. The NHMRC research will provide unique and informative insights and will help guide an appropriate response to e-cigarettes in Australia. It will provide evidence. Facts, not speculation.

In the meantime, Australian smokers wishing to quit have the support of the medical profession and access to a range of evidence-based and subsidised cessation support options available to them. And, for those who do not smoke, there is no good reason to start using nicotine.

Dr Michael Gannon is the president of the Australian Medical Association.

 

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Poll

Vaping acts as a gateway to cigarette smoking for teenagers
  • Strongly disagree (52%, 133 Votes)
  • The evidence is not yet clear (15%, 38 Votes)
  • Strongly agree (13%, 32 Votes)
  • Disagree (13%, 32 Votes)
  • Agree (8%, 21 Votes)

Total Voters: 256

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14 thoughts on “AMA responds to e-cigarettes debate

  1. Simon Chapman AO says:

    Late last week, the US National Academies of Sciences, Engineering and Medicine (NASEM) published a 615 page door stopper of a report in e-cigarettes. The report contains 47 recommendations, each graded by level of evidence from conclusive to none. These can be found here https://www.nap.edu/resource/24952/012318ecigaretteConclusionsbyEvidence.pdf and the full report here http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=24952&_ga=2.227315540.810940964.1516640363-1933305849.1453397105

    NASEM is arguably the US’s and perhaps the world’s foremost reviewing authority of science.

    Reader would do well to bookmark the 47 conclusions as a ready-reckoner bull-dust detector for the hype that almost daily issues from some of those in the forefront of ecigarette advocacy.

  2. Adrian Grace says:

    Whether you like it or not the vaping cat is already out of the bag, and as a consumer-driven harm reduction tool and alternative to the smoking of tobacco it has proved (anecdotally, of course) to be effective for many people at no cost to any government agency (other than those reliant on tobacco taxes).

    Surely if the ultimate aim is to remove the stranglehold that tobacco has on society, any and all disruptive technologies should be brought in to play to meet that end – be it vaping, snus, or heat-not-burn.
    Given the opportunities with current, continuing and future research all technologies are bound to improve the scope of harm reduction and render the smoking of tobacco obsolete in a shorter period than ever thought possible.

    Concern for the children is always admirable, but it should not be at the expense of the current smokers whose lives are already on the line – those children’s parents, siblings, relatives and friends.

    And yes – I vape. I am one of those anecdotes who two years ago used vaping to end a thirty year pack-a-day (30 cigarettes) addiction to cigarettes and have significantly reduced my exposure to the many toxins they contain, as evidenced by the NASEM review listed in a comment above.

    “Conclusion 18-1. There is conclusive evidence that completely substituting e-cigarettes for combustible tobacco
    cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes.”

  3. Randal Williams says:

    Tobacco smoke contains dozens of toxins in addition to nicotine, both natural and those added by cigarette manufacturers . Nicotine vapour has to be the better of the two options. I have a number of acquaintances who have switched to vaping and are hoping to stop completely in time. Passive smoking is also pretty much eliminated.
    I see vaping as the lesser of two evils, and worthy of consideration as a a valid method of withdrawing from the powerful addiction of nicotine. I don’t see a lot of young people vaping , mostly older age groups whom i assume are trying to give up.

  4. Dr Scott says:

    A sensible approach from the AMA. These contentious issues are often led by vocal groups on either extreme. I commend Dr Gannon and the AMA for their thoughtful and evidence based positions on this and other recent issues e.g. assisted dying. Surely as with other things in medicine we should wait for the evidence before making radical changes (i.e. legalising vaping) that have easily foreseeable potential negatives.

  5. Andrew Thompson says:

    I vape. I don’t care whether or not it is ‘approved’ by a doctor’s union (who have COI from their long ties with Big Pharmaceutical companies) or by my GP.

    The only thing that matters to me is that it is safer than smoking.

    So, given noone is seriously claiming that vapor products are more harmful than smoking, I make my informed, adult decision to vape.

    I don’t want your ‘vote of confidence’ in my choice, I just want you to stop lobbying for nicotine to be kept illegal.

    > I make no apology for being sceptical when Big Tobacco claims to have a solution to a problem that they have caused.

    Your skepticism is irrelevant. If the tobacco industry wishes to compete in the e-cig market, they’ll need to match or beat the offerings from non-tobacco companies that specialize in vapor products. Given their long experience with nicotine, I look forward to seeing what they can come up with.

    > The NHMRC research will provide unique and informative insights

    No it won’t. Pretty much all the research the NHMRC is doing is misdirected, or has already been done and comes down in favor of e-cigs being legal as an alternative for smokers.

    On some other Fear, Uncertainty & Doubt being peddled by the pill-pusher.

    > THE MJA article, Regulating e-cigarettes in Australia: implications for tobacco use by young people, by Wolfenden, Stocking and Yoong, raised concerns that e-cigarettes may act as a gateway to tobacco smoking.

    This is an article to which I don’t have access (you might think that if the researchers were so concerned for the public, it might be accessible to the public). I doubt it has anything of value to add to the debate, given age restrictions can be imposed (which are more effective than they are with cigarettes, for a variety of reasons), and that there is no effective way to *prove* whether or not a ‘gateway’ exists (A then B is irrelevant given the potential for a common interest in nicotine), while the population level data suggests that greater vape availability leads to less smoking. This is the elephant in the room that all ‘caution on gateways’ rhetoric fails to address.

    I would go on, but I have better things to do – promoting vapor products to smokers. I do that without any money from or allegiance to the tobacco, vape *or* pharmaceutical industries.

    Well, that and educating politicians to the fact that tobacco harm reduction is not only their obligation under the terms of the FCTC, but also a matter of political survival.

    Keep shoveling the FUD, Micheal. We’ll see who ends up on the ‘right side’ of history.

  6. Bee Baker says:

    More emphasis should be placed on the toll on people’s lives when a valid option for smokers to remove themselves from lit tobacco consumption is actively impeded and made illegal by many a health org in Australia.

  7. Steve McCoy says:

    I agree completely with Andrew, I vape and will continue to vape legally or illegally. Who cares what the AMA thinks.

  8. Openyoureyes says:

    The politically driven head in the stand stupidity being displayed by the AMA is astounding

  9. Joe Kosterich says:

    “If the evidence was clear that e-cigarettes were effective as cessation aids, the AMA would support these products being available for smokers engaging in a quit attempt”. Evidence is never 100%. The new report notes that vaping exposes people to a significantly lower amount of dangerous chemicals. As a medical group I have full confidence that the AMA will come to see that there is sufficient evidence to support vaping as a less harmful option to smoking. I do not expect those with no medical background reliant on government funding for “quit or die” programs to do the same.

  10. Lj.Kljaic - @Switchtoecig says:

    “From the mountain of research available, the AMA is aware of an increased risk of dual use – that is, smoking tobacco as well as using e-cigarettes.”
    My uncle is70. He used to smoke 40+ cigaretettes a day. Until this summer when he replaced 30 of them with an e-cigar. Which means he still has a dozen cigs with his coffee and after meals. Now he tells me he can breathe normally again. I feel for Australian smokers and vapers. You definitely don’t make their life easier.

  11. Broony Saint says:

    The AMA lost all credibility when Dr Gannon tried to put himself & his ideology on vaping above the prestigious Royal College of Physicians and their 3000+ members

  12. Andrew Day says:

    When looking at the population level vaping is undoubtedly increasing cessation rates where e-cigarettes are widely used. Those who chose to inmgnore this evidence are lying to themselves and risking lives of those they deter from trying e-cigarettes as a means of reducing harm.

    http://onlinelibrary.wiley.com/doi/10.1111/add.14020/abstract
    https://academic.oup.com/ntr/article-abstract/doi/10.1093/ntr/ntx166/4096490/The-Relationship-of-E-Cigarette-Use-to-Cigarette?redirectedFrom=fulltext
    http://www.bmj.com/content/354/bmj.i4645
    http://www.bmj.com/content/358/bmj.j3262
    http://tobaccocontrol.bmj.com/content/25/Suppl_1/i90.full

  13. Mik R. Coleman-Dion says:

    It is unconscionable that doctors in AU. would rather have people keep smoking than use a device which has far less toxicants and does much less damage than smoking. Take your heads out of the sand and try to listen to what people who have switched from smoking to vaping are telling you! They don’t get paid to promote vaping, they are bettering their health by choosing to use a product like vaping when all the other “recommended NRT’s” failed. I was a 3 PAD smoker who also used 3-10 cigars a day when a friend told me to try an ecig since patches weren’t working for me. I only wanted to cut down on my cigarette consumption. In three days time I found I couldn’t stomach the taste of my beloved Kool’s. I had accidentally quit smoking much to my astonishment! That was in 2010 and I’ve not had a single puff since that day. Not a single puff! Most of us vapers don’t dual use.
    Our choices haven’t cost the government a penny. The very least you doctors, TobaccoCONtroll and Public Health groupies could do is hear what we’re saying.

  14. Anonymous says:

    I agree with quite a few, but Andrew Thompson has clearly stated my POV.

    I would add, I vape, I no longer smoke after 40 years, and the AMA should just get out of my way 🙂

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