THE e-cigarette debate highlights the futility and sometimes downright pomposity of the trendy new uber-simplistic concept of evidence-based health policy.

History reminds us of the “arcane intellectual speculation” of 17th century academics over how many angels could dance on the head of a pin. Although it was probably never a significant preoccupation, it serves as a metaphor of “tedious concern with  irrelevant  details”.

In the latest salvo in the e-cigarettes debate, one side consumed considerable column inches arguing that there are only 178 000 angels dancing on the end of the pin and not the preposterously large estimate that 250 000 angels are dancing on that pin as the other mob contends; sorry, that was the number of vapers in Australia, +/- occasional users and whether to count them. The debate raged in the comments section.

Why are we seeing these innocent statistics tortured beyond credulity? Doesn’t the United Nations have a convention against torture?

A generation of factoid-wielding partisans has forgotten the admonition, possibly falsely attributed to Benjamin Disraeli, that there are three types of lies: lies, damned lies and statistics. This quote can also be seen as an acknowledgment of system complexity.

Many of us feel a sense of our head spinning from the whirling statistics. We might feel it is all too hard and actively get turned off the whole issue and, therefore, view it with the same sense of relevance as the angels–pin debate. Which is a shame, because this debate is not irrelevant or arcane. Potentially, the wellbeing of millions of Australians over the coming decades will be affected by what happens.

It seems that there are not only duelling experts but duelling societies. One side quotes the “door stopper” report Public health consequences of e-cigarettes by the US National Academies of Sciences, Engineering, and Medicine.  Proponents of e-cigarettes quote a report by Public Health England (PHE). Although an appeal to authority per se is a logical fallacy, these societies do add considerable weight to each side’s claims.

For example, PHE confidently asserts that: “Concern has been expressed that e-cigarette use will lead young people into smoking. But in the UK, research clearly shows that regular use of e-cigarettes among young people who have never smoked remains negligible, less than 1%, and youth smoking continues to decline at an encouraging rate. We need to keep closely monitoring these trends, but so far the data suggest that e-cigarettes are not acting as a route into regular smoking amongst young people”.

Conversely, the US National Academies report claims that: “There is substantial evidence that e-cigarette use by youth and young adults increases their risk of ever using conventional cigarettes”.

But even if it is “substantial” (which is debatable), what is the relevance of the evidence of “ever using conventional cigarettes”? A commonly cited study labelled teens as smokers if they even had “just one puff”.  Really? Should any of us who have ever had even a “single puff” immediately travel to Victoria for voluntary euthanasia?

Similarly, the anti-e-cigarette lobbyists cite evidence that “eviscerates” the claim that vaping is at least 95% safer than smoking. Yet, PHE this year confidently reasserted that same claim based on (yes, you guessed it) the evidence.

With this complexity in mind, using the e-cigarette debate as an example, we need to question what “evidence-based” health policy really is. It has the allure of the scientific method and is an obvious copy of evidence-based medicine. Who could argue with evidence? Science is objective, surely there is no opinion in science? There are just facts. But what fidelity of information can an evidence-based system really provide? For such complex and ever-changing systems involved with health policy, it is wholly predictable that the answer would be “not much”.

Consider the following:

Laboratory-based research should be the very definition of a system that is able to be held constant except for one variable and, therefore, be reproducible. Yet, there has been a reproducibility crisis in even basic biological research.

The increased complexity of clinical medicine makes reproducibility harder still.

At the other end of the spectrum, consider the inordinately increased complexity of the systems that underlie public health policy. Do whole societies stay exactly the same in order to be reproducible? All manner of societal and health changes occur across time. Not only can the smallest of definitions change “the evidence” but trying to predict and project what will occur decades into the future is representative of nothing more than pure speculation. Opinions and speculation are important in order to move forward and evolve. However, evidence-based health policy is a modern self-congratulatory phenomenon whereby the mutton of mere opinion is being dressed up as the lamb of science.

The knowledge problem was described over 70 years ago to detail the fundamental problem of system complexity, whereby there could never be enough knowledge for economic and social planners to understand, and therefore control, the inordinate ways a complex system could behave.

The evidence-base paradox describes the problem of using evidence as related to complex systems.

But the main lesson to learn is that the system is not symmetrical between any two opposing or shouting camps. Both the e-cigarette naysayers’ and proponents’ preferred authorities, the National Academies and PHE, agree that vaping e-cigarettes is not as harmful as the combustion of tobacco in conventional cigarettes.

We could obfuscate to the end of the Earth and neither camp is going to concede regarding whether e-cigarettes should or should not be legal.

The liberal order, in the true sense of liberalism, would suggest that unless there is an overwhelming threat, we need to give autonomous people the option of the almost certainly less harmful e-cigarettes instead of the much more harmful conventional cigarettes.

One major rationale of e-cigarette prohibitionists is that the safer (not completely safe) option of vaping will somehow “normalise” the unsafe option of smoking. By this logic, during the AIDS crisis of the 1980s, we should have banned the use of condoms for safer (but not completely safe) sex because it normalises unsafe sex without a condom. Indeed, it can be shown that condom use among teens has a massive association with unsafe sex without condoms, compared with teens who had never used condoms (because the majority weren’t having sex with or without a condom).

The irrational nature of that argument is surely clear to everyone.

Associate Professor Michael Keane is a specialist anaesthetist and part-time visiting medical officer at Monash Health, with research possitions at Swinburne University and Monash University.


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29 thoughts on “Vaping “normalises” smoking? Be rational

  1. George Crisp says:

    Reasonable argument until this sentence: .. unless there is an overwhelming threat, we need to give autonomous people the option of the almost certainly less harmful e-cigarettes instead of the much more harmful conventional cigarettes”

    If that were true we might release new drugs before completing clinical trials, and allow illicit drugs too, which do not pose an ‘overwhelming threat’.

    Point is that a lack of certainty relating novel therapies cannot be used as reassurance of safety. Quite the contrary, the less we know the greater the risk of inadvertent harm. It is precisely these things that should be regulated.

  2. Marcus says:

    I think George you may have missed the point the author was making, which is one of classic liberalism. Let people make their own choices.
    It is a sensible viewpoint, confounded only by the fact that the rest of us have to contribute to the costs of their healthcare of they make ‘ bad’ choices. But given the existing tab for alcohol and cigarette related illnesses, which we are apparently content to meet, that too is not a strong counter-argument.

  3. Evert Rauwendaal says:

    The principle of equal liberty dictates that each person has a vital interest in not having his liberty denied while others are allowed an equal or more harmful liberty.

    Australia’s prohibition on nicotine (and other substances) for use in vape devices violates this principle. The vaper poses no greater threat to state interests than the smoker, indeed much less, and yet they are treat differently and more harshly under the law.

  4. George Merridew says:

    After 39 years practising anaesthesia, critical care and pain medicine, I am only too familiar with the clinical evils of tobacco.
    It is obvious to oppose:
    Inhaling everything in tobacco smoke, except the water vapour and CO2
    Bathing one’s oral mucosa with the substances leached from chewing tobacco
    Believing any tobacco industry assertion, unless validated by strong external evidence
    Published work does not show a consistent association with vaping and reducing numbers of smokers.
    High levels of evidence are needed to guide decisions in this important public health matter.
    The paper below, available on the www address listed, diminishes confidence that vaping is benign.

    Hyun-Wook Leea, et al. E-cigarette smoke damages DNA and reduces repair activity in mouse lung, heart, and bladder as well as in human lung and bladder cells. (from the New York University School of Medicine)

    The ultimate test is the eventual morbidity and mortality shown to be due to vaping, compared with neither vaping nor using tobacco.
    The caution of the current official Australian position seems reasonable.
    In addition, it helps provide a control group.

  5. Annette says:

    George I think you may also have got confused with ecigs being a new drug. Rather than a much safer way of delivering a very well known drug. A drug which doesn’t cause cancer, it’s health effects are very similar to caffiene. And the current delivery method kills two out of three users. And is available at every corner shop and service station in Australia

  6. George Crisp says:

    Hi Marcus, I’ve not missed the point at all.
    I’m well aware of the direction of this article. Also broadly agree with the concept of autonomy unless there is good reason for protective regulation. But this must be balanced with social and community responsibility. Remember that harmful products are being advertised to the general public and to vulnerable groups who do not have access to relevant knowledge or skills to determine the consequent risks. The debate is inherently asymmetrical. If we claim to act in the interests of patients and communities then we need to advocate for public health on the best evidence we gave available. It is a long held and treasured role. We should not dilute that basic responsibility in the interests of individualistic ideology.

  7. George Crisp says:

    Hi Annette. Thanks for your concern regarding my decision making capacity. Fortunately, as a current practising GP, I’d assure you that in fact I’m fully aware of the difference between different drug delivery systems and different drugs.
    Here’s a question for you though; do we know all the chemicals produced in and by vaping devices, their potential for harm at different exposures and in younger age groups, or what the effects they might have in combination? Remember also the companies marketing and selling these products are the same ones that made billions out of selling cigarettes and fought tooth and nail to stop tobacco regulation. The same ones that spread doubt about the harm of smoking and then passive smoking. It’s taken decades to turn the tide even when we’ve had compelling evidence. You want to use that story to promote their new industry?

  8. Paul Vigo says:

    Contrary to a lot of the media coverage it is not the big tobacco companies which are leading the vaping market. It is predominantly smaller businesses run by people who started out looking for a less harmful alternative to smoking, and is largely a cottage industry. Big tobacco is more interested in heavy legislation because it locks smaller players out of the market. As such there is a wide community monitoring research into the potential health effects of additives, and the market is quick to adapt to consumer concerns, such as phasing out Acetyl Propionyl on flavourings despite no medical evidence of harm in the concentrations consumed by vapers. The difference between smoking and vaping is that we know smoking is terrible for us and will remain so despite innovations. Vaping may still be harmful, but as a concerned consumer we can change what we vape and the means of delivery based on continuing research into the safest alternatives.

  9. Marion says:

    George Crisp — you have legitimate concerns. However, most of these concerns can be largely controlled by sensible regulations. I’m a vaper in Canada, and I buy my e-liquid from small companies whom I trust to use only pure ingredients. The list of ingredients in e-liquid is small: propylene glycol, vegetable glycol, food flavouring and (optionally) nicotine. Only the flavouring aspect is really cause for concern, and these companies (and the self-regulating Canadian industry) have been responsible about responding to any possible bad effects.
    Something you should know is that the Tobacco industry is really a small player in the vaping world. Vaping is a “grass roots” development comprising many small independent companies (usually formed by ex-smokers who escaped by switching to vaping.) Big Tobacco would love to get into vaping, and tried to by buying small closed-system manufacturers that are sold cheaply. Most regular vapers wouldn’t touch them, largely because of BT’s track record. This is why BT is now trying the Heat Not Burn technology.
    It’s very important that you recognize this — vaping is not smoking, and the vape industry is not Big Tobacco.

  10. Matthew Peters says:

    Oh Dear. No problem letting logic get in the way of a rant. A teenager vapes trebling the risk of later smoking. She smokes regularly and, ergo, can no longer be a never-smoking user of e-cigarettes. No wonder these are rare. The problem, progressing from e-cigarette use to cigarette smoking, inevitably makes the statistic chosen to dispute this low. The National Academies report, deserves a more accurate citation. “The net public health effect, harm or benefit, of e-cigarettes depends on three factors: their effect on youth initiation of combustible products, their effect on adult cessation of combustible products, and their intrinsic toxicity. If e-cigarette use by adult smokers leads to long-term abstinence from combustible tobacco cigarettes, the benefit to public health could be considerable. Without that health benefit for adult smokers, e-cigarette use could cause considerable harm to public health in the short- and long-term due both to the inherent harms of exposure to e-cigarette toxicants and to the harms related to subsequent combustible tobacco use by those who begin using e-cigarettes in their youth. Neale and other advocates choose not to define an e-cigarette – specific constituent, specific device, specific toxin outputs. I can hear Neale in OT now ” Nurse this patient is waking up. Pass me some liquid in a syringe. Syringe liquid is good.

  11. Andrew Thompson says:


    > do we know all the chemicals produced in and by vaping devices, ..

    Do we have 100% knowledge? No. We do however, know that e-cigs do not emit carbon monoxoide or tobacco aerosol residue when used as intended. When a situation occurs that was not intended, the vapor tastes disgusting, and would not be tolerated by the user for more than a fraction of a second. We know that when diacetyl was identified as a (very minor, given the low levels) risk to pulmonary health, consumers pressured e-liquid companies to find alternatives, which they did. Regulatory authorities in the US and EU have now formally banned the use of diacetyl in e-liquid.

    > .. their potential for harm at different exposures and in younger age groups,

    While I personally would prefer to see young smokers switch to vaping, it is pretty universally accepted that age restrictions should be implemented. I know of no retailer in Australia who would knowingly sell to persons under the age of 18. And that was long before there were regulations stating ‘no under 18s’.

    > .. or what the effects they might have in combination?

    In combination with what?

    Vape does not agree with some people. There are people that find propylene glycol to be an irritant. But that becomes apparent pretty quickly, and the user stops vaping or changes to a liquid with 100% glycerin excipient. Nicotine too strong? One new user was given 100 mg /mL nicotine by a friend. They used it not realising it was intended to be diluted. I did not find out about this via an autopsy report, I found out about it by the new user asking an online forum why he was suffering head-aches and found the liquid to be harsh.

    The point is, any adverse effects of vaping can be quickly ameliorated by stopping using the device. Since vapor products started to become popular around a decade ago, there have been exactly 0 deaths from using them.

    Don’t get me started on ‘but we won’t know the long term effects’. But since I brought it up (in brief) toxicology has progressed vastly since the time that cigarettes were becoming popular over a century ago. Testing equipment to detect potential toxic substances, in either the liquid or the vapor produced, are also now available and can provide details of constituents down to miniscule levels.

    And then we come to the part where you ‘jump the shark’ in your ‘fear, uncertainty and doubt’ narrative.

    > Remember also the companies marketing and selling these products are the same ones that made billions out of selling cigarettes and fought tooth and nail to stop tobacco regulation.

    What?! Are you claiming that eVic, Kangertech, Aspire, Provape.. sold cigarettes? Because they are the companies based in China that did most of the development of these devices, and currently sell the best ones. And no, those companies *never* sold combustible tobacco products.

    Oh.. you’re alluding to the tobacco industry are you? Sure, they dipped their toe into the e-cig market when they became convinced they were not just a FAD. They sell mostly 1st generation cigalikes, which have their own benefits, but hold a a minimal share of the market. Even in the US where cigalikes are most prevalent, they hold no more than 15-20% of the overall market. Not even all cigalikes sold, are sold by the tobacco industry. NJoy has a sizable chunk of that market.

    BAT also sells 2nd generation e-cig devices (more power, refillable tanks etc.), but their units are simply rebadged versions of the devices developed by the companies I mentioned earlier. Unless the tobacco industry can provide as good as, or better products than the extant e-cig companies like Aspire & NJoy, they will never gain much of that market.

    The tobacco industry is concentrating on:
    PMI – iQOS
    BAT – Glo
    JTI – Ploom

    These are heat-not-burn, or as they prefer to refer to them, heated tobacco products. These are technologies in which the industry can make them specific to their own consumables. And that is where the money is. I fail to see how BAT can expect to make much money off their rebadged 2nd gen. e-cigs, given the consumer could refiill it with e-liquid made by anyone else. They are, of course, not e-cigs and not what we are discussing at the moment.

    > The same ones that spread doubt about the harm of smoking and then passive smoking.

    A role they were prevented from doing some decades ago. If you’re looking for the real FUD shovellers these days, look directly to tobacco control. They’ve taken the ‘big tobacco playbook’ and turned it into a ‘tobacco control gospel’.

    > You want to use that story to promote their new industry?

    We want to promote that smokers should have a choice of products for nicotine delivery, some of which are (obviously) vastly safer than inhaling burnt tobacco leaves. If the tobacco industry can do that through the HnB devices, all power to them, and it can only be for the good. Not all current smokers will take to vape, perhaps HnB will provide them a viable route to tobacco harm reduction.

    Would you deny consumers who would otherwise smoke, access to vastly safer products? Why? On what grounds?

  12. Anonymous says:

    Why on earth should sane people risk addiction to nicotine in the first place anyway? Cigarettes or ecigs alike are just silly or dangerous profit making commodities pushed by a highly addictive non-helpful drug.

  13. Joe Kosterich says:

    An excellent article Michael. The comparison to condom use is very apt. The perfect is the enemy of the good especially to those with a strong ideological position. If smoking did not exist there would not be a need for vaping but smoking exists and vaping is a less harmful (note not harmless). It has helped many smokers. The problem we have is that those in ivory towers generally do not talk to smokers who tend not to frequent cafes in Fitzroy and Glebe and thus they have no understanding or empathy for the life experience of real people. The normalising argument is another ideological furphy. Teaching a child to drink water from a glass does not normalise drinking vodka.

  14. Donna says:

    Hi George,

    I think you miss the point. E-cigarettes are not ‘new drugs’, they are a harm reduced consumer product designed to compete fairly and squarely with the incumbent ‘tobacco smoking’. FYI, tobacco smokes are highly regulated legal, and freely available but nicotine vaping is illegal for users in every state/territory in Australia. We are subject to huge fines should the authorities decide to come and get us which they do in Queensland. I’m not talking about sales, I’m talking about ‘use or possession’

    If the consensus was they are as or more harmful than smoking, I’d agree with strict restrictions and possibly illegality (although we know prohibition doesn’t work).

    However, they are not.

    In saying the above though, I’m not opposed to regulation which would include 18+ sales, no advertising to kids, child proof packaging, waning notices, ingredients list etc. The opponents to vaping try to make it out to be ‘wild west’ or TGA approval as the only two pathways. This is not the case.

    Do you know any vapers? I smoked a pack+ a day for 32 years and switched more than four years ago. Recently, I was out with my Registered Nurse daughter and someone asked me about vaping.

    My daughter, a never smoker/vaper said to the person….’mum’s health was so bad she had undiagnosed COPD which mum used to call a ‘bit of asthma’. She couldn’t laugh without coughing for five minutes not to mention the stuff she used to cough up every morning. Within about three weeks of switching to vaping, she stopped coughing and hasn’t used the asthma inhaler for years.’ She went on to say, I’d never recommend anyone that doesn’t smoke should vape but for smokers, it truly is life saving.

    I would welcome you to have a chat to myself or my daughter. You can contact me at


  15. Donna says:

    Matthew Peters, I am but a mere vaper but I’ve read your post now quite a few times and I can’t work out who NEALE is. Maybe it’s an inside Doctor joke?

    “Neale and other advocates choose not to define an e-cigarette – specific constituent, specific device, specific toxin outputs. I can hear Neale in OT now ” Nurse this patient is waking up. Pass me some liquid in a syringe. Syringe liquid is good.”

    But but…..

    Regardless of who Neale might be, if it’s not advertised or promoted as curing anything, therefore medicalised as a quit aid, there is no need to specify. Regulation as a consumer product will take care of that. Just look to the UK for regulation and you’ll see how easy it is.

  16. Simon Chapman says:

    Vaping activist Andrew Thompson who has “studied at Northern Sydney Institute – TAFE NSW” ( asks us to not “get started” on the entirely accurate concern (‘but we won’t know the long term effects’) of vaping’s possible longer-term health problems with e-cigarettes. He advises us that “toxicology has progressed vastly since the time that cigarettes were becoming popular over a century ago. Testing equipment to detect potential toxic substances, in either the liquid or the vapor produced, are also now available and can provide details of constituents down to miniscule levels.”

    That would be all that advanced toxicology capable to detecting risk so brilliantly that since 1962, 598 drugs initially assessed as being likely to be safe have been withdrawn or discontinued (see some causing death, or very serious health problems. Remember thalidomide?

    The reason why we have TGA drug assessment, scheduling, adverse event reporting and the possibility of recall and bans are because drug trials can never provide data on long term use. Vaping activists were recently jubilant about a 2 year follow-up of just 9 subjects (with another 7 having dropped out) which, hey presto, showed no “long term” ill-effects. This frankly laughable follow-up compares with the 30-40 years that passed before the huge upswing in smoking in the first decade of the twentieth century began to show lung cancer in case control studies in the early 1950s. Lung cancer today is the biggest cause of cancer death. Thompson’s equivalents in 1920 may have written letters to The Times about health concerns being poppycock.

    The recent report of the US National Academies of Sciences, Engineering and Medicine found:

    • There is substantial evidence that e-cigarette aerosols can induce acute endothelial cell dysfunction, although the long-term consequences and outcomes on these parameters with long-term exposure to e-cigarette aerosol are uncertain.
    • There is substantial evidence that components of e-cigarette aerosols can promote formation of reactive oxygen species/oxidative stress. Although this supports the biological plausibility of tissue injury and disease from long-term exposure to e-cigarette aerosols, generation of reactive oxygen species and oxidative stress induction is generally lower from e-cigarettes than from combustible tobacco cigarette smoke.
    • There is substantial evidence that some chemicals present in e-cigarette aerosols (e.g., formaldehyde, acrolein) are capable of causing DNA damage and mutagenesis. This supports the biological plausibility that long-term exposure to e-cigarette aerosols could increase risk of cancer and adverse reproductive outcomes. Whether or not the levels of exposure are high enough to contribute to human carcinogenesis remains to be determined.

    These findings have all occurred within a few years of widespread use. Reckless calls to just allow e-cigs to flood corner stores unregulated and be promoted with advertising like this promising “risk free” vaping and within one corker of a sentence, that vapers can “entirely avoid the harm” while “lessen[ing] the possibility of inducing danger on your lungs” is the sort of world we are supposed to embrace by these flatulent arguments.

    He waxes lyrical about the vaping cottage industry, nobly supplying products to a grateful market. This is an unregulated industry using flavouring agents never tested for inhalation safety and batteries which have exploded causing hideous burns. If ecigs are so safe and so effective, their manufacturers have nothing to fear by applying for registration. Oh wait …

  17. Geoff says:

    There’s plenty of junk science out there for anti-harm reduction activists in Australia to use to convince politicians to keep tobacco harm reduction away from smokers and to keep them illegal and even make laws that place vaping (even though illegal) in the same camp as tobacco complete with bans at beaches, parks and wide open spaces.

    Suddenly certain people in public health while previously believing that the evidence for harm for bystanders from tobacco smoke in wide-open spaces was non-existent now believe that vaping has that effect by wanting them to have the same bans as tobacco smoking.

    Sounds like a lot of irrationality from the tobacco control/public health industry that will ultimately harm smokers and cause death and disease by depriving smokers of a much much safer option.

    That’s ok. Support for their harm inducing stance is dwindling and i’m sure the incidence of dodgy junk science greatly outweights dubious and dodgy advertising of now archaic vaping tech.

  18. Elja says:

    The companies that are selling E-cigarettes are MOSTLY NOT the same are selling tobacco cigarettes !!!! Only 20% of the E-cigarette market is owned by Big tobacco. The E-cigarette was designed by a pharmacist whose father had lung cancer, and who wanted to make a healthier alternative. After that, many companies that have nothing to do with the tobacco market have developed the e-cigarette further. The specialized E-cigarettes that are most efficient to help most people with smoking cessation have been developed by these specific E-cigarette companies!!! Big Tobacco generally sells cigarette-like E-cigarettes and are used by a small minority of people that are quitting with smoking.

    I have been able to quit smoking very easily, after a 40 years of tobacco smoking addiction and various unsuccessful quit smoking attempts. And to my surprise it was very easy to quit using tobacco and replacing it with an E-cigarette. My oncologist supported my quit attempt using the E-cigarette. And the E-cigarette is also the only means I know that people bought to experiment with, without actually wanting to stop smoking. And after weeks they found out that they had stopped smoking.

    ease give people the choice for a healthier alternative. That they can also live healthier and longer.

    After surgery and radiation treatment, I got a second chance. When I had still smoked during the radiation treatmentI had a greater chance of a heart attack, because the radiation also touched my heart. And without E-cigarettes I really could not stop smoking. Because that’s what I tried. I bought the E-cigarette only 3 days before the radiation treatment which would take place every month started.

    And I’m really not the only one. There are many, often older people, who benefit greatly from this.

  19. Mike says:

    Michael Keane points out the insane part of this debate. Both sides agree that vaping nicotine is less risky than smoking tobacco.

    There are a small number of Australians lobbying hard to prevent other Australians from switching from smoked tobacco to safer forms of nicotine. Bans on the sale, possession and use of nicotine for vaping indicate they’ve been getting their way.

    Their position suggests these people would prefer Australians who can’t or won’t quit smoking to bear a higher health risk than they would if they switched to vaping nicotine.

  20. Paul Vigo says:

    It is right to be concerned about flavour inhalants in vapes, but an overcautious approach which denies smokers an alternative does a disservice to the consumers right to choose a method of nicotine delivery which is by any measure much safer than smoking tobacco. We must remember that tobacco ALSO contains flavourings, on to of the burning leaves which you can’t really do much about. The main constituents of eliquid can all be sourced at medical grade and the flavourings approved for human consumption. They are vaporised at a controlled temperature to minimise the volatile chemical reactions which produce many of the harmful products of cigarettes. As a smoker I know that vaping is not 100% safe, but that it gives me complete control over what I am consuming with minimal known risks, and the ability to change the constituents of what I vape should future risks come to light.

    This is the essence of a workable solution to harm minimisation. Existing nicotine replacement therapies have not worked for me, because they do not well replicate the nicotine delivery properties I have become accustomed to, are generally unpleasant and have their own side effects. Nicotine addicts self titrate, so commercial NRTs do not cater well for long term heavy smokers. Indeed well meaning regulation to reduce nicotine in cigarettes often lead to smokers increasing their consumption to compensate, and thus their consumption of tar, aldehydes, MAOIs etc.

    The other alternative currently available to me is to take drugs with evidence of mood changes and the risk of suicide in patients with poor tolerance. Given that even medically approved cessation strategies are not without unknown risk, it seems to me that extreme arguments for caution are somewhat disingenuous. Smokers know they are at risk from unknown toxins, and merely want to replace them with lesser, generally known toxins.

    Unfortunately those taking a hard line anti vaping have managed to promote quite a bit of junk science inflating the known risks; formaldahyde, popcorn lung, heavy metals, antifreeze etc etc, even the absurd exploding battery scare stories. Despite being trotted out constantly these risks have been thoroughly debunked long ago. The vaping community and advocates for harm minimisation in the medical community don’t have time for these scare factoids because we are too busy looking at legitimate research to identify actual plausible risks. Fun fact: did you know that the antifreeze they put in vapes is the same antifreeze they put in ice-cream and IV drugs?

    As I have been unable to quit my addiction (which of course would be preferable) I simply want the option to choose a means of delivery which allows me to monitor and minimise risk going forward.

  21. Andrew Thompson says:

    Matthew Peters:

    “The net public health effect, harm or benefit, of e-cigarettes depends on three factors: their effect on youth initiation of combustible products, their effect on adult cessation of combustible products, and their intrinsic toxicity.”

    1) “their effect on youth initiation of combustible products”
    A study from the US (prior to the FDA’s blanket ban on sales to under 18s suggested that smoking rates in states that allowed sales to under 18s were dropping faster than in states that banned sales to under 18s.

    2) “their effect on adult cessation of combustible products”
    The population level effect of vaping is salient here. US & the UK both allow retail sale of nicotine containing e-cigarettes, while Australia does not.

    3) “their intrinsic toxicity”
    Only the most virulent anti-science e-cig campaigners would claim that vaping is anything but less toxic than smoking. So while most would not recommend non-smokers take up vaping, for smokers wishing to reduce harm, it is an obvious choice.

  22. George Alexander Crisp says:

    Curious an interesting that so many commentators who clearly have little or no interest in public health (and a comparable quantity of expertise) get so animated on this subject. What could possibly be the motivation?

  23. George Alexander Crisp says:

    And here’s something else pro-vapers might like to think about; there is overwhelming evidence that air pollution even at very low concentrations (see Harvard Six Cities study etc) is causally related to lung cancer, heart disease and asthma and very likely to stroke, preterm births and a number of other diseases.

    Much of this burden of disease is mediated through fine particulate matter – droplets or solid particles that act as a delivery system of toxic agents to the small airways and alveoli. The majority of impacts are not immediate but delayed and cumulative (like smoking), they are also disease that are already common, meaning that often large numbers need to be included in studies (over long periods) to demonstrated statistic impacts.

    The default position here is that vaping will produce materials that would behave in a similar way to other similarly derived particulate sources. It is actually a leap of faith to assume that there will be a different outcome.

    The onus of proof must be on safety first, as doctors we cannot possibly short cut patient safety on the basis of a lack of data.

  24. Joe Kosterich says:

    Blinkers can be a problem when trying to see laterally. Vaping is not a top down imposed public health measure. It is a community driven way for people (especially those with disadvantages) to be empowered to help themselves. This will be something of a curiosity to those in ivory towers and those who practice in wealthy areas. Vaping is safer than smoking, the only argument is to what extent. Thus there is no short cut on patient safety by smokers moving to vaping.

  25. Paul Vigo says:

    If you wan to bring pollution into the argument, we replaced the lead in petrol with several other toxic substances as a public safety issue. The logic being that the health profile of the latter toxins in low concentrations were better than the former. We weren’t going to give up on gasoline entirely, so replacing the most damaging replaceable component was the best pragmatic solution we could implement.

    Plenty of studies will tell us that vaping is not entirely healthy, but as a drop in replacement for smoking I have yet to see any which put risks anywhere’s near as high as smoking is known to be, even speculatively. Sure, we know that vaping nicotine introduces the danger of nicotinic nitrosamines forming in vivo, but at similar rates as existing legal NRT medications, and at vanishingly lower rates than induced by cigarette smoking. Given the proven danger appears to be on par with approved over the counter medications I can only conclude that medicos who have become alarmist about these results haven’t read past the summary. There’s plenty of other studies into nicotine consumption, but given it I still legal to chew, inhale, absorb through the skin or smoke I don’t think nicotine itself is the issue.

    As for the delivery mechanism, there are concerns about heavy metals from heating coils which have been widely publicized recently, but it didn’t take more than a few days for those concerns to die down when it was realized that these studies found metal concentrations were compared to environmental standards for air quality which did not take into account vapers only breathe these particulates a tiny fraction of the day, putting their exposure well within safety standards and again (for most metals) well below the exposure of tobacco smokers, or indeed passive smokers.

    The other alarmist medical speculations I hear isn’t about eliquid itself and the potential harm of flavors and aromatics as inhalants. Fair enough, but unlike tobacco smoke we can substitute out any that prove problematic should the need arise, and they’re already approved for human consumption (which includes cooking) so that’s a good start.

    So nicotine is legal, except for vaping, and the medical literature is yet to provide evidence that Vape does nicotine is any more dangerous than existing NRTs, whilst it is patently obvious that vaped nicotine alone is far safer than smoking. So on to everything else: the delivery system and eliquids themselves. Well, there is no medically argument there, because vaping zero nicotine eliquids is legal already. People will do it if they wish to, they are just denied the tools to use it as a smoking cessation strategy.

    I welcome the medical profession looking into possible harms of vaping and guiding the development of safe practice, but alarmist speculation about possible unknown harms just gets in the way of vapers making a positive health choice. We don’t want vaping medicalized as yet another NRT because it will then be productsed into yet another depressing alternative on the chemist shelves amid nauseating patches and tasteless gums. Vaping works as a substitute for (and cessation technique from) smoking because it is satisfying in ways existing NRTs are not. Ideally we would not be breathing foreign particulates into our lungs at all, but as a 27 year heavy smoker vaping is the only thing which has stuck, and I certainly feel healthier for it.

    So by all means do longitudinal studies and keep an eye on the long term harms of vaping – it should be much easier than smoking as the constituents are known compound s approved for human consumption so some of that work is already done. Just calm it with the alarmist speculation – that’s not real science, and even if it is well informed ignores the basic human component that we are trying to minimize harm because mitigation has proven impractical. Vapers are aware of risks but choose vaping over smoking based on plausible risk assessment.

  26. George Crisp says:

    With Lead (or tetra-ethyl lead), we knew that it was a specifically highly toxic additive in petrol affecting the IQ of a generation of children, and despite this its’ removal was resisted by vested interests in much the same way as tobacco co.s fight regulation. Lead wasn’t just replaced with a ‘less harmful alternative”, there were no long lived or environmentally cumulative toxic products, that was known in advance. So it’s a poor analogy.

    The goal in harmful / addictive drug use is abstinence. Your comments that current substitutes are not satisfying is rather telling. You are in essence arguing for a safer version of smoking. This supports public health arguments that vaping will a) encourage new users b) deter addicted individuals from achieving cessation. As for a pathway to cessation – show me the evidence.

    You then go on to say “we don;t want it medicalised” because it won’t be as palatable! Do you think we should do the same with other harmful drugs? Honestly that is not an argument for vaping, it is a frank admission that this is a way of avoiding addressing nicotine addiction.

    Your comments about assumptions of safety are, quite frankly, naive. There is a duty of care to prevent harm, new products do need testing as consequences are not always apparent or predictable, and no, we can’t just infer from other products that something will be safe. And I pointed out that vaporising / combusting organic materials is very likely to produce a range of toxic inhalable and untested compounds.. As you say, we should look into the potential harms of vaping, but it should be before large scale use and / or commercialization of these products.

    Using terms like “Alarmist” (especially “medical Alarmist”) and repeatedly, is clearly a pejorative term and clearly does not encourage constructive dialogue.

  27. Paul Vigo says:

    Firstly you misunderstand what we are refering to regarding vaping. “Combustible organic materials” are the products of so called “heat not burn” technologies being pushed by big tobacco, to effectively stick the same tobacco product in contact with a hot coil and kinda-almost burn it but not quite. I am just as skeptical as anyone of such products. It’s lipstick on a pig finding a safer way to burn existing tobacco – less toxins, same product.

    I am all for HNB as a more healthy alternative for smokers, but HNB for personally bought tobacco IS A LEGAL PRODUCT in Australia. According to existing research (of which we should be wary as it comes from big tobacco, but nonetheless) it is a viable method for existing tobacco smokers to reduce their consumption of harmful chemicals by modifying the method of smoke delivery, so it surprises me that health authorities aren’t getting behind it. “Don’t smoke, but if you do, choose a means of delivery which is less harmful.” To my mind though this is not the best way forward because people are still consuming tobacco fumes with all the unintended extra chemistry that involves, and subsequent (if reduced) health burden on the community. That is of course outside the problems of addiction to tobacco inhalation, which is unchallenged by such a product.

    Eliquid vaporisers instead use (optionally) nicontine infused liquids designed from scratch to be safe, and vaporised at much lower temperatures in order to avoid combustion breaking down the indended flavor profile. Surely the safety profile of a technology designed component by component to be safe and already chosen by consumers and in the market is worth supporting over continued support of products which deliver tobacco as a complete package, including chemichals such as MAOIs which contribute to their addiction profile.

    I apologize for using the word “alarmist” pejoratively, but the media has a habit of amplifying the reach of junk science, and to hear debunked research then repeated by public health experts in a position to advise on policy (who frankly should know better) is extremely frustrating. We just want to hear the best advice of health experts who actually know what they’re talking about.

    I understand that a respiratory specialists default response must be “don’t suck foreign particulates into your lungs unless you have to” but the oft quoted “95% less dangerous particulates” oft attributed to vaping has got to count for something. You can quibble about the percentage but unless something has been massively overlooked it is a promising start.

    Long term smokers know that smoking isn’t normalized but stigmatized in todays society, and that vaping is a similarly fringe and frankly seen as odd. Like any addiction based behavior it is frowned upon, and there is plenty of societal, health and economic impetus to give up. For the small percent who still smoke despite this the existing cessation strategies and affordances have failed. You don’t need to ask a lifelong smoker if they have tried to give up, but how many times. Barriers to smoking have turned illicit tobacco into a billion dollar black market industry in Australia but seem to have hit a roadblock.

    I gave up smoking for vaping about seven years ago, and felt the health benefits at the time, eventually giving up entirely. Like many long term smokers it wasn’t long until I rebounded. By that time the availability of nicotine eliquids had became scarce due to increased legislation, and the difficulty of self importing, combined with the FUD (fear uncertainty and doubt) induced by suspicion of buying from entirely unregulated markets, the propagation of truly alarmist junk science etc… well I went back to tobacco.

    The verified safety of the technology and eliquids since then has moved on considerably and I now consider vaping a viable health choice, if not without risk. It gives me the dignity of being able to control and manage my addiction on my own terms rather than being proscribed a palliative, the naive notion that the only course for addiction is cure and dismissing the contribution of management. This is a simplistic view of addiction which ignores the complexities of lived experience.

  28. George Crisp says:

    Thanks for your clarification and considered reply – you make some good points.

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