New research has found that the overall effect of youth vaping is to lead more adolescents AWAY FROM regular smoking than towards smoking ie that vaping has a net effect as a gateway OUT OF smoking.
The study by leading UK researchers analysed data from the 2014-2017 US National Youth Tobacco Survey and was published today in the journal Tobacco Control.
The study found that only 1% of teens who used an e-cigarette first became *established smokers. They were 85% less likely to go on to be established smokers than those who smoked first (OR 0.15 CI 0.12-0.18).
They were also less much likely to become established smokers than similar, matched teens who had not tried vaping (OR 0.76 CI 0.62-0.93).
This suggests vaping has a protective effect in reducing the risk of an adolescent becoming a smoker
The likely explanation is that many teens who would have smoked if vaping was not available were diverted from progressing to smoking.
Overall positive effect from teen vaping
This is in stark contrast to the conventional narrative that vaping is leading young people who would not otherwise have smoked to become smokers.
This research suggests that any gateway effect from vaping to smoking must be small and is outweighed by a much larger effect of diverting youth away from smoking, ie a ‘reverse gateway’
This is consistent with the rapid decline in youth smoking rates in the US. According to the Monitoring the Future study, the smoking rate of 12th graders fell by an unprecedented 21% in 2018 and 25% in 2019.
The current analysis suggests that the association of e-cigarette initiation with subsequent smoking is largely explained by shared vulnerability such that those who try an e-cigarette first would have gone on to smoke cigarettes anyway.
The study used a statistical analysis called propensity score matching which reduces the risk of confusion from common risk factors (confounders) and provides a less biased result.
This protective effect of vaping calls into question the ban on youth vaping. Vaping may be having an overall positive effect on public health
* Unlike most other studies, this study examined the impact of vaping on established smoking rather than ‘ever smoking’. This is important because most ‘ever users’ do not go on to regular smoking. Only regular or established smoking will result in subsequent premature death and disability.
Australia is the only western democracy to ban the sale and use of nicotine for vaping. Australian policy is out of step with the scientific evidence and denies smokers who can’t quit a safer and potentially lifesaving alternative. There are better policy options available.
First published on John Menadue – Pearls and Irritations 19 November 2019
Australia is no longer a world leader in tobacco control. The decline in smoking in Australia has slowed considerably over the last 6 years in spite of plain packaging, the world’s highest cigarette prices and strict tobacco control laws.
However, in other western countries such as the UK and US, smoking rates are declining faster than ever, in a large part due to vaping (using an e-cigarette). (Figure 1) Vaping nicotine is the most popular and most effective quitting aid in the world, yet it is banned in Australia. Why?
Most smokers want to quit. However, the reality is that many try and fail repeatedly, even with the best available treatments. Tobacco harm reduction is a pragmatic solution to reduce the harm in smokers who are unable to quit by switching to reduced-risk nicotine products such as vaping. It is similar to using methadone as a safer alternative for heroin users.
Vaporisers heat a liquid nicotine solution into an aerosol that the user inhales, delivering the nicotine the smoker craves but without the tar, carbon monoxide and other toxins that cause almost all the harm to health. A key misperception is that nicotine is the harmful component in tobacco smoke. Nicotine is addictive but is relatively benign. Long-term use has a health risk similar to caffeine.
Public health policy should be based on the best available evidence. In the case of vaping, the public debate is also driven by ideology, politics, vested interests, moral judgements and a hatred of Big Tobacco.
However, the scientific evidence is increasingly clear. Vaping is a safer alternative for smokers who are otherwise unable to quit and is an effective quitting aid.
According to the UK Royal College of Physicians, the risk from long-term nicotine vaping is unlikely to exceed 5% of the harm from smoking tobacco.
The recent outbreak of serious lung disease in the US was caused in almost all (if not all) cases by black-market THC oils, contaminated with Vitamin E acetate or other toxic ingredients. No cases have been linked to nicotine vaping.
A large randomised controlled trial found vaping was twice as effective in helping smokers quit as nicotine replacement therapy, such as patches and gum. Large population studies in the United States and United Kingdom show that vaping is increasing quit rates and is contributing to a rapid decline in smoking at a population level.
Yet there are potential risks. The main concern is that young people will take up vaping and become smokers. However, in spite of a lot of experimentation by teenagers, regular vaping is uncommon and is mainly confined to smokers, even in the US where some claim there is a “youth vaping epidemic”. In fact, youth smoking rates in the US fell twenty five per cent from 2018 to 2019 and it is likely that vaping is diverting some youth from smoking.
Evidence-based public health policy
Public health policy should balance the benefits and the risks to determine the net public health impact. As the long-term risks will not be known for 30 years, simulation or modelling studies are used to estimate the effect. All modelling studies so far, except for one, have found that vaping has an overall positive impact on public health.
Opponents of vaping claim that the precautionary principle justifies a vaping ban. They argue that there are uncertainties about long-term risks, so it is best to delay the introduction of vaping. Being cautious to prevent harm sounds like a virtuous approach but in this case it will actually increase harm.
While the exact long-term health risks of vaping nicotine may not be clear for many years, the risks of tobacco smoking are well-known, with up to two-thirds of continuing smokers expected to die from tobacco-related diseases.
History has shown that prohibition is not an effective solution. It did not work for alcohol or the ‘war on drugs’ and it is not working on vaping. Prohibition pushes the problem underground, creating a dangerous black market with no control over quality or safety and will not stop access for young people.
The current laws are also ethically indefensible. The ban on vaping is a paternalistic policy that over-rides the autonomy of adult cigarette smokers. Vaping is a personal choice which causes no harm to others. Most experts agree that second-hand vapour, unlike smoke, causes minimal risk if any to bystanders.
It is hard to justify the widespread sale of deadly combustible cigarettes, while denying access to a safer, potentially lifesaving alternative.
Legalisation and regulation
A ban is an unnecessarily restrictive policy when a more nuanced approach would achieve a fairer and better public health outcomes. The legalisation and sensible regulation of nicotine liquid would allow access for addicted adult smokers who are otherwise unable to quit while reducing access to youth.
To reduce access for young people, the sale of vaping products should be restricted to suitable outlets such as vape shops, tobacconists or pharmacies, with strict age-verification and enforcement.
Laws should reflect the substantial risk difference between vaping and smoking. It is not appropriate to regulate vaping under the current strict tobacco control laws.
Sensible, risk-proportionate regulation with product standards, restricted sale to adults-only, restricted marketing, accurate labelling and child-resistant containers has led to great success in the UK. Regular vaping by young people who have never smoked is rare (<0.5%) and there are an estimated 3.6 million former adult smokers who now vape.
Taxation of vaping supplies should be kept to a minimum to maintain the financial incentive for switching.
Twenty one thousand Australians die prematurely from smoking every year. Australian policymakers should legalise nicotine and regulate vaping as a consumer product to provide a safer alternative for adult smokers who are unable to quit by other means. Access by young people could be restricted with sensible regulation.
Vaping is displacing large segments of the smoking market in many countries and has the potential to make cigarettes obsolete. This is an opportunity that Australia cannot afford to miss.
Colin Mendelsohn is a Conjoint Associate Professor in the School of Public Health and Community Medicine at the University of New South Wales, Sydney and a tobacco treatment specialist (www.colinmendelsohn.com.au). He is the Foundation Chairman of the Australian Tobacco Harm Reduction Association, a health promotion charity (www.athra.org.au).