Policy in a puff of smoke: vexed options on vaping regulation

By Stephen Easton

January 21, 2015

By the end of June, the Department of Health should be in a better position to advise on what is to be done about electronic cigarettes, when an outsourced policy research project on the controversial public health issue is due for delivery.

January 9 was the closing date for tenders from anyone who fancies they can identify and analyse policy options on vaping, as the pastime is known. Health’s requirements include a summary of evidence around “the risks and potential benefits to population health” as well as analysis of existing regulations at all levels of government and attempts to discourage e-cigarette use in Australia, international responses, and any other information that could shine a light on the pros and cons of the devices. The department specifies:

“This information should include but may not be limited to: prevalence of use of electronic nicotine delivery systems, records of adverse events (such as poisonings from nicotine ingestion), environmental health issues, and marketing practices including public relations and lobbying.”

The research project will then need to identify “policy options to minimise the risks” of e-cigarettes, put together a discussion paper and run a “targeted consultation process with key stakeholders who have relevant technical expertise and knowledge”.

Whoever gets the job will have to navigate a complex and polarised debate within the public health field. A well organised group of anti-vaping academics and advocates favour keeping restrictions tight on the basis of the precautionary principle, their apprehension reinforced by the presence of tobacco companies in the booming global market for the devices. These fears are well summarised in an open letter sent to the World Health Organisation last June and signed by 129 international “public health and medical experts”.

That letter was sent in response to another fired off a month earlier and signed by 53 “specialists in nicotine science and public health policy”, which suggested the WHO consider the potential public health benefits of lower-risk nicotine products including e-cigarettes — as distinct from nicotine replacement therapies designed to aid quitting.

The idea of harm reduction is tarnished by its association with tobacco companies, which use the term to market their own vapour cigarettes — as they have in the past to dress up filter-tipped and low-tar cigarettes as safer options — while they fight tooth and nail against any policy designed to reduce smoking rates. But there are compelling arguments in favour of the potential for e-cigarettes to deliver a large net improvement to public health, coming from credible sources who are not shills for the cigarette makers.

Ron Boland
Ron Boland

One of them is internationally renowned tobacco control, cancer and smoking cessation expert Ron Borland, who signed the first letter. Borland, the inaugural director of the VicHealth Centre for Tobacco Control, believes a major shift from smoking to vaping could offer large benefits to public health, but accepts there are “serious grounds for concern”.

“We don’t know to what level of harm [e-cigarettes] might have,” he told The Mandarin. “Taking what is effectively theatrical fog with a bit of nicotine in it into your lungs 50-100 times a day, for 30 years, may not do your lungs any good. It may not do them any harm either. There are legitimate concerns about that.”

Most of the other worries — like a possible risk to children and others from accidental poisoning and second-hand vapour, and to users from nicotine overdose — are variously “overstated, misleading and really not well-grounded”, in Borland’s opinion. This view is shared by yet another open letter, in which 15 scientists accused the European Union of misrepresenting or ignoring the actual conclusions of their work, at the same time as citing it in their proposed legislation, shortly before it was enacted last February. The letter details several counterarguments to assertions underpinning the EU policy directive and argues that:

“… electronic cigarettes have a very good safety profile and are likely to provide a gateway away from rather than into smoking … If wisely regulated, electronic cigarettes have the potential to obsolete cigarettes and to save millions of lives worldwide. Excessive regulation, on the contrary, will contribute to maintain the existing levels of smoking-related disease, death and health care costs.”

Borland says his main cause for concern is that electronic cigarettes might lead kids who would not otherwise have smoked to become addicted to nicotine. “I think it’s reasonable caution to say we don’t want young people to be taking it up, but if they were otherwise going to smoke then they should be taking this up rather than smoking, because this is going to be less harmful,” he said.

‘The potential to actually get rid of cigarettes’

The difficulty is that for e-cigarettes to replace their much deadlier ancestors through market forces, they have to be at least as satisfying to the user, as well as safer. They are not an effective aid to kicking the nicotine addiction, but could, especially with further development, become the drug delivery system of choice for nicotine addicts. Regulations like the EU’s that try to walk the line between the two opposing expert opinions make it harder for the devices to outcompete cigarettes by limiting their appeal.

“Smokers don’t want to kill themselves,” Borland said. “At the moment [e-cigarettes are] not as good as cigarettes and they take some getting used to … and because they’re getting a lot of bad press, a lot of smokers are not convinced that they actually are a safer alternative, so they’re not looking to them. But if they become convinced they are a less harmful alternative and they are as good or nearly as good as cigarettes, then we have the potential to actually get rid of cigarettes, effectively, as a mass consumer product in Australia.

“We know cigarettes contain 60-80 chemicals which are known to cause adverse health in the sorts of levels that people get exposed to when they smoke cigarettes, all going into their lungs. We know that even the dirtiest versions of these e-cigarettes have a small fraction — about half a dozen of those chemicals or dozens at the most — and the levels of exposure are orders of magnitude lower. In the case of some of the known carcinogens, they’re virtually undetectable in the e-cigarettes in many cases or in two or three orders of magnitude — 100 to 1000 times — lower concentrations.”

The national CEO of the Cancer Council, Professor Ian Olver, is on the side of keeping a wary eye and a firm regulatory hand on vaping — including a “tightening of the loopholes” that make it easy to import them to Australia for personal use, despite the fact nicotine-containing liquid is illegal to sell or possess in any state or territory. But Borland, the Nigel Gray distinguished fellow in cancer prevention with the Cancer Council’s Victorian branch, thinks restrictions could be gradually eased in the right areas to make Australians healthier. The catch, he says, is that the more attractive e-cigarettes become, the more non-smokers will take them up — the net outcome is almost certain to be positive.

“… more than the entire population would have to take them up before you’d be having a net public health loss.”

“If you take the most pessimistic scenario and say they might be 10% as harmful as smoking, and you could get rid of nearly all smoking, then more than the entire population would have to take them up before you’d be having a net public health loss,” he said. “So the maths says it’s almost impossible there wouldn’t be a public health gain — if these products will get people off smoking.”

Borland is no fan of the tobacco industry — his personal views are that “all tobacco executives current and past and board members should be charged with mass murder” and that “while we have our current corporations law, the government is in fact insisting that tobacco companies continue to kill people”.

“But,” he added pragmatically, “if we can get them to stop selling the most harmful forms of the products and sell less harmful forms, then that’s highly desirable.”

One radical policy option is for the government to take over the retail market and sell e-cigarettes from its own monopoly outlets, a system Borland says could control consumption and give the government the upper hand over the pernicious industry.

“I proposed more than 10 years ago that what we should be doing with cigarettes is we should be taking them out of the hands of the for-profit companies,” he said.

“In the US there’s research to suggest that in states where you have government alcohol controls, you have less outlets because the government only set up a few of them [and] prices tend to be lower, but the consumption in the states with the monopolies is still lower, even allowing for the fact that many people from the surrounding states travel interstate, buy the cheaper booze and take it back into their own states.

“So there’s no doubt that availability in some cases can be a much more potent influence on consumption than price, so controlling the availability of cigarettes will make a huge difference and at the moment, when you can get cigarettes anywhere and you can’t get e-cigarettes, except through nefarious under-the-counter schemes or by importing them yourself, it’s hardly an even playing field, even though the e-cigarettes are considerably cheaper than cigarettes.”

More at The Mandarin: Indigenous smoking: the need for a stronger response

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