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Volume 208 - Issue 1

Regulating e-cigarettes in Australia: implications for tobacco use by young people

Authors:  Luke Wolfenden, Emily Stockings and Sze Lin Yoong

Med J Aust 2018; 208 (1): 89. || doi: 10.5694/mja17.00787
Published online: 11 December 2017

Policy decisions surrounding the regulation of e-cigarettes need to account for their potential unintended harm on youth

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Policy decisions surrounding the regulation of e-cigarettes need to account for their potential unintended harm on youth

E-cigarette use is a relatively new field of research and policy development. Few issues, however, have been as divisive as the role of e-cigarettes in improving community health.1 Some tobacco researchers and organisations, including Public Health England and the Royal Australian and New Zealand College of Psychiatrists, have advocated for the use of e-cigarettes to assist quitting.2,3 However, the World Health Organization and many other government and health organisations do not support this use,4 citing concerns regarding the robustness of evidence for their efficacy as a cessation aid, product safety, tobacco industry action in the area, and the potential for e-cigarette experimentation in youth to increase the risk of subsequent smoking and nicotine dependence.4

The risk of e-cigarettes acting as a gateway to tobacco smoking is a particularly salient concern in tobacco control, given that nine out of ten adult smokers initiated tobacco use as adolescents.5 A recent meta-analysis of nine longitudinal studies (including over 17 000 young people) found that e-cigarette use among non-smokers quadrupled the odds of past 30-day cigarette smoking (odds ratio [OR], 4.3; 95% confidence interval [CI], 2.5–7.3).6 The findings are consistent with an earlier meta-analysis of longitudinal studies that we conducted for the WHO, which found that young non-smokers (mean age, = 20 years) who used e-cigarettes at baseline had an increased adjusted OR of being tobacco users at follow-up (adjusted OR, 2.2; 95% CI, 1.5–3.3%; I2 = 60%).7 These findings are also similar to those reported in literature reviews published in a recent report from the United States Surgeon General.5 Nevertheless, the use of observational studies to test gateway effects has been challenged, given the limitations of these designs in accounting for variance in the propensity of adolescents to smoke.8 A gateway hypothesis has also been suggested to be incompatible with evidence of an inverse relationship between the prevalence of adolescent use of tobacco and e-cigarettes in some countries.8 However, the consistency and strength of the findings from meta-analyses suggest that young non-smokers who use e-cigarettes are between two to five times more likely to subsequently initiate combustible tobacco smoking.

Few adolescents try to quit smoking using any sort of cessation aid or professional intervention. Nonetheless, the efficacy of e-cigarettes in improving smoking cessation in youth is equivocal. While there are promising results from a small number of randomised trials of adults showing that use of e-cigarettes under experimental conditions may improve smoking cessation,9 e-cigarettes are not associated with cessation among youth smokers,10 and adolescent smokers do not cite cessation as the primary reason for their use.5 Indeed, e-cigarettes may enable the delivery of nicotine and continued simulation of smoking in contexts that prohibit the use of combustible tobacco products,11 a hypothesis supported by a recent meta-analysis of cohort studies which found that users of e-cigarettes are less likely to quit than non-users.12

Adolescence is a time of particular vulnerability to e-cigarettes, given young people’s curiosity with e-cigarette experimentation and susceptibility to marketing of e-cigarette products that are designed and flavoured to appeal to them.5 Since their introduction into the international marketplace, the prevalence of e-cigarette use among youth has increased globally.7 In the US, e-cigarette use has more than tripled since 2011.13 Further, and in light of evidence of a potential gateway effect, marked increase in product use among young non-smokers internationally is a particular concern, including in the US, where the prevalence of ever use rose from 1.8% in 2011 to 4.4% in 2012 among non-smoking middle and high school students.7 In the 2016 National Drug Strategy Household Survey, 7.1% of Australians aged 12–17 years had ever used e-cigarettes.14 Prevalence of ever use appears to be higher than reported in 2013 (4.3%), although changes to items assessing e-cigarettes between surveys make comparison difficult. Classification of nicotine as a Schedule 7 dangerous poison means that the sale of nicotine for use in e-cigarettes is not permitted in Australia.15,16 Regulatory controls such as this have likely prevented widespread use of e-cigarettes among young people in this country to date.

In the US, 2015 was the first year in which cigarette consumption increased since 1973, an outcome which has been suggested to be associated with increased access and use of e-cigarettes.11 The experience of the US should be of salience in the context of an Australian House of Representatives Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers.17 Any policy action arising from the review has the potential to strengthen, protect or erode tobacco control efforts that over successive decades have yielded substantial reductions in tobacco use in this country.

Given the dominance of tobacco companies in the e-cigarette market,11 and in light of claims of industry so-called astroturfing tactics and alleged coordination of supportive submissions to the inquiry by the industry,18 future policy action on this issue should consider carefully the uncertainty of the existing evidence base. While limited, collectively, research suggests that any move by the federal government to relax existing regulation of e-cigarettes or their marketing in the hope of supporting smoking cessation has the potential for unintended harm, among youth in particular. Further research to understand the nature and use of e-cigarettes in youth, their potential impact as a community cessation aid, and the effects of product promotion and greater product accessibility on uptake, use and quitting behaviour would greatly improve policy decision making and avoid any unintended consequences on the health and wellbeing of Australians. If the conclusions of an earlier Senate Inquiry on the Vaporised Nicotine Products Bill 2017 are a guide, regulatory changes in Australia may well wait until such research is undertaken. In the meantime, the implementation of evidence-based measures to further reduce adolescent tobacco use in this country is warranted.

Authors

  • Luke Wolfenden1,2
  • Emily Stockings3
  • Sze Lin Yoong1,2
  • 1. University of Newcastle, Newcastle, NSW
  • 2. Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW
  • 3. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW

Correspondence: Luke.Wolfenden@hnehealth.nsw.gov.au

Competing interests

No relevant disclosures.

References

Linked content

  • MJA InSight: E-cigs and teens: evidence warns of harms and gateway effect

Provenance: Not commissioned; externally peer reviewed.

View this article on Wiley Online Library

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