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27 Jun 2018

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

The Canadian Government recently announced plans to adjust e-cigarette regulation. The Canadian aim is to de-regulate e-cigarettes for adults over 18 years old, but to still ban sale to adolescents, as well as advertising and flavours of e-cigarettes likely to appeal to young people. A tricky, if not impossible, balancing act. Clinicians need to be thoughtfully involved in this debate, drawing on the increasing evidence base.

The AMA has a thoughtful policy regarding e-cigarettes which underlines the potential harm of these products and notes that young people (largely from self-reported cohort analyses) do find e-cigarettes a gateway into habitual tobacco smoking.  Conversely, the same self-report studies do suggest adults can use e-cigarettes as a successful quitting technique and to reduce cigarette consumption, such as a recent New Zealand self-report trial (six-month abstinence 7.3 per cent with e-cigarettes vs NRT patch 5.8 per cent vs placebo e-cigarette 4.1 per cent). Currently, Australian States and Territories ban e-cigarettes in a similar fashion to traditional cigarettes.  Should we follow in the Canada’s footsteps, however, or is the threat still too worrying?

Bear in mind e-cigarette use is increasing across all age groups. It is interesting to note that a large Canadian cohort study of grade 9-11 students was published last month showing 45 per cent of e-cigarette users tried a tobacco cigarette after two years, compared with only 13.5 per cent of non-current e-cigarette users. Moreover, e-cigarette advertising (taken together in all its forms, including online) contributed to expansion of the tobacco market by attracting low-risk adolescents who would otherwise be unlikely to initiate smoking. Ouch! It is completely unclear how the blunt instrument of legislation will be able to differentiate an opposite effect on young people who are not yet habitual smokers versus established smokers wanting to quit who have perhaps failed at other quit attempts and not just been seduced by the notion of ‘safe nicotine’.

The e-cigarette market globally in 2016 was worth US$11.5 billion and double digit growth is anticipated to achieve a market size of up to US$90 billion in 2025.  In 2016 Australian tobacco smoking rates have continued to decline to approximately 14 per cent (16 per cent male and 12 per cent female). In the same year, smoking prevalence in Canada was 15 per cent, France 24 per cent, Greece 40 per cent and Indonesia 57 per cent. In the age group 18-24 years in 2016 in Australia, smoking prevalence was also 14 per cent (but more in females) – down from 27 per cent in 2001. Australia has therefore done reasonably well without e-cigarettes.

We must remember vulnerable groups within our population, including Aboriginal and Torres Strait Islander people who represent 2.8 per cent of our total population. In 2014-15, 39 per cent of them over the age 15 years smoked daily. Prevalence is decreasing, but clearly this report card is not good.  I suspect e-cigarettes help us no more here than they do in our mental health patients who continue to smoke at double the general population rates. Interestingly, 14 per cent of all Australian families are one-parent families and the single parent smokes at more than double the general population rate at 31 per cent. The other challenges and disadvantages faced by these people creates a context that clearly requires more thought than e-cigarettes.

A NSW Government survey recently found approximately 70 per cent of all e-cigarettes contained nicotine. This compound remains addictive, damages and inflames airways, is ill-advised in pregnancy, can negatively impact higher cognitive function development in adolescents, and may be linked to cardiovascular morbidity/mortality and cancer risk. In a large UK cohort study published this month (which the Canadians seem to have missed), adolescents knew e-cigarettes were less harmful than tobacco cigarettes, but were unaware most products still contained nicotine, were unaware nicotine was addictive, and were unaware the addiction to e-cigarettes did increase their likelihood of later tobacco use. The Cochrane review in 2014 favourably comparing nicotine-containing e-cigarettes versus non-nicotine-containing e-cigarettes in terms of long-term abstinence doesn’t compare with other quitting mechanisms and therefore shouldn’t inspire confidence to invest in e-cigarettes as a safe and credible quitting tool. 

The 2016 Australian National Drug Strategy Household Survey asked smokers about any cessation strategies they might have used (respondents were able to choose multiple responses). Among adult smokers who had tried to quit in the previous year (successfully or unsuccessfully), 3 per cent had contacted the Quitline, 14 per cent had asked their doctor for help, and 22 per cent had used nicotine gum, patches, or inhalers. Seven per cent reported using a smoking cessation tablet. Other responses included using some other type of product (9 per cent), reading cessation literature (11 per cent), using the internet (6 per cent), or using a mobile phone app (7 per cent). Going cold turkey was by far the most popular method, with about two in five quit attempters (39 per cent) adopting this strategy

In this light, we might be better served augmenting access to cognitive behaviour therapy or small group sessions to help with non-pharmacologic solutions.  Abrupt versus gradual reduction with a quit date whether supported by pharmacotherapy, behavioural therapy or self-help therapy in either case had comparable quit rates at six months. We have combination nicotine replacement therapy theoretically available (too often people do not use enough NRT and this is why they fail) and Champix (if you are old fashioned there might be a limited role for nortriptyline).  Zyban is no longer available. Champix (Varenicline) costs many times more than the expected A$60 million after the first five years. E-cigarettes are not cheap either. A month of vaping costs up to $40 per person depending on what one buys.

Three decades ago the World Health Organisation clearly established that a fundamental tenet of reducing tobacco consumption be not only via reducing overall smoking rates, but also encouraging non-smokers to remain non-smokers. The evidence does not suggest e-cigarettes should be viewed as safer or more successful than NRT. It is seductive for our addicted patients to think there might be a safe and clean way to ingest nicotine – but this misguided notion should be struck down immediately and with the full might of medical evidence available. 

E-cigarettes may have the potential to assist some smokers to quit, but will increase harm from tobacco if they increase the number of children who become addicted to nicotine, reduce the likelihood smokers will quit completely in a mistaken belief they are safe with vaping, tragically entice former smokers back to smoking, or ‘re-glamorise’ the act of smoking.

E-cigarette success rates in general do not exceed those in unassisted or low assistance NRT trials and current evidence remains insufficient, in my view, to demonstrate that e-cigarettes enhance quit attempts/success. Moreover, those attracted to e-cigarettes may be a different sub-group to those who have accessed conventional NRT (younger, non-white, higher income, lower dependence, shorter smoking history, higher lifetime quit attempts). It must be recognised, however, that the nicotine dose may be insufficient in e-cigarettes trialled to date (but patients can just use combination NRT anyway) and the level of counselling support has often been insufficient. 

Perhaps nicotine used in e-cigarettes should be a scripted item no different than Champix when used as part of a supported quit attempt with cognitive behaviour therapy and GP/addiction physician input. Anything else is fraught and has no credible evidence basis. We would perhaps be better served expanding public and clinician education regarding quit aids and techniques and improving access to other more credible cessation aids e.g. let us fund combination NRT (patch and oral form together) for an appropriate period of time. We cannot sacrifice the vulnerable in the hope we achieve durable smoking cessation in a few. Let’s stay our course for now and keep e-cigarettes in the shadows,  thinking very carefully about any system that legitimises them as a quitting aid. Meanwhile, keep your eyes on Canada to see how they fare.


Published: 27 Jun 2018