e-Cigarette report renews vaping debate – RACGP

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The study questions nicotine vaping as a cessation aid and claims it encourages people to take up smoking, but it has generated significant pushback.

The TGA recently tightened regulation around the sale and use of e-cigarettes containing nicotine.


According to the Department of Health-funded research, using e-cigarettes triples the chance of a non-smoker taking up cigarettes and there is ‘insufficient’ evidence to support its use as a quitting tool.
 
The new study follows a recent tightening of regulation around the sale and use of e-cigarettes containing nicotine, along with the RACGP’s decision to include vaping as a potential second-line treatment only in its smoking cessation guidelines.
 
To form their conclusions, Australian National University (ANU) and University of Melbourne researchers reviewed the worldwide evidence on e-cigarettes and smoking behaviour, relevant to the Australian context. 
 
Lead researcher Professor Emily Banks said while they found limited evidence e-cigarettes help people give up smoking, the study shows people who used to smoke who use e-cigarettes are more than twice as likely to relapse than those who do not.  
 
‘Most people who give up smoking successfully don’t use any products like patches or medication to do it – they do it by themselves, for example, by going cold turkey,’ Professor Banks said. 
 
‘Our review found that there wasn’t sufficient evidence to conclude that e-cigarettes are effective for quitting smoking compared to other approaches, but there are promising signs that they have potential to help.  
 
‘The evidence also indicates that e-cigarettes tend to lead to prolonged use of nicotine, rather than quitting the habit entirely.’ 

Professor Nick Zwar, Chair of the Expert Advisory Group for the RACGP’s Supporting smoking cessation: A guide or health professionals, told newsGP the study’s findings related to people who used to smoke relapsing after vaping are ‘surprising’, but cautioned more research is needed to form solid conclusions.

‘There aren’t many studies. There have been a small number of randomised trials comparing nicotine vaping with standard nicotine replacement therapy, but we need more studies to expand the evidence base,’ he said.
 
‘It’s a high priority for further research because they’re important questions: is there a benefit? If so, what’s the extent? And are there safety issues, particularly long term?
 
‘At the moment we just don’t know enough about long-term safety of e-cigarettes.’
 
Professor Zwar also said while most people who successfully quit do so without aids, it does not tell the full story and that support from a health professional helps.
 
‘Unaided quitting has always been the most common method, but many don’t quit before succumbing to the illness that kills them,’ he said.
 
‘More than 20,000 people die each year from smoking in Australia.’
 
‘That’s not to say people can’t quit without [help], but the evidence is clear that they are more likely to quit successfully with support.’
 
This position is supported by GP and vaping proponent Associate Professor Colin Mendelsohn, who said he finds the report’s support for unaided quitting hard to understand given this is the least effective method and has a failure rate of 95–97%.
 
Associate Professor Mendelsohn, who is also a director of the Australia Tobacco Harm Reduction Association (ATHRA), challenged almost all of the findings included in the study and said it relied heavily on non-peer-reviewed research.
 
‘Many smokers will try repeatedly and quit unaided eventually, but often after smoking-related harm has developed over many years,’ Associate Professor Mendelsohn said.
 
‘The best advice for smokers is to quit as soon as possible with the most effective method, and vaping has proven worldwide to be one of them.’
 
However, Professor Zwar cautioned against drawing too many conclusions from existing research into nicotine vaping, which is often observational in nature.
 
‘Supporters of vaping argue strongly that higher levels of vaping are associated with lower levels of smoking. The problem with that is any observational studies are open to interpretation, so I think that’s where the variation comes from,’ he said.
 
The review by the Joanna Briggs Institute did find some benefit of nicotine vaping. The evidence is not extensive and there are caveats around the quality, but I think it is still sufficient to think there is a role, albeit a limited one, in terms of smoking cessation.’

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A 2019 report from the US Centers for Disease Control and Prevention found an increase in tobacco consumption among high schoolers in 2018 was driven by a ‘surge’ in e-cigarette use.

Aside from questioning the benefits regarding e-cigarette use as a smoking-cessation aid, the researchers also claimed to have found ‘clear evidence’ that non-smokers who use e-cigarettes – in particular young people – are much more likely to take up smoking than those who do not.
 
‘e-Cigarettes could undermine a wonderful smoke-free start in life,’ Professor Banks said. 
 
‘There are around 2.3 million smokers in Australia, and it is our number one cause of premature death and disability.  
 
‘Avoiding e-cigarettes in non-smokers is vital to keeping progress going against smoking … we definitely don’t want something widely available that is going to increase people taking up smoking.’  
 
Associate Professor Mendelsohn questioned this assertion and pointed to the UK and New Zealand as countries that have supported the use of vaping and not seen an increase in young people engaging in long-term e-cigarette use.
 
‘There is no evidence that vaping actually causes a significant number of young people to try smoking if they would not otherwise have done so,’ he said.
 
‘Most youth vaping is experimental and short term, and most young people who try vaping are already smokers.
 
‘Vaping appears to be diverting youth from smoking. For example, in the US, the decline in smoking accelerated 2–4 times in youth after 2014 when vaping became popular.’
 
However, a 2019 report from the US Centers for Disease Control and Prevention (CDC) also found an increase in overall tobacco consumption among high schoolers in 2018 had been driven exclusively by a ‘surge’ in e-cigarette use.
 
According to the CDC report, there were around 1.5 million additional high school-aged e-cigarette users in 2018 compared with the previous year, and those who used e-cigarettes were using them more often. No change was found in the use of other tobacco products, including cigarettes, during this time.

Professor Zwar said the number of teenagers vaping in the US is ‘scary’, but likely influenced by local factors, such as regulation.
 
‘The experience in the UK has been different to the experience in the US,’ he said.
 
‘It may be related to context around marketing and availability. If products are promoted on social media, for example, it may influence patterns of use. So it depends on the regulatory context to some extent.’
 
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