Vaping regulation in Australia
Unlike most countries including New Zealand, the United Kingdom, United States, South Africa and the rest of Europe who see vaping as a Tobacco Harm Reduction tool, Australia has had a very precautionary approach to regulating vaping which has meant it is currently scheduled as a prescription only medicine
The reason for Australias’ cautious approach to regulating vaping comes down to the TGAs belief that vaping should be regulated using a 0 base risk assessment (i.e. considering the potential risks vs inhaling fresh air) rather than as a tobacco harm reduction tool. Although Australian public health officials generally agree vaping is significantly less harmful when used as an alternative to smoking combustible tobacco, they have the view that vaping should only be used as a last resort cessation product for instances where a smoker has tried all possible alternative methods to quit.
The Banks Review
To help assess the “0 base risks” associated with vaping the Australian Department of Health commissioned a report aka “The Banks Review” led by Professor Emily Banks, a leading public health physician and epidemiologist with interest and expertise in chronic disease and Aboriginal and Torres Strait Islander health.
The Banks Report selected and reviewed available scientific evidence in an effort to draw conclusions on the health effects of vaping products at an individual and population level.While the banks report refers to other studies which consider the relative health effects compared to tobacco usage, the scope of this report was to provide an overview of potential “0 base risks” rather than a population assessment on the relative risks vs smoking tobacco.
The Banks Review Findings:
Vaping Causes Addiction
The Banks Review notes that there is significant evidence that regular use of vaping products amongst non-smokers results in addiction and that exposure of nicotine to adolescents can change the structure and function of the brain.
Nicotine is addictive:
The significant evidence that regular use of vaping products amongst non-smokers leads to dependance is based on 2 studies published in 2020:
- Camara Medeiros et al., 2020 - An online survey in Canada was conducted targeting youth who vape aged 16-25 years on various social media groups. The average responders age was 18.7 years, and they were asked if they think they are addicted to vaping; lots of the youth responded that they felt they were addicted.
- Hughes et al., 2020 - 18 young adult vapers in the United states who claimed to have smoked less than 100 cigarettes in their life were recruited. Half of the participants were asked to stop vaping for a week. Of the 9 participants who stopped vaping for the week, 3 claimed to experience symptoms that impaired their function (cravings, anxiety, difficulty concentrating etc.), whereas only 1 of the 9 participants who kept vaping reported similar symptoms.
Adolescence Structure and Function of the Brain.
Interestingly the report notes there is no evidence on how vaping affects the development of adolescents. This claim is actually based on studies about how smoking combustible tobacco during adolescence can impact brain development. These studies found there was a link between adolescents who smoke tobacco and behavioral disorders such as substance abuse, depression and anxiety with several of these studies attributing the behavioral changes to nicotine.
Vaping Causes Injury
The banks review claims that vaping causes injury with impacts including poisoning, seizures, burns and lung disease.
Evidence referenced is primarily surveillance reports and case studies ranging from accidental ingestion by children to self harm where nicotine concentrate of up to 990mg strength was injected causing seizures and in some cases, fatal outcomes.
For cases of accidental ingestion there were no medical effects reported in 38%, minor in 38%, moderate in 4% and 20% were not followed, in most instances patients returned to baseline levels within 6 hours.
For seizures involving ready to vape products, evidence referenced was deemed low methodical quality across 3 studies of isolated incidents.
Lui and McIntosh, 2020: Related to 2 cases of youths recently prescribed trazodone who experienced seizures while vaping.
Hughes and Hendrickson, 2020: Relates to one case of an adolescent prescribed fluoxetine, tested positive for THC and experienced a seizure while vaping an unknown product.
Wharton et al., 2020: A patient who occasionally vaped with Idiopathic epilepsy experienced 5 seizures in a week
None of the evidence relating to severe or fatal poisoning involves ready to vape nicotine eliquids. Consumers should not have access to nicotine concentrate used by eliquid manufacturers under strict lab conditions and proper care should be taken by vapers to keep vaping products away from children and pets.
The Banks Review notes conclusive evidence that vaping can cause burns and injuries, which can be severe and can result in death.
The evidence refers to incorrect use resulting in short circuiting of high powered unregulated devices without safety mechanisms or improper care taken with removable 18650 batteries in pockets coming into contact with metal objects such as coins.
The Banks Review confirms there is insufficient evidence to link vaping to respiratory problems, including asthma, bronchitis and COPD in both smokers and non-smokers, although it does note that there is limited evidence that asthmatic smokers who vape can experience some respiratory resistance and impedance.
The claim that vaping can cause lung disease is not in reference to nicotine vaping products but based on evidence that the blackmarket THC oils laced with vitamin E acetate illegally sold in some parts of the United States in 2018 was linked to respiratory disease (EVALI) when consumed.
Not Harmless Vapour
The Banks Report notes there are hundreds of chemicals in e-cigarettes, including formaldehyde, heavy metals, solvents, and volatile organic compounds.
This is in reference to various studies over the years on vaping aerosol which have detected trace amounts of chemicals within vapour known to potentially have serious health impacts. What the report goes on to highlight is that under typical conditions of use, the number and concentrations of potentially toxic substances emitted from unadulterated e-cigarettes are significantly lower than in tobacco smoke.
Vaping is a gateway to smoking
Evidence used to come to this conclusion is based on studies which have concluded that “never smokers” who vape are 3 times more likely to become “ever smokers”, which is misconstrued into a claim that vaping is a gateway into smoking.
Some examples of studies in the report used to come to this claim are:
Berry 2019 - In the United States youth with an average age of 13 years were surveyed in 2013, with 2 follow up surveys over subsequent years on their smoking and other risk taking behaviors. The study found that respondents that had vaped were 4 times as likely to have tried a cigarette than respondents who had never vaped. The study goes on to warn that it does not prove that vaping is a gateway to tobacco smoking and that the results could be due to a risk seeking behavior of these respondents that leads them to try a range of risky activities, and that findings in the study should be interpreted with caution.
Chien 2019 - In Taiwan secondary school students were asked in 2014 and 2016 whether they had ever tried vaping, ever tried smoking, and if they would ever consider trying smoking. In 2014, 18% of the students had tried smoking and 4% had tried vaping. In 2016 the proportion of students who had tried smoking had grown to 26%, and of the additional students who had tried smoking (at least once), those who had tried vaping in 2014 were 2 times as likely to have tried smoking by 2016, although those who said they would consider trying smoking in 2014 were 4 times as likely to start vaping. The study then goes on to note that although there is a relationship between vaping and smoking, there was no data that explains the association between initial e-cigarette use and subsequent smoking and that other factors not included in the survey may help explain. In 2023, smoking rates in Taiwan remain relatively high and all vaping products are prohibited.