In spite of legal barriers and restricted availability, smokers in New South Wales are turning to electronic cigarettes (e-cigarettes) to reduce the harm from tobacco. According to a recent study by the Cancer Institute NSW, nine percent of smokers and seven percent of recent quitters are currently using an e-cigarette, principally to help them quit.
As in other Australian surveys, e-cigarette use ('vaping') was highest (16 percent) among people aged 18-29 years, compared to those 30-55 years (eight percent) and over 55 years (four percent). The main reasons for use were "to help me quit smoking" (32 percent), "to cut down on the number of cigarettes I smoke" (26 percent) and "not as bad for your health as cigarettes" (20 percent).
The telephone study was conducted from January 2014 to June 2015 and included nearly 3,000 adult (18+) smokers and recent quitters.
The rate of e-cigarette use appears to have risen considerably since the NSW Population Health Survey conducted in 2014 which found that 4.9 percent of NSW smokers were using an e-cigarette, as well as 0.7 percent of non-smokers.
Good news for public health
The authors of the Cancer Institute study have framed these findings as "a worrying pattern of e-cigarette use among young people". However, it is clearly good news that smokers are turning to new and safer options to help them quit or reduce harm from tobacco, often after other treatments have failed repeatedly.
The appeal of e-cigarettes to younger smokers is especially pleasing as they have the most to gain from quitting. Quitting before the age of 35 years leads to complete recovery of smoking-related harm.
Also important is the finding that e-cigarettes have a broad uptake across the social spectrum. Smokers from lower socio-economic groups have high rates of smoking and more difficulty quitting, and vaping may be of special benefit to this priority group.
Evidence from randomised controlled trials and surveys in England indicate that using an e-cigarette in a quit attempt increases the chance of success compared with using nicotine replacement therapy (NRT) such as nicotine patches or gum purchased over-the-counter.
Evidence from England also shows that the availability of e-cigarettes has led to a substantial increase in the number of long-term quitters who would not otherwise have quit.
E-cigarettes are also much safer than tobacco products. A recent comprehensive report by the highly respected Royal College of Physicians in the United Kingdom concluded that the risk to health of long-term vaping is unlikely to exceed five percent of the risk of smoking.
In the Cancer Institute study, many NSW smokers used conventional cigarettes and e-cigarettes concurrently (dual use). For many users, there is typically a transition period of dual use after they start using e-cigarettes which ultimately leads to quitting. The same is true of how many smokers use NRT or varenicline to reduce their smoking and increase future cessation.
Furthermore, most dual users substantially reduce their smoke intake resulting in a significant reduction in exposure to carbon monoxide and other toxins. In the Cancer Institute study, three out of four dual users were not smoking daily. Nevertheless, it is always important for smokers to quit completely wherever possible.
How to optimise public health benefits
The Royal College of Physicians encourages the widespread use of electronic cigarettes as 'it has huge potential to prevent death and disability from tobacco'. Education of smokers and health professionals as well as regulatory changes are now needed to reap these benefits in Australia.
In the UK, e-cigarettes have been incorporated into mainstream quit services. Smoking cessation specialists in the NHS Stop Smoking Service are being trained to use e-cigarettes as a treatment tool with their clients. Research from the UK suggests that substantially improved outcomes are possible when e-cigarettes are combined with behavioural counselling and other stop-smoking medications, such as NRT or varenicline. Health professionals will need to be trained to provide this service.
Users also need to be educated on the correct use and care of e-cigarette devices and solutions. Research suggests that the best outcomes are associated with daily use of e-cigarettes whereas in the Cancer Institute study, only one in four users was vaping daily.
Choosing the correct device also affects quit rates. Early-generation e-cigarettes deliver only small amounts of nicotine, whereas more advanced models are more satisfying and have higher quit rates.
Currently, nicotine is classified as a Schedule 7 dangerous poison and is illegal to possess or use in Australia without approval. It is not surprising that in a 2013 survey, only 43 percent of Australian e-cigarette users reported using nicotine.
Changes to the Poisons Schedule and other legislative changes would allow access to more effective and safer nicotine solutions and devices. It would also avoid making criminals of hundreds of thousands of Australian smokers who are simply trying to stop smoking deadly tobacco by using a much less dangerous way of obtaining nicotine.
Conflict of interest statement: The author has received payments for teaching, consulting and conference expenses from Pfizer Australia, GlaxoSmithKline Australia and Johnson and Johnson Pacific. He has no commercial or other relationship with any tobacco or electronic cigarette companies.