Vaping, by Grahame Elder

The DRILL is back, looking at the evidence behind topical issues. And since the last DRILL on nuclear small modular reactors (nuclear SMRs), the Liberal National party have made SMRs a centrepiece of their ‘clean’ energy policy. Here’s the link to that article if you want to refresh why the technology is a very bad option for Australia in the short term, and probably just as bad in the longer term.

But this month I’ve been distracted by vapes, 1st devised by the Chinese pharmacist Hon Lik in the early 2000s. By 2019 in the USA, up to 27.5% of high school students were vaping, (Circulation.2023:148:703-728). In Australia, data, from the first quarter of 2023, shows that about one in seven 14- to 17-year-olds and one in five 18- to 24-year-olds are current vapers. New vaping legislation this month may curb that increase, but there is a simultaneous proliferation of ‘Smoking Stations’ and tobacconists in shopping centres and on street corners. It was hard not to notice the ironic juxtaposition of one directly opposite St Vincent’s Hospital and the Kinghorn Cancer Centre in Darlinghurst, Sydney. 

‘Tobacco for Less’ opposite St Vincent’s Hospital and the Kinghorn Cancer Centre.

And on a recent central Sydney walk, there were 5 outlets around a single block, open late, brightly lit and with colourfully packaged confectionary at the entrance. With watermelon and ice-cream flavoured vapes under the counter, it takes little to guess the target market. 

So, for this edition of the Drill, I wanted to answer the following questions:

  • Who owns the tobacconist stores? 
  • How easy is it to set one up?
  • What are outlets legally allowed to sell?
  • What is the uptake of vaping amongst younger people, and does it lead to cigarette use?
  • Is there evidence that vaping assists quitting cigarettes?
  • How does Australian legislation compare internationally?
  • What happens when access to vapes is phased out in Australia?
  • What about Australian Democrats policy on vaping, cigarettes, and recent Australian legislation?
  1. Who owns the stores? 

Hard to say about all, but Tobacco Station Group Australia Pty Limited (TSG), trading as BetEasy in Australia and New Zealand, operated over 520 franchised stores in Australia in 2022. TSG derives its revenue from sports betting activities online and over the phone, and its parent company is The Star Group Inc., a Canadian-based gambling company. 

TSG has a track record in promoting cigarette consumption. In July 2011 its spokesperson addressed the Standing Committee on Health and Ageing in relation to plain tobacco packaging and stated there was  ‘no evidentiary basis to conclude that plain packaging will deter young people from taking up smoking .… Pack design … does not play a role in uptake of smoking or continued smoking’.

That was subsequently shown to be totally wrong.

Of course, there is quite a problem with selling tobacco legally at present. Federal Government taxes are currently about 65% of the purchase price of cigarettes and tobacco, with increases of 5% annually for the next three years. Because the cost of legal tobacco is prohibitive and margins are so low, the head of the peak body for convenience stores said that ‘retailers have been unable to make a profit on legal sales’. On the other hand, if outlets sell ‘under the counter’ tobacco or vaping products brought into the country without paying excise, the businesses can be highly profitable. This has led to ‘more than 1000 illegal outlets in Melbourne’, with involvement of bike gangs and organised crime. The ‘tobacco wars,’ fought over profits from illegal tobacco sales, have resulted in several assassinations: this 2023 ABC YouTube video reports on the 29th attack on Melbourne tobacco outlets and the 3rd in one area in 2 weeks. 

Similar arson attacks have been reported in NSW, Queensland and Western Australia.  And the illegal market is huge. On 8th February 2024, the ABC reported that the previous week, health authorities from the Therapeutic Goods Association and NSW Health seized over 30,000 vapes, 118,000 cigarettes and 45 kilograms of flavoured and loose-leaf tobacco, and 284 containers of nicotine pouches from 60 retailers in south-east Sydney. 

2. So just how easy is it to set up a store? 

To find the answer, I contacted the Sydney City Council. 

The guy in charge of planning assessments was very helpful (5 smileys) and provided a number of useful links. To my surprise, they indicated NO rules governing sites for tobacco outlets, and of course no guidelines regarding proximity to schools (or hospitals or cancer centres). For development application, tobacco outlets are assessed as convenience stores, and “if the land use is permissible and the application meets all the relevant controls, then it will be approved”.

That’s not to say that there are no rules associated with selling tobacco products. There are requirements about advertising and sale, but nothing on site or numbers.

3. What are outlets legally allowed to sell at present?

On 1st  October 2021, the Therapeutic Goods Administration (TGA) placed nicotine vaping products in schedule 4 of the Poisons Standard, making them a prescription only substance. However, non-nicotine containing vapes could still be sold in retail outlets.Consumers could also import nicotine e-cigarettes and liquid nicotine with a doctor’s prescription.

From January 1st  2024, disposable vapes, which are particularly favoured by children as they are cheap and easy to use, could no longer be legally imported, although non-nicotine containing disposable vapes imported prior to that date could still be sold; and there appear to be millions of those.  From the 1st March 2024, vapes containing nicotine could only be supplied in pharmacies, and it became illegal for Australian retailers such as tobacconists, vape shops and convenience stores, to sell vapes containing nicotine, even with a prescription. Also, from the 1st March 2024, the importation of disposable or non-disposable vapes, irrespective of nicotine content, was generally banned.,nicotine%2C%20even%20with%20a%20prescription. People can still access unapproved nicotine vapes with a prescription through pharmacies, which can source them from Australian wholesalers or overseas suppliers. They can also be compounded – but guidelines regarding approval and quality are likely to deter most compounding pharmacies.

4. What has been the uptake of vaping amongst younger people, and does it lead to cigarette use?

Data, from the first quarter of 2023 showed that about one in seven 14- to 17-year-olds and one in five 18- to 24-year-olds were vapers. Young Australians who vape are around 3 times more likely to take up tobacco smoking compared to young Australians who have never vaped. Mark Butler, the Minister for Health recently said there are “18 billion posts on TikTok promoting vaping, and 18,000 influencers on Instagram pumping out pro vaping messages”, with heavy sponsorship by tobacco companies.

So, what are the risks of e-cigarettes? An Irish Health Research Board report concluded that adolescents using e-cigarettes were three to five times more at risk of future cigarette smoking than those who have never smoked e-cigarettes.

The report was consistent with others, including one from the Australian National University, which found that, across multiple settings, non-smokers who use e-cigarettes are consistently more likely than non-e-cigarettes users to initiate cigarette smoking. 

Once adolescents start smoking cigarettes, the serious health risks for cancer, cardiovascular disease, lung disease and early death are well established and incontrovertible. The health risks of vapes are less clear, but certainly present; these include the risks from the multiple chemicals and metals in vapes, and like smoking, these risks are likely to become clearer over time. 

5. Is there evidence that vaping assists quitting cigarettes?

You would have to say it’s motley! A search of ‘PubMed’ uncovered some references, including a meta-analysis, which generally provides the best grade of evidence if studies included in the meta-analysis are of good quality and can be compared. Neither criterion was met by most included studies.  Of 64 studies that were included, 55 were ‘observational,’ meaning the participants were not chosen in any way and there was plenty of room for error in the results. These studies reported that for adult smokers, including those who were ‘motivated to quit’, e-cigarette use was not associated with quitting. However, when e-cigarettes were provided free of charge, more people using the e-cigarettes managed to quit than people using ‘conventional therapies’. The authors concluded that ‘E-cigarettes should not be approved as consumer products but may warrant consideration as a prescription therapy’ (Wang et al, Am J Public health 2021:111(2):230-246 (Meta-Analysis.). 

The Royal Australian College of General Practitioners smoking cessation guidelines stipulate that ‘nicotine containing e-cigarettes are not first line treatment for smoking cessation. However, for people who have tried to achieve smoking cessation with approved pharmacotherapies but failed, and who are still motivated to quit smoking and have brought up e-cigarette usage with their healthcare practitioner, nicotine containing e-cigarettes may be a reasonable intervention to recommend’.

6. How does Australian legislation compare internationally?

In 2022, New Zealand went even further than Australia by passing ‘world first’ legislation aimed at phasing out tobacco completely, and stopping anyone born after January 2009 from ever being able to legally buy cigarettes. However, the law has now been scrapped, with the new finance minister, Nicola Willis saying that revenue from cigarette sales is needed to fund planned tax cuts.  New Zealand vaping laws are now much weaker than those in force in Australia. Disposable vaping products have been banned, and this week, on March 21st, NZ introduced “a ban on vaping products with images of cartoons or toys on the packaging, and limiting flavour names to generic descriptions”. Reusable vape products will have until October 2024 to include removable batteries and child-proofing mechanisms.

Proposed legislation in the UK seems similar to that originally proposed by New Zealand. With no definite timeline, it could potentially face a similar fate.

On 28th January 2024, the UK government announced plans to ban disposable vapes and to put restrictions on vape flavours and packaging. The government also proposed restricting the sale of vaping alternatives to children, such as nicotine pouches. On the 30 January, the British PM, Richi Sunak, announced that children turning 15 this year or younger ‘will never be legally sold tobacco’, and that the age of sale will be raised by one year each year, to prevent future generations from ever taking up smoking’. The government indicated that England, Scotland and Wales intend to bring in legislation as soon as possible. 

From my reading, the result of these laws, if they are brought in, is that people aged 16 and over from the time the legislation is introduced, will be able to vape or smoke indefinitely, and vapers will still be able to access refillable and reusable vapes containing nicotine. However, the cohort aged under 16 will be prohibited from smoking and vaping. So, although useful in the extremely long term, the legislation would seem very likely to increase the overall number of nicotine vapers and, as a result, tobacco consumers, for many years to come.

7. What happens when access to vapes is phased out in Australia?

It would be naïve to think that the vape phase out in Australia will not increase the black-market sales of tobacco and vaping products. The government has committed to increasing funding to Border Force, to the Therapeutic Goods Administration and to improve access to Quitline services. However, there is clearly a strong backlash from some organised groups and members of the public. The Greens’ policy on vaping is particularly weak. They say that nicotine vaping is legal and widely available in the UK, US, Canada, New Zealand, and the European Union, and that there should be a prohibition on harmful chemicals in vapes, nicotine content should be limited and that they would legalise nicotine vapes for 18 and over and require health warnings.

Rather strangely, Labor and the Coalition appear to have very similar policies on vaping. After a shaky start, the former Minister for Health, Greg Butler stated in 2017 that “smoking remains the leading preventable cause of death and disease in Australia…Smoking continues to kill approximately 20,000 Australians every year…frankly it’s big tobacco which is arguing the case for these e-cigarettes and they’re only doing it because it’s in their interests. I have a very strong, clear, categorical view that this is not something that should occur in Australia”.

8. What about the Australian Democrat policy on vaping, cigarettes, and recent Australian legislation?

ADs have diverse and eclectic views on most topics, so I expect the same in this policy area. 

To summarise my thoughts, we now have the most restrictive laws on vaping internationally, and that is going to receive pushback, similar to Australia’s first laws on smoking in bars and restaurants, health warnings and plain cigarette packaging. They created opposition, and legal cases brought by major cigarette manufacturers, but are now generally accepted. They also resulted in marked reductions in cigarette consumption and have saved thousands of lives.  This is not a first. We went against the predominant world view to introduce the 1st female suffrage in the colony of South Australia in 1884, and if it weren’t for New Zealand, Australia would have been the first nation to introduce the vote for women,

and we introduced mandatory wearing of seat belts before other countries. There is no doubt that the new laws will increase black market trading but does that differ from current black market cigarette trading. Despite the black market, since prices rose, advertising ceased and packets of cigarettes were covered in gruesome images of the real consequences of smoking that I see in clinics every day, the incidence of smoking has plummeted in Australia.

Cancer Council of NSW image

Source: ABS NHS 1990, 1995, 2011, 2004–05, 2007–08, 2014–15 and ABS Australian Health Survey 2011–12

The idea that these 34 years of gains could now be at risk, is one we should strenuously resist.

My view is that the Australian Democrats should strongly endorse the current restrictions on sales and importation of vaping products, except on prescription for smoking cessation.

Should we also consider support for a ban on sales of tobacco products to children aged 16 or under when legislation can be introduced; and following the UK suggestion, restrict sales to those children as they grow into adults. I do have concerns about this 2 -tiered approach to supply of tobacco in the community, and it would seem extremely difficult to enforce. Imagine millions of people aged 50 and over able to smoke legally, with millions of people aged 49 and under being fined for the same activity. I think it is impracticable and it would need to be all or none. It may also be unnecessary if vaping does not take hold, and if current smoking rates can be reduced with education. Smoking is seen by many children currently as an expensive habit for losers; so, the concept that it could virtually die out, figuratively and literally, is not impossible.  Here’s hoping it’s not a pipe dream. 

I welcome comments and debate.

And the next DRILL: has anyone told you recently that lithium batteries are more damaging and dangerous than driving a petrol-fuelled car? Happened to me 2 weeks ago. And despite my immediate gut response, the statement needs a careful, rational, evidence-based reply. Are we killing the planet and ruining people’s lives by mining lithium and producing lithium batteries that can’t be properly disposed of? 

That’s the next DRILL.

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