Vaping

These recommendations apply to any electronic cigarette that heats a liquid to produce an aerosol that can be inhaled and exhaled. This does not include heat-not-burn cigarettes, which are illegal in Australia.
 

• Use discussions about e-cigarettes and vaping as an opportunity to talk about the harms of smoking and the benefits of quitting smoking.
• Respond to community concerns about vaping with evidence, avoiding overstatement. Monitor and critically appraise the emerging research evidence.
• Contribute to discussions about the emerging public health response to e-cigarettes.
• Avoid all contact with tobacco companies, even when they claim to be shifting away from cigarettes.
• In some remote areas where there is as yet no vaping, it may be best to not mention vaping (including vaping cessation and preventing vaping uptake), because this may inadvertently increase curiosity about e-cigarettes.

Other resources for health professionals

• Quitline: telephone 13 7848 or 13QUIT or go online to arrange a free call back and follow-up telephone calls
• National Health and Medical Research Council (NHMRC): The 2022 CEO statement on electronic cigarettes and associated literature reviews summarise the latest evidence about the harmful effects of e-cigarettes 
• Cancer Council Victoria: Tobacco in Australia: Facts and issues is a regularly updated comprehensive review of the major issues in smoking and health in Australia (www.tobaccoinaustralia.org.au), with an in-depth discussion of e-cigarettes

Background

Electronic cigarettes (e-cigarettes) heat liquid to produce an aerosol to be inhaled and exhaled, which is known as vaping. This topic uses the generic terms ‘vaping’ and ‘e-cigarettes’, but e-cigarettes are also referred to as electronic nicotine and non-nicotine delivery systems (ENDS and ENNDS), alternative nicotine delivery systems (ANDS), nicotine vaping products, e-cigs, vapes and vape pens, among other names. This topic does not discuss heat-not-burn cigarettes, which heat tobacco (to a lower temperature than when burnt in a cigarette) rather than a liquid, because they are effectively illegal in Australia and their use is rare.² 

The e-cigarette market is evolving rapidly, with a wide variety of older and newer types of devices available. The most recent large Australian survey (the Victorian Smoking and Health Survey of 12,000 adults in January–May 2022) found that 51% of people who had vaped in the past year usually used disposable e-cigarette devices, with an even higher preference for these devices among young users aged 18–24 years compared with older adult users.¹ These newer disposable and pod devices use nicotine salts rather than freebase nicotine, with higher concentrations of nicotine. Most (58%) survey respondents reported that they usually vaped liquid containing nicotine, but fewer than 9% of these individuals reported having a prescription for this nicotine despite this being required by Australian law.¹ Approximately half (47%) the people who had vaped in the past year had only used other people’s e-cigarettes, which was even more common among young people aged 18–24 years (61%) and never-smokers (74%).¹ 

The NHMRC’s 2022 CEO statement on electronic cigarettes and associated literature reviews summarise the latest evidence about the harmful effects of e-cigarettes.⁵ 

The liquids used in e-cigarettes (e-liquids) may contain many chemicals and, like the devices, their composition is constantly changing, leading to uncertainty and concerns about their safety.⁵ The NHMRC toxicological review found that most (69%) of the 369 e-liquid chemicals assessed had some harmful health effects, but almost all (89%) had no information on toxicity when inhaled as an aerosol, leaving little confidence in the safety of the inhalation of aerosols from e-liquids.³ Vaping indoors increases airborne particulate matter.⁵ 

E-liquids may contain nicotine, even when labelled ‘nicotine free’.⁵ Vaping nicotine-containing e-cigarettes can lead to nicotine dependence.⁵ This dependence may be less than from smoking cigarettes but more than from using NRT.^5,8 The US Surgeon General warns that nicotine exposure can harm the developing adolescent brain.⁹ 

The NHMRC review found very little evidence about the impact of e-cigarettes on health outcomes.^5,8 This does not mean that e-cigarettes are harmless, just that there is insufficient evidence yet about their safety and harms. Although there is little evidence of the impact of e-cigarettes on important long-term clinical outcomes, e-cigarettes can cause uncommon immediate serious health problems, such as poisoning (from nicotine toxicity) and seizures.¹⁰ E-cigarette or vaping associated lung injury (EVALI) has led to 2807 hospitalisations and 68 deaths in the US and is mainly linked to e-liquids containing tetrahydrocannabinol (THC) or vitamin E acetate.¹¹ Although almost all reported cases of EVALI have been from the US, one case of EVALI has been reported in Australia.^4,12 E-cigarettes also cause less serious immediate health effects, such as throat irritation, cough, dizziness, headache and nausea.⁵

Given the well-established harms of smoking, the NHMRC review also assessed the impact of vaping e-cigarettes on smoking uptake and smoking cessation. More never-smokers who use e-cigarettes than those who do not start smoking (odds ratio 3.19 from 17 observational studies).^5,13 Another recent meta-analysis found a similarly strong association between vaping and starting smoking, but expressed reservations about whether this association was causal, and may instead be due to confounding by common causes of vaping and smoking, such as impulsivity and risk taking.¹⁴ (For a discussion of the role of e-cigarettes in smoking cessation, see Chapter 2: Healthy living and health risks, Smoking.) 

The prevalence of e-cigarette use is increasing in Australia, with a higher prevalence among young adults aged 18–24 years than in younger and older age groups, as well as among smokers and ex-smokers than never smokers.¹⁵ Some reports refer to the prevalence of ‘ever’ use of e-cigarettes, but this is much higher and less useful than the prevalence of ‘current’ use, especially daily use. The most recent National Drug Strategy Household Survey in 2019 reported that 1.1% of people aged 14 years and over used e-cigarettes daily; in contrast, 11.3% had ever used e-cigarettes, including 6.7% who had only used them once or twice.¹⁵ The most recent large Australian survey (the Victorian Smoking and Health Survey) found that adult daily e-cigarette use had increased from 0.9% in 2018–19 to 2.4% in 2022.¹ 

The Australian Bureau of Statistics National Aboriginal and Torres Strait Islander Health Survey in 2018–19 found that 1.3% of adults (and 2.0% of adults aged 18–24 years) were using e-cigarettes daily or weekly.¹⁶ More adults in cities (10.1%) and regional areas (8.7%) than remote areas (2.6%) had ‘ever’ used e-cigarettes. The 2017 National Australian Secondary Students’ Alcohol and Drug survey found higher e-cigarette use among Aboriginal and Torres Strait Islander students than other students, but was only able to report ‘ever’ use (22% versus 14%) and the data is now old, with subsequent surveys delayed due to the COVID-19 pandemic.¹⁷ 

Curiosity was the most common reason given for trying e-cigarettes in the 2019 National Drug Strategy Household Survey (54% of those aged 14 years and over), especially for young adults aged 18–24 years (72%) and never smokers (85%).¹⁵ Although curiosity was the most common reason for all age groups aged under 40 years, for all age groups aged 40 years and over the most common reason was to help quit smoking.^15,18,19 The next most common reasons were thinking e-cigarettes were less harmful than regular cigarettes (23%) and to try to cut down the number of cigarettes smoked (22%).^15,18,19 

Marketing on social media, product design, packaging and the wide range of sweet flavours of e-cigarettes are being used to increase their appeal to adolescents.² Cross-sectional and longitudinal studies have shown an association between exposure to this social media marketing of e-cigarettes and initiation of vaping among adolescents.⁵ 

There are obvious concerns in many Aboriginal and Torres Strait Islander communities about the rising prevalence of e-cigarette use among children and young adults. These concerns are possibly increased by the newness of e-cigarettes, alarming media stories of rising e-cigarette use among young people, limited research evidence about vaping but known harms caused by smoking and the involvement of discredited and distrusted tobacco companies. 

The first commercialised e-cigarette became available in 2003, and initially e-cigarettes were made by small new companies. In recent years, large established transnational tobacco companies have moved into and are now a large influence in the e-cigarette market.² Their claims of shifting their companies from cigarettes to safer e-cigarettes are generally met with scepticism. Philip Morris has approached Aboriginal and Torres Strait Islander organisations to support the legitimacy of their harm reduction claims, with no success.²⁰ Philip Morris International has pledged US$80 million for the Foundation for a Smoke-Free World. The Foundation only focuses on switching to vaping and alternative products as the way to end smoking.²¹ Australian Aboriginal and non-Indigenous researchers have pledged to not accept any funding from this Foundation, consistent with Article 5.3 of the Framework Convention on Tobacco Control, which obliges governments to protect public health by refusing any contact with the tobacco industry.²¹ The tobacco industry should not be allowed to use e-cigarettes to re-establish its legitimacy and influence on policymakers and policies affecting Aboriginal and Torres Strait Islander people.²² 

There is almost no high-quality research evidence about what works to prevent patients from starting to vape e-cigarettes or to help patients quit vaping, and no evidence about what works for Aboriginal and Torres Strait Islander patients. This will change as researchers catch up. It is not yet clear whether the approaches used for smoking can be effectively applied to vaping, but nearly half (46%) of current adult e-cigarette users also smoke (‘dual users’) and may approach smoking cessation services (eg Quitline) to quit vaping.¹ 

As the NHMRC’s 2022 CEO statement on electronic cigarettes concluded that e-cigarettes are harmful, this guideline recommends that clinicians ask whether their patients vape e-cigarettes and advise children to not start vaping.⁵ 

A recent systematic review found that many children and adults report wanting to quit vaping and having made quit attempts, but there was considerable variation between studies and there are no results reported yet for Aboriginal and Torres Strait Islander people.²³ So far, there has been only one completed RCT of a vaping cessation intervention;²⁴ other studies have been case series or small pilot studies.²³ In the RCT, which included 2588 e-cigarette users aged 18–24 years in the US, more of the participants who were allocated to the nine weeks of tailored text messages than no treatment had successfully quit by seven months (24% versus 19%; odds ratio 1.39; P<0.001).²⁴ 

Despite the insufficient evidence, this guideline recommends that clinicians advise all adults who vape (but do not smoke) to quit vaping. Given the well-established harms of smoking, and the benefits of e-cigarettes in helping people quit smoking see Chapter 2: Healthy living and health risks, Smoking)and concerns about prolonged vaping after quitting smoking, this guideline recommends advising all adults who vape and smoke to quit smoking, and then quit vaping as soon as they can to prevent going back to smoking.⁶ 

Because the small risks of using smoking cessation pharmacotherapies (NRT, varenicline and bupropion) are greater than for advice alone, and there have been no adequate RCTs or evidence-based guidelines about their use for vaping cessation, this guideline makes no recommendations for their use in vaping cessation.⁷ Similarly, because there are no RCTs of vaping cessation support among children and insufficient evidence of smoking cessation support among children (see Chapter 2: Healthy living and health risks, Smoking), this guideline makes no recommendations about vaping cessation support among children. 

State, territory and Commonwealth governments have introduced varied and evolving legislation to restrict the sale, use and possession of e-cigarettes.² In all Australian jurisdictions, it has been illegal for minors to purchase e-cigarettes and illegal to vape in designated smoke-free areas.² These bans have not stopped the increasing prevalence of other uses of e-cigarettes, such as vaping by young people and prolonged dual use of e-cigarettes and cigarettes. In May 2023, Federal Minister for Health Mark Butler announced that the Commonwealth Government would work with states and territories to ban the sale of all e-cigarettes as consumer products, ban flavours, ban disposable e-cigarettes and ban e-cigarettes with high nicotine content, while maintaining access to e-cigarettes for those trying to quit smoking, but only on prescription in pharmaceutical-like packaging.²⁵ Community concerns about the apparent rising use of e-cigarettes, especially by children, means that legislation will continue to evolve. The Aboriginal and Torres Strait Islander Community Controlled Health Services sector should be involved in these and other public health policy discussions about e-cigarettes. 

As yet, the research evidence, mainly from the US and Canada, has found mixed impacts of these and other public health preventive measures recommended by the US Surgeon General and in this guideline.^2,4