E-Cigarettes - AMA takes on big tobacco and the vaperatti | AMA (WA)


Person vaping

E-Cigarettes – AMA takes on big tobacco and the vaperatti

Thursday December 20, 2018

The past year has seen numerous blows to the case for e-cigarettes, despite mounting pressure from vaping advocates to relax Australian legislation around the products.

The debate is surprisingly polarising, with mudslinging and personal attacks commonplace in forums such as Twitter.

The tobacco industry, along with “grassroots” campaigners, continue to apply pressure to state and federal governments to legalise and promote vaping.

Consistent and intense lobbying gets results. Despite two parliamentary inquiries in as many years concluding that Australia’s precautionary approach to e-cigarettes is appropriate – and the declaration that legalisation of e-cigarettes would not happen on his watch, Federal Health
Minister the Hon. Greg Hunt announced a further inquiry into the health impacts of nicotine e-cigarettes.

Standing firm are Australia’s leading independent health bodies, including the AMA, National Health and Medical Research
Council (NHMRC), the Therapeutic Goods Administration (TGA), the Heart Foundation and the Cancer Council.

In the July edition of Medicus, AMA (WA)’s Policy and Research Lead – Clinical, Dr Katharine Noonan wrote about
the toxic friendship between big tobacco and the medical profession. The article called out e-cigarette companies
for targeting youth with overly sexualised and glamorous advertising. It also pointed out how “well-meaning physicians
and leaders who desperately want to improve the health of their patients” were falling into big tobacco’s “trap”.

The article fuelled debate on 6PR talkback radio with Dr Joe Kosterich, one of the doctors named in Dr Noonan’s article,
vigorously defending his stance on e-cigarettes.

In October, the AMA (WA) wrote to all West Australian Federal parliamentarians, urging them to consider the evidence
around e-cigarettes, including a recent comprehensive, independent review by CSIRO and emerging research from the US.

Sharing our media release about the letter on Twitter garnered a lot of debate, reaching just under 5,000 people. It also
drew a number of negative comments from the usual anti-public health dinosaurs who chose to attack the AMA for its
unwavering approach.

For the AMA, however, evidence-based research will always win over unscientific arguments founded in ignorance.


Perhaps most damning is the consistent finding that e-cigarettes are both being taken up at epidemic rates by youth, and serve as a gateway to conventional cigarette smoking.

FDA Commissioner Scott Gottlieb has referred to the “public health tragedy” that they have created for themselves in the
US, and the benefits of policies which we have in place in Australia.

Between 2017 and 2018, there was a 78 per cent increase of e-cigarette use among high school students, as well as a 48 per cent increase in middle school students to a total of 3.6 million students. In the same time period, use of any tobacco product among high school students increased from 19.6 per cent to 27.1 per cent. This has reversed the decline taking place in the US in recent years.

The evidence is now unmistakably clear that youth e-cigarette use leads to smoking, particularly in adolescents who are low-risk for taking up the habit. There are now threats by the FDA to pull e-cigarettes off the US market if the astonishing surge in teen use doesn’t slow.

Expressions of concern about young people from Juul and other manufacturers mean little – they will continue selling and promoting their products. Industry marketing that appeals to children provokes strong reactions. It also creates the impression that we must choose between protecting kids and the health of adults.

Research around the harms of e-cigarettes continues to emerge, disputing the oft cited “95 per cent safer than cigarettes” figure. This estimate, which is in reality little more than a best guess put forward by a UK vaping advocate, has had so many holes poked in it that it is now threadbare.

The CSIRO review concluded that available evidence suggests regular use of e-cigarettes is likely to have adverse health consequences. There is a lack of clarity about the magnitude of health harms and the quantity of e-cigarette use required to trigger them.

Higher cessation rates through the use of e-cigarettes are not a given. Evidence on population-level cessation benefits for e-cigarettes remains speculative, and in fact suggest that they may suppress quitting. While many smokers and former smokers state a preference for e-cigarettes as a smoking cessation method, the effectiveness of this method compared with other smoking cessation methods is not known.

Additionally, the health benefit can come only if a smoker switches completely from cigarettes to a nicotine replacement device. In many countries where appropriate evidence is available, it appears that e-cigarette use occurs at the same time as cigarette use (‘dual use’).

The 2018 National Academy of Sciences report concludes that it is currently unknown whether e-cigarettes have an overall positive or negative impact on public health. Whether or not the end result is good or harmful for public health depends on more than whether the product is less harmful than a cigarette.

Why don’t we have more answers? Electronic Nicotine Delivery Systems (ENDS) are not a homogenous product, but rather a category of products, making it difficult to conduct rigorous scientific studies. Additionally, the differences in cultures, policies and industry behaviour between countries are often complex.

At the same time, we have seen in Australia and overseas that passions dominate data. No one ever changes their position based on new research.

In order to defend a previous position, we have seen scientific uncertainty and the undeniable impact of marketing be flatly ignored. This is not fundamentally a debate about whether harm reduction is good or bad – it is about how to maximise the benefits and minimise the risks, in order to protect public health.