The Senate has established a Select Committee on Tobacco Harm Reduction, the latest in a series of parliamentary and other inquiries.
The Select Committee will inquire (quickly) into tobacco reduction strategies, with particular reference to:
- the treatment of nicotine vaping products (electronic cigarettes and smokeless tobacco) in developed countries similar to Australia (such as the United Kingdom, New Zealand, the European Union and United States), including but not limited to legislative and regulatory frameworks;
- the impact nicotine vaping products have had on smoking rates in these countries, and the aggregate population health impacts of these changes in nicotine consumption;
- the established evidence on the effectiveness of e-cigarettes as a smoking cessation treatment;
- the established evidence on the uptake of e-cigarettes amongst non- smokers and the potential gateway effect onto traditional tobacco products;
- evidence of the impact of legalising nicotine vaping products on youth smoking and vaping rates and measures that Australia could adopt to minimise youth smoking and vaping;
- access to e-cigarette products under Australia’s current regulatory frameworks;
- tobacco industry involvement in the selling and marketing of e-cigarettes; and
- any other related matter.
inquire into and report on the use and marketing of electronic cigarettes (E-cigarettes) and personal vaporisers in Australia, in particular:
1. The use and marketing of E-cigarettes and personal vaporisers to assist people to quit smoking;
2. The health impacts of the use of E-cigarettes and personal vaporisers;
3. International approaches to legislating and regulating the use of E-cigarettes and personal vaporisers;
4. The appropriate regulatory framework for E-cigarettes and personal vaporisers in Australia; and
5. Any other related matter.
1 that the National Health and Medical Research Council fund an independent and comprehensive review of the evidence relating to the health impacts of electronic cigarettes (E-cigarettes). This review should be updated every two years to take into account the findings of new research into E-cigarettes. Topics covered by the review should include:
- The effectiveness of E-cigarettes as an aid to help people quit smoking tobacco cigarettes;
- The health effects of ingredients commonly used in E-cigarette liquids. Following the review, any ingredients found to have significant negative impacts on human health should be prohibited from use in E-cigarette liquids;
- The likelihood that E-cigarettes will increase the number of young people using nicotine and the number of young people smoking;
- The health impacts of long term E-cigarette use;
- The relative health impacts of E-cigarettes as compared to tobacco products.
2 that the Department of Health convenes an international meeting of health experts from similar economic jurisdictions to discuss different policy and legislative approaches to electronic cigarettes.
3 a national approach be taken to the regulation of non-nicotine electronic cigarettes.
4 that the Therapeutic Goods Administration continues to oversee the classification of nicotine and relevant exemptions, and the assessment of any electronic cigarette product as a therapeutic good.
5 that the Australian Government establish a regulatory process for assessing and, if necessary, restricting colourings and flavourings used in electronic cigarettes.
Last month's ANU 'Summary report on use of e-cigarettes and relation to tobacco smoking uptake and cessation, relevant to the Australian context' by Emily Banks, Katie Beckwith and Grace Joshy (National Centre for Epidemiology and Population Health) for the Australian Department of Health) draws on the following reports:
1. Review of smoking prevalence and trends in Australia 2. Review of smoking prevalence and trends in the Aboriginal and Torres Strait Islander population 3. Review of evidence regarding changes in smoking behaviour with decreasing smoking prevalence, including that relating to the “hardening hypothesis” 4. Review of the patterns of e-cigarettes use 5. Systematic review of evidence regarding combustible smoking uptake in relation to e-cigarette use; and 6. Systematic review of evidence regarding the efficacy of e-cigarettes for combustible tobacco or nicotine cessation.
The authors state
Despite world-leading tobacco control, smoking remains Australia’s leading cause of preventable disease and death, including for Aboriginal and Torres Strait Islander peoples. In many countries, e-cigarettes are explicitly or implicitly marketed as aids to smoking cessation and, among e-cigarette users, smoking cessation is a commonly reported reason for use. However, the substantial majority of smokers who quit successfully do so unaided and no e-cigarette products have been approved by the Australian Therapeutic Goods Administration as smoking cessation aids; the situation is similar in many other countries. In the context of the exceptional harms of combustible tobacco use and the current promotion of e-cigarettes it is important to review the current relevant evidence on e-cigarettes and smoking behaviour, to support informed decision-making.
The key findings are -
Smoking prevalence and trends in Australia
• From the 2019 National Drug Strategy Household Survey, 11.0% of people aged 14 and over in Australia were current daily smokers (equivalent to 2.3M people): a statistically significant drop from 12.2% in 2016, and following sustained reductions in smoking prevalence over recent decades. These falls were largely driven by younger people not taking up smoking.
• The proportion of never smokers has increased over time, in adults and particularly among youth in Australia. 96.6% of youth aged 14-17 in 2019 had never smoked, with youth never-smoking prevalence increasing five-fold between 2001 and 2016.
• The majority of Aboriginal and Torres Strait Islander people do not smoke. The prevalence of current daily smoking was 40.2% in 2018/19 in Aboriginal and Torres Strait Islander adults, following substantial and significant reductions over the past decade, particularly in major cities and regional areas and among younger adults and among youth.
“Softening” of the Australian smoking population over time
• Based on published reviews and large-scale repeat cross-sectional studies from Australia and similar high-income countries, declining smoking prevalence has generally been accompanied by increasing motivation to quit, reduced dependency and greater quit rates among smokers.
• In 2010, an estimated 2.0% of the general population of Australia aged 18 and over were smokers who were unmotivated to quit and had difficulty quitting.
• Based on the weight of the available evidence from Australian and similar high-income countries, the “hardening hypothesis” – proposing increasing difficulty quitting among the population of smokers as smoking prevalence declines – can be rejected. This concept should be replaced by the evidence- based conclusion that declining smoking prevalence is accompanied by “softening” of the smoking population, whereby smokers are, on average, more readily able to quit.
Patterns of use of e-cigarettes
• The prevalence of e-cigarette use varies widely between countries and has increased substantially in many countries over the past decade, particularly among young people. In countries where e- cigarettes are available as consumer goods, such as the United States, use is becoming common, particularly among youth, with recent data indicating 10-20% of US high school children report recent use of e-cigarettes.
• Among people in Australia aged 14 years and over in 2019, 11% had ever used e-cigarettes, most of whom (60%) reported using e-cigarettes once or twice only; 2.0% (equivalent to 412,000 people) reported current use (daily, weekly or monthly) and 1.1% (equivalent to 227,000 people) reported daily use, according to the 2019 National Drug Strategy Household Survey. Use has increased significantly over the last six years.
• Among people in Australia aged 14 years and over in 2016, 0.5% were estimated to be dual current users of e-cigarettes and combustible cigarettes, and 0.2% dual daily users; current e-cigarette use was reported by 4.4% of current combustible cigarette smokers, 1.5% using e-cigarettes daily.
• Population patterns consistent with short-term use of e-cigarettes for smoking cessation would predominantly include past use of e-cigarettes in ex-smokers, little ongoing use in current smokers and virtually no use in never-smokers.
• However, among current daily e-cigarettes users in 2016, 32% were also daily smokers, 11% were non-daily smokers, 38% were ex-smokers and 18% were never-smokers. Hence, an estimated 43% of daily e-cigarette users in Australia in 2016 were dual e-cigarette users and combustible tobacco smokers. In 2019, 1.9% of ex-smokers reported past use of e-cigarettes and 5.2% of never-smokers reported ever using e-cigarettes.
E-cigarette use in never- and former-smokers, and combustible tobacco smoking uptake
• Observational evidence from three systematic reviews and 25 primary research studies was included.
• A meta-analysis of data from these studies showed that never smokers who have used e-cigarettes were, on average, around three times as likely as those who have not used e-cigarettes to try smoking conventional cigarettes and transition to regular tobacco smoking. All studies found evidence of an increased risk, with wide variation in the magnitude of this risk.
• Where evidence on nicotine content was available, it indicated that a substantial majority of e- cigarettes in these studies delivered nicotine.
• The studies reviewed were observational in nature as it is not ethical or appropriate to randomise non-smokers to e-cigarette exposure. The quality of the evidence from the reviews and primary research studies was rated moderate overall.
• The limited available evidence indicates that former smokers who had used e-cigarettes were around twice as likely to relapse and resume current smoking as those who had not used e-cigarettes.
The efficacy of nicotine-delivering e-cigarettes as an aid to smoking or nicotine cessation
• Reliable evidence on the efficacy of use of e-cigarettes for smoking cessation requires large-scale, independent randomised controlled trial (RCT) evidence from multiple studies.
• The randomised controlled trials identified found no significant difference in quit rates between smokers randomised to nicotine-delivering e-cigarettes versus no intervention or non-nicotine e- cigarettes, although point estimates of risk ratios were all above 1.00.
• Of the four trials of nicotine-delivering e-cigarettes versus other nicotine-replacement therapy identified, three found no statistically significant difference in smoking cessation between the groups and one found significantly greater cessation with nicotine-containing e-cigarettes than with other nicotine-replacement therapy.
• Data derived from three RCTs suggest that smokers randomised to nicotine-containing e-cigarettes versus other types of nicotine-replacement therapy were substantially more likely to be using any form of nicotine (i.e. e-cigarettes or nicotine-replacement therapy) at follow up. One study found that around 80% of successful quitters randomised to e-cigarettes continued to use them at one- year follow up while 9.0% of those randomised to other nicotine-replacement continued to use it.
• The overall quality of the evidence was rated as low and uncertain: the few RCTs conducted were generally small, employed a wide range of study designs across diverse settings and the majority had methodological issues indicating a high risk of bias.
• Overall, there is insufficient evidence that nicotine-delivering e-cigarettes are efficacious for smoking cessation, compared to no intervention, placebo existing nicotine-replacement therapy or other best-practice interventions. However, preliminary evidence highlights the potential for nicotine-delivering e-cigarettes to support cessation, and more reliable, large-scale evidence is needed.