When cancer biologist Miranda Ween spoke at a medical conference in Canberra earlier this year about her research investigating the effect of electronic cigarette vapour on the lungs, she put up a poster at the venue showing how e-cigarette flavourings could harm cells in the airways.
She later found the poster vandalised and on the floor.
Even roomfuls of health experts at medical conferences are divided over whether e-cigarettes and vaping products are useful aids to quit smoking or a potentially harmful and new means for big tobacco to try to remain profitable and keep people smoking in countries with tightening tobacco control policies.
Many e-cigarette brands are owned by tobacco companies, making the device the last hope for tobacco giants trying to remain profitable and relevant in Australia, which has some of the toughest tobacco control policies in the world.
When the evidence began to filter in showing the significant harm caused by smoking, it pitted health experts firmly in one camp, staring down the tobacco giants. E-cigarettes, however, have left these same experts and peak health bodies in disagreement about what approach the regulators should take.
Debate falls into two main camps: those who advocate a harm-reduction approach and say any product that is safer than cigarettes and can help even small numbers of people quit should be readily available; and those who say there is not enough long-term evidence about the safety of e-cigarettes, and the involvement of big tobacco is a cause for serious concern.
Ween, a researcher with the University of Adelaide, falls in the latter group. “Our work, and that of others around the globe, is starting to show that the flavours in e-cigarettes can be harmful as well as the nicotine. The flavours used are food-safe, but have not been tested once superheated and vaporised and inhaled into the lungs,” she says.
“The biggest issue is that we have no idea of what damage long-term use could do. It took decades to realise cigarettes caused cancer, and longer still to get that message to those using them. We don’t want to repeat the same mistakes again. We need more research, and no one should be declaring them ‘harmless’.”
E-cigarettes convert a liquid, often flavoured and containing nicotine, into vapour. They are safer than cigarettes, though how much safer is unclear because they haven’t been around long enough. A statistic often cited is they are 95% safer than cigarettes, but this has been disputed. Being battery-powered, e-cigarettes do not omit the harmful byproducts carried in smoke; and they are devoid of many of the poisons found in cigarettes.
The question of whether vaping products containing nicotine should be available for sale in Australia is being examined through the government’s parliamentary inquiry. People who “vape” are largely forced to import vaping products containing nicotine. The scientific evidence about the harms of the products and their efficacy as an aid to quitting is often confusing, contradictory and limited in scope. No electronic cigarette product has been approved by the Therapeutic Goods Administration, the Australian government’s regulator.
There are smokers who credit e-cigarettes with having help them quit. The scientific literature, however, suggests they are not all that effective, and the Australian Medical Association says the evidence is not significant enough to suggest e-cigarettes are successful in helping people quit smoking long term.
Dr Alex Wodak, the president of the Australian Drug Law Reform Foundation, says while the evidence is still building about the efficacy of e-cigarettes, “we know for certain that cigarettes are responsible for 15,000 deaths per year in Australia, that up to two out of three smokers will die of a tobacco-related condition and that the dangerous part of smoking is inhaling smoke from burning tobacco and that the risks of nicotine are modest”.
“It’s true we don’t know the risk of e-cigarettes to two decimal places but we know enough to be certain that the risks are much less than tobacco,” he says.
“As with all toxins, the dose is critical. The risks of nicotine in the doses ingested with e-cigarettes are small, and certainly much much less than the risks associated with inhaling tobacco smoke.”
But Becky Freeman, a tobacco control expert at the University of Sydney, says supporting e-cigarettes with the current evidence is irresponsible. “We shouldn’t treat smokers as guinea pigs,” she says, adding that public health experts with little experience in the area of tobacco control have “hijacked” the debate around e-cigarettes and are making untested claims around their safety.
“We have no long-term evidence for the safety of e-cigarettes or their efficacy as quit aids,” she says. “The threshold for whether these products are safe is always about how they fare in comparison to cigarettes. But I can’t think of anything more harmful to human health than cigarettes, so that’s a pretty low bar.”
Freeman doesn’t dispute e-cigarettes are safer than tobacco. But there is emerging evidence about the harms caused by nicotine. In February, the Therapeutic Goods Administration said it would maintain its ban on the sale of nicotine-containing e-cigarettes because of fears the products may normalise smoking, and concern about the long-term harm of nicotine.
A study published in the medical journal Frontiers of Oncology says: “The role of nicotine as the major addictive component of tobacco products may have distracted our attention from toxicological effects on cell growth, angiogenesis, and tumour malignancy.”
The study found: “Effects on cancer disease are important aspects in the evaluation of possible long-term effects from sources of nicotine, such as e-cigarettes and products for nicotine replacement therapy, which both have a potential for lifelong use.”
But tobacco companies insist they have public health in mind in the sale and promotion of e-cigarettes. In its submission to the e-cigarette inquiry, tobacco giant Philip Morris International says it has a vision for a “smoke-free future”.
“To improve public health, smokers who do not quit should be encouraged to switch to smoke-free alternatives such as electronic cigarettes and personal vaporisers,” the submission says. “Our vision and commitment … are leading the drive toward a smoke-free future, where smoke-free products will replace cigarettes.”
The company says it invested nearly $4bn in developing and testing products that deliver nicotine without the harmful smoke of cigarettes, employing more than 400 scientists, engineers and technicians to do so.
But Freeman believes e-cigarettes are part of a ploy by tobacco companies to get children used to the idea of smoking in a country that has plain-packaging laws, ever-rising cigarette prices and outdoor smoking bans in a growing number of premises.
In her submission to the government’s e-cigarette inquiry, Freeman described how one online Australian retailer, Vapeking, “uses juvenile cartoon imagery on its website to promote flavours such as sunrise and wicked watermelon”. Another flavour is promoted by encouraging customers to “wake up to the taste of sweetened condensed milk, dried red berries and a healthy serving of sweet honey coated cereal”.
In its submission to the parliamentary inquiry, Cancer Council Australia included evidence from a meta-analysis of nine studies tracking 17,389 people aged 14 to 30, published in the Journal of the American Medical Association’s Paediatrics. The study found initial e-cigarette users are more than three times more likely than non-e-cigarette users to subsequently become tobacco smokers. The Australian Medical Association, the peak medical body for doctors, is also worried about e-cigarettes, saying that the growth in e-cigarette products internationally has provided sections of the tobacco industry with the opportunity to rebrand themselves as part of the effort to reduce smoking despite there being no evidence that e-cigarettes work as a deterrent.
But Dr Colin Mendelsohn, a tobacco treatment specialist, says if big tobacco wants to be a part of the solution, health experts should let it. Tobacco companies are beholden to shareholders and can’t simply withdraw cigarettes from sale overnight, he says.
“E-cigarettes are not some big tobacco conspiracy,” he says. He believes experts such as Freeman are basing their arguments on ideology and values rather than evidence because they have become accustomed to fighting tobacco firms on conventional cigarettes. He says it is true there is no “perfect data” on the harms of e-cigarettes, but adds “we never know what will happen long term for any new drug”.
“You have to make decisions on what evidence you have at the time,” Mendelsohn says. “I’m more than comfortable recommending e-cigarettes to people from what we know already about the vapour and the toxicology. No one is saying vaping is harmless, and nothing is as good as fresh air. But we can’t leave smokers who can’t quit to die while we wait for more evidence.
“The problem at the moment is we have no regulations so we have a black market supplying these products and people are mixing them at home, sometimes with high concentrations of nicotine.”
Wodak agrees, saying he would rather “the tobacco industry continues to make huge profits from selling a nicotine product that is 5% as harmful as tobacco rather than making its huge profits selling a product that kills up to two-thirds of its customers”.
But world-renowned tobacco control expert Prof Simon Chapman says there is little evidence big tobacco genuinely wants to be part of the solution. Tobacco companies vigorously oppose any attempts to reduce tobacco sales including fighting plain-packaging, which he says should cause people to view their smoke-free commitment with scepticism.
“I would say there is a conspiracy to get people to smoke and that’s because if you look at where big tobacco companies get their income, they get nearly all of it from the sale of cigarettes,” Chapman says.
He adds that cigarette companies are still pushing their products in developing countries where plain-packaging laws and high prices are not in place, and have not set a deadline for a smoke-free world and removing tobacco from the shelves.
“All big tobacco is doing is stopping or challenging any policy that has any chance of reducing cigarette sales,” Chapman says. “They vigorously opposed plain packaging and price rises.”
The emails Chapman receives in response to these views reveals how vicious the debate can become. An email he received this week describes him as “dumb as a rock” and “one disgusting and deplorable individual”.
A study led by Prof Robert West from University College London and published in the British Medical Journal found e-cigarettes may have helped about 18,000 people in England give up smoking in 2015, out of the estimated 2.8 million people in the UK estimated to use e-cigarettes.
“That’s a trivial number,” Chapman says. “Those number are not a game-changer. We hear people saying they’re as good as other nicotine-replacement products, but if you take 100 people who use a nicotine-replacement product [such as gum or patches], one year later, only 5% of them will be off cigarettes completely.” He adds that while some people may have quit, e-cigarettes may have led others to continue smoking, unable to quit fully.
Wodak disagrees that these numbers of quitters are trivial. In his submission to the e-cigarette inquiry, he wrote that anti-smoking policy should be strengthened to nudge people towards choosing e-cigarettes instead of continuing to smoke tobacco.
“The inappropriate scheduling of nicotine as a controlled poison stands in the way of more widespread use of e-cigarettes,” he said in his submission.
“Furthermore, electronic cigarettes that do not contain nicotine are unlikely to help people completely abstain from smoking tobacco. E-cigarettes should be regarded as a consumer device and regulated accordingly rather than as a therapeutic intervention regulated by the Therapeutic Goods Administration.”
There is no doubt e-cigarette companies and the evidence they present should be viewed with a healthy degree of scepticism. Two years ago the Australian Competition and Consumer Commission became the first regulator in the world to successfully take legal action against e-cigarette companies for making false and misleading claims about the carcinogens in their products. The companies falsely claimed their products did not contain harmful carcinogens and toxins.
The question of how harmful these products are and whether they can save significant numbers of smokers from a lifelong addiction may still be up for debate. But there is no doubt if the products take off in Australia and become more widely available, big tobacco’s under-pressure profit margins will have some relief.