No smoke without fire

Julia May
October 25, 2013
The Age

Electronic cigarettes are only slowly being taken up by local nicotine addicts, due to a regulatory minefield, and scant – and fiercely contested – evidence about their potential health effects.

Hazy issue: e-cigarettes. Photo: Bloomberg
The website is enticing, evoking a golden age of Marlboro Men and Virginia Slim girls. ”We’re about the adventure of living. We’re the end of compromise and the beginning of being alive.” Veppo, the US-based electronic cigarette and cigar company with this slick website, also ships to Australia, reassuring the ”People of Oz” that it’s legal to do so.
Veppo is just one of many overseas companies supplying Australian nicotine e-cigarette users, or ”vapers” (the electronic inhalers generally simulate tobacco smoking by releasing a cloud of vapour), with the batteries, heating elements, liquid nicotine and flavours that they need. These companies are picking up trade where Australian companies can’t because while it’s legal for individuals to import nicotine e-cigarettes from overseas, it’s illegal to sell them in Australia.
Worldwide sales of e-cigarettes are approaching $US2 billion this year and are forecast to top $10 billion by 2017, according to Wells Fargo & Co. While there are no national statistics on the local e-cigarette market or take up, it’s clear that Australian uptake of vaping has been comparatively low.

Illustration by Matt Davidson.
Between 1-2 per cent of Victoria’s 650,000 smokers have tried it, according to the Victorian Smoking and Health survey. But the e-cigarette users that Fairfax Media spoke to, via the 5500-strong Aussie Vapers web forum, are passionate advocates. Most say they tried e-cigarettes to kick conventional cigarettes after failing with other methods, and vaping has enabled them to quit tobacco once and for all. They are adamant e-cigarettes pose fewer health risks than cigarettes, providing many examples of health improvements since quitting cigarettes and taking up vaping.

They question why, from a public health perspective, e-cigarettes should not be freely available just as cigarettes are – not to mention nicotine patches, inhalers and other cessation aids.
Public enemy number one for the vaping community is Simon Chapman, professor of public health at Sydney University and a prominent tobacco control activist. He believes if nicotine e-cigarettes were to become freely available, smoking, which has become socially unappealing, would become ”renormalised”, undoing all the good work done on its reduction. His concern lies particularly with young people – to whom vaping, with its colourful paraphernalia and tasty flavours, has been shown to appeal. Fiona Sharkie, executive director for Quit Victoria, shares Chapman’s anxieties.

Advertisements for electronic cigarettes bear an uncanny resemblance to the famous cigarette ads of the past.
It’s legal for Australian retailers in some states to sell e-cigarette flavours (”e-juice”, which comes in small, attractive vials). But they can’t contain nicotine, only flavours, which range from spices and fruit to cocktails and desserts. On Wednesday, however, the NSW department of health issued a safety warning, saying that 70 per cent of samples tested contained ”high levels” of nicotine, suggesting there is an active black market in Australia. If ingested, these could be lethal. NSW chief health officer Kerry Chant warned that ”children may find the contents of the liquids enticing”, and that there had been reports of harm to children ingesting the liquid in Australia and a death reported overseas.
One vaper, Mary Gordon, says: ”The fact that there is a black market [in Australia] at all just proves that many people would prefer to buy locally from tobacconists and market stalls and not go online to import it from overseas, which is legal but requires a lot of information gathering.”
Another vaper, ”Marty”, says it’s very hard to buy quality nicotine liquids in Australia, which is why many vapers buy in bulk from overseas. He keeps his in a padlocked refrigerator in a locked room. ”I have taught the children in my family to stay away from my [e-cigarettes] and bottles, and even at a very young age of two, they were able to comprehend that my vaping products were ‘yucky medicine’,” he says. ”However, I still worry about this all the time.” It is outrageous, he says, that the Australian government does not allow stable, quality nicotine e-cigarettes to be sold here. ”I am having to choose between my health and the safety of [my] children.”
The government, some researchers and anti-smoking advocates agree there is not enough proof e-cigarettes are safe long-term and an effective cessation tool. A spokesman for the federal Department of Health says: ”The impact of wide-scale use of these devices on tobacco use generally is not known, and the outcome on the community could be harmful.” He says the Therapeutic Goods Administration has not evaluated them as safe nor effective, and e-cigarette manufacturers have not provided evidence they are.
The research that is available is counter-interpreted by those on both sides of the vaping fence; indeed the conclusions of one of the most cited pieces of research, a survey of 6000 cigarette smokers in the US, UK, Canada and Australia, are interpreted differently by Chapman and Konstantinos Farsalinos, a research fellow at the Onassis Cardiac Centre, Athens.
Farsalinos says: ”Every e-cigarette opponent is falsely using this study to make the misleading conclusion that e-cigarettes did not help in quitting. The study did not evaluate the effectiveness of e-cigarettes in smoking cessation because it was not designed for that,” he said. But he quotes the conclusion in the study’s abstract that ”[e-cigarettes] may have the potential to serve as a cessation aid”. Chapman, however, points to the text of the paper, which says that ”only 11 per cent of current [e-cigarette] users reported having quit” over a given period. ”The legendary perils of only reading the abstract,” he says.
Farsalinos revealed to Fairfax Media this week the preliminary – and as yet not peer-reviewed – results of the largest global survey of vapers. His online survey, of 19,500 e-cigarette users who were motivated to quit, was designed to study the characteristics, patterns of use, reported benefits and side-effects of e-cigarettes, not cessation rates, but it did find that a staggering 81 per cent had quit tobacco altogether – with the median time since the last cigarette being seven months. The remaining 19 per cent reported reducing their tobacco consumption from 20 cigarettes per day to a median four. Farsalinos openly admits the study was funded by an e-cigarette advocacy group, with contributions from manufacturers. He says the cessation results cannot be extrapolated to the broader community, because it was self-selecting rather than randomised. But he argues: ”[Saying] e-cigarettes are ineffective is a denial of reality. Hundreds of thousands of smokers or more, from all over the world, have quit smoking with the use of e-cigarettes.”
Chapman says studying people who have quit tobacco using e-cigarettes needs to be done using controlled – randomised – cohorts rather than self-selecting groups. He also questioned how respondents were recruited: ”If through vaping blogs, this is like surveying people who belong to whisky on-line discussion groups and pretending that they are representative of everyone who has a bottle of Scotch in their drinks cabinet.”
Quit doesn’t count someone as having stopped smoking until they have ceased for a year. Sharkie points to a New Zealand study that found vaping was only marginally more helpful – at 7 per cent – than nicotine patches in helping people to quit.
She worries about the lack of evidence about long-term effects of the chemical interaction of nicotine and flavoured liquids, recalling the introduction of low-tar ”Light” and ”Mild” cigarettes. ”We all thought ‘This is going to be safer,’ but it turned out not to be safe. We started to see new diseases such as lower lung cancers because people were dragging more heavily,” she says.
Chapman is also concerned that vaping enables smokers to get a nicotine hit in places where they can’t smoke: ”Most people don’t quit; they use both.”
But these arguments, and many others, are wasted on committed vapers, for whom the proof is in the puffing. As Gordon says, ”Going from e-cigs to cigarettes would be like going from Kool Mints to mothballs.”

Vaping is addict’s lesser of two evils

Margie Boyd, from Hobart, started smoking at 17. Forty years later and smoking 35 cigarettes a day, an MRI scan for a broken rib showed up emphysema.
Boyd, now 60, says, ”I had to stop smoking. I was coughing all the time and having trouble breathing.” She had tried to quit before, using patches, gum and inhalers without success.
Boyd imported e-cigarettes and liquid nicotine from the US and bought flavours online in Australia, receiving advice from the AussieVapers forum on mixing her own. She managed to kick cigarettes and has relapsed once, when a family member was hospitalised last year. ”I picked up three cigarettes, had them and thought ”Yuck. This is ridiculous.” She hasn’t smoked since.
Three years after starting vaping, though still on emphysema medication, Boyd’s breathing has improved – no wheezing, coughing or ventolin inhaler. She concedes a lack of information exists on vaping risks, but believes cigarettes are more dangerous.
”You know you’re not getting the tar and the 4000 chemicals. You might be getting trace amounts of carcinogens [in vaping], we don’t know yet. But I’d much rather take the risk and vape than smoke again.”
(Tests on two e-cigarette brands by the US Food and Drug Administration found detectable carcinogens and toxic chemicals in e-cigarettes, but other studies found them to be at lower levels than cigarettes.)
Boyd and another forum member have met independent MP Andrew Wilkie, to discuss vaping and users’ concerns about its regulation . She said he ”saw the ridiculousness in something being legal to consume but not legal to sell”. Boyd believes vaping has given her longer to live. ”I just hope I live long enough to see results of all the vaping research.”
Julia May is a Melbourne writer. Twitter: @juliacmaybe

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