Unless we act now – urgently – to enforce regulations designed to support access to prescription e-cigarettes, we will fail to protect the health of current and future generations of Australians.
IN June 2022, the National Health and Medical Research Council (NHMRC) published an updated review of evidence concluding that people who do not smoke but use e-cigarettes are more likely to start smoking than people who neither smoke nor do not vape. A review of the evidence by the Australian National University, commissioned by the Australian government and published in April 2022, came to the same conclusion.
The health risk presented by e-cigarettes is not only an increased propensity to start smoking. NHMRC’s evidence review found that e-cigarette aerosols contain dozens of chemicals known or suspected to be harmful when inhaled, causing irreversible lung damage (e.g. diacetyl, acetoin and acetyl propionyl) and organ damage with prolonged exposure (eg, manganese and nickel) . Twenty chemicals, including acrolein, formaldehyde, mercury, benzene, toluene and cadmium, have been detected which are harmful if inhaled and have the potential to be fatal.
Another very recent study, which did not attract media attention in Australia, was conducted by the American Heart Association and specifically assessed cardiopulmonary risks for adolescents. The authors concluded that teens who vape, like teens who smoke, are likely to have lower lung function and be particularly vulnerable to any additional lung damage, such as asthma or pneumonia. Similarly, the authors concluded that it is very likely that adolescents who vape, like those who smoke, will be at increased risk of cardiovascular disease in later years due to damage to endovascular and myocardial cells.
Since October 2021, Australia has adopted a prescription model for e-cigarettes containing nicotine. The approach aimed to limit the use of e-cigarettes by children and to provide adults, with guidance from a healthcare professional, with a pathway to use e-cigarettes as part of a structured attempt at smoking cessation. . The Royal Australian College of General Practitioner’s Smoking Cessation Guidelines 2021 update recommends nicotine-containing e-cigarettes as “second-line treatment” for use when all other Therapeutic Goods Administration (TGA)-approved drug therapies have failed.
However, an investigation by the ABC program Four corners (Vape Haze, aired June 27, 2022) showed just how much e-cigarette importers and retailers are breaking the law. Essentially, e-cigarettes containing nicotine are highly accessible because individual entrepreneurs and businesses can import them easily and retailers feel able to stock and sell them with impunity. Combine great accessibility with appealing flavors and online marketing aimed at kids, and it’s no wonder kids (and young adults) are getting addicted to nicotine-containing e-cigarettes.
In theory, the prescribing model in Australia should work like this: liquid nicotine is a Schedule 4 drug and therefore e-cigarettes containing nicotine, or Electronic Nicotine Delivery Systems (ENDS), will not should only be imported or sold by a national pharmacy with a valid prescription. ENDS is not expected to be available in a consumer market.
Basically, however, the prescription model is not applied. The Australian Border Force is failing to stop the importation of hundreds of thousands of ENDS, especially cheap disposable devices, that end up in schoolyards. Enforcement of retail law is complicated because jurisdictional drug and poison laws, which govern the enforcement of Schedule 4 drugs, and tobacco legislation, which governs advertising and sale of tobacco products, but not Schedule 4 drugs, apply to ENDS. Not all states and territories have a clear path to enforcing the illegal sale of ENDS at convenience stores, gas stations, and tobacconists.
E-cigarettes that do not contain nicotine or electronic nicotine-free delivery systems (ENNDS) hamper all law enforcement efforts. ENNDS are legal as a consumer product, but may not be sold to children in all states except Western Australia, where they are banned outright because they look like a product from the tobacco. Since ENNDS and ENDS are identical in appearance, importers and retailers can simply claim that their products are legal ENNDS (associated with deliberate mislabeling of devices), not illegal ENDS, and – unless they seize and to destroy the goods to test the nicotine in a laboratory – the authorities have no way of disproving this assertion.
There are multiple consequences of not applying the prescription model. By far the most important is the growing adoption of vaping by children and the public health tragedy that portends. Other consequences relate to minimizing the known harms of e-cigarette use and maximizing the potential benefits of quitting smoking.
First, the illegal consumer market is detrimental to therapeutic use by those likely to benefit from it. Second, there is no commercial incentive for an ENDS manufacturer to submit their product for TGA approval, which would reduce a key medical-legal concern for GPs and pharmacists. Third, none of the e-cigarettes sold illegally meet the very minimum safety standards set out in the TGA’s Therapeutic Goods Ordinance (TGO 110) for prescribed “nicotine vaping products” available for sale in Australian pharmacies. . The lack of child-resistant packaging, coupled with deliberately mislabeled ENDS, is of particular concern given the risk of nicotine poisoning in children.
There is another important consequence of not applying the prescription model as a matter of critical urgency. The longer we wait before taking strong action to prevent the sale of illegal e-cigarette products, the harder it will be for governments to resist the continued efforts of those with commercial interests to undo the creation of sound public policy.
All signs point to the creation and use of a “regulations impact small business” strategy used deliberately (again) by Big Tobacco. Several retail associations and pressure groups are already funded by the tobacco industry to lobby politicians. These groups are now cynically calling for “regulation to protect children,” but their idea of “regulation” is to abandon the prescription model and make ENDS available as a consumer product.
We made that mistake with cigarettes in the 1920s; we’ve surely learned enough not to make that mistake again in the 2020s. Unless we act now – urgently – to enforce regulations designed to support access to prescription e-cigarettes, we will fail not protect the health of current and future generations of Australians.
|Three steps that would simplify and strengthen the app to support the Australian prescribing model:
Dr. Sandro Demaio is the CEO of VicHealth. He is a world-renowned physician and public health expert and advocate. Previously CEO of the EAT Foundation, the global science hub for food systems transformation, Dr. Demaio also served as the Medical Officer in Charge of Non-Communicable Diseases and Nutrition at the World Health Organization.
Todd Harper is the CEO of Cancer Council Victoria. Todd is a board member and past president of the Geneva-based NCD Alliance.
Dr Sarah White is the director of Quit Victoria. She had been director of communications and fundraising at the Royal Women’s Hospital in Melbourne. Previously, Dr. White spent seven years directing communications at the Ludwig Institute for Cancer Research, an international research institute based in New York.
Statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of WADA, the MJA Where Preview+ unless otherwise stated.
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