The growing use of e-cigarettes, or vaping, in Australia poses a "serious public health risk" and threatens to introduce a new generation to smoking.
That's according to the authors of a major new government report into the health effects of e-cigarettes, which found vaping can be harmful, particularly for non-smokers and young people.
The global systematic review, undertaken by researchers at the Australian National University, is the most comprehensive review of vaping-related health impacts to date.
"We reviewed the global evidence in order to support informed choices on vaping for Australia," said review lead author Emily Banks from the Australian National University's National Centre for Epidemiology and Population Health.
"The evidence shows e-cigarettes carry significant harms."
The review found vaping increases the risk of multiple adverse health outcomes, including poisoning, addiction, seizures, burns, lung injury and smoking uptake.
Professor Banks said the high and increasing rate of vaping among young people was causing addiction in "a new generation of users".
"Nicotine is a key ingredient and one of the most addictive substances known," she said.
"Young non-smokers who vape are around three times as likely to take up smoking than non-vapers."
In Australia, it is illegal for anyone to possess a nicotine-filled vape unless they are over 18 and have a prescription to help them stop smoking.
But in recent years, medical experts and educators have expressed concern about young people continuing to access disposable vape products — often containing nicotine — at convenience stores and other retailers.
"[E-cigarette] use is more common among youth, particularly young males … and the majority is not for the purposes of smoking cessation," Professor Banks said.
Vaping on the rise despite health concerns
E-cigarette use has increased steadily in Australia in recent years.
Data from the 2019 National Drug Strategy Household Survey showed 11 per cent of people aged 14 and over — roughly 2.4 million Australians — had used e-cigarettes at least once, and 2 per cent of people reported current use. Among people aged 18-24, that figure was 5 per cent.
More recent data from the Australian Bureau of Statistics showed one in five people aged 18-24 had tried vaping.
Professor Banks said high-concentration nicotine products were being targeted at young people with fruity, confectionary flavourings and discrete packaging.
"They are not harmless water vapour. They contain a lot of chemicals and there's evidence that they're harmful to health."
'You don't know what it's doing to you'
Brisbane woman Alison Bolton knows firsthand just how crippling a smoking-related disease can be.
She was diagnosed with lung cancer five years ago and needs medication daily to keep the advanced cancer from spreading.
So she was shocked to discover her teenage son had started experimenting with vaping.
"We found a vape at home … I can see it from his point of view — it's so normalised, accessible, and everyone's doing it," Ms Bolton said.
She doesn't want to see other young people needlessly go down the same path as her.
She worries that, much like smoking in her youth, the full health implications of vaping remain unknown.
"You don't know what's in vapes for a start," she said.
"You don't know what it's doing to you."
Evidence of lung injury and uncertainty about the long-term
The new report found conclusive evidence that e-cigarettes can cause acute lung injury, predominantly in cases where people use vapes containing the psychoactive substance THC and vitamin E acetate (but not always).
In February, the autopsy of a Queensland man showed he died of a severe lung injury that was probably caused by vaping.
Similarly, a 15-year-old Sydney girl ended up in intensive care last year with what doctors believe was e-cigarette- or vaping-related lung injury, also known as EVALI.
But one of the biggest concerns outlined in the report was how little is known about the potential impacts of e-cigarettes on most major health outcomes.
"We don't know, for example, what [e-cigarettes] do to cancer [risk]," Professor Banks said.
"We don't know what they do to cardiovascular disease, we don't know what they do to reproductive health, and we don't know what they do to mental illness.
"That means the safety for those things has not been established."
Vaping to help quit smoking
While vaping is sometimes promoted as a way to quit smoking, the report found there was only "limited evidence" that nicotine e-cigarettes were effective in helping people to quit.
"Most people who quit smoking successfully do so unaided," Professor Banks said.
"E-cigarettes are likely to be harmful for non-smokers and for people who use them while continuing to smoke — the commonest use pattern currently."
According to the report, 53 per cent of current e-cigarette use in Australia is by people who also smoke, 31.5 per cent is by past smokers, and 15.5 per cent is by people who have never smoked.
"E-cigarettes may be beneficial in the small number of smokers who use them to quit smoking completely and promptly, but there is a huge uncertainty about their effectiveness and the overall balance of risks and benefits for quitting," Professor Banks said.
In contrast, the report found "substantial evidence" that e-cigarette use results in dependence on nicotine, and that e-cigarettes can increase the uptake of tobacco smoking in people who don't smoke.
Independent expert backs findings
Guy Marks, a respiratory physician and environmental epidemiologist from the Woolcock Institute in Sydney, said the report — which he was not involved in — was "very comprehensive and methodologically sound".
"Broadly speaking, the conclusion that there is significant overall harm, and evidence of limited benefit … was not surprising," said Professor Marks, who is president of the International Union Against Tuberculosis and Lung Disease.
He said it was important that health policy was made on the basis of large comprehensive reviews like this, and not "piece-meal evidence".
"There's a lot of pressure from industry to loosen the restrictions on e-cigarettes, and the evidence in this document should prevent that from happening."
Professor Marks said there was a place for e-cigarettes as a nicotine-replacement therapy for "a small group of highly addicted smokers".
"There's evidence that for some smokers, it's effective," he said.
"However, they need to get access to this product in the context of a well-designed and supervised smoking cessation program.
"Using e-cigarettes and smoking at the same time is unlikely to be a helpful strategy."
Health organisations call for government action
Cancer Council's Public Health Committee chair Anita Dessaix says the report sends an urgent message to Australian governments, and should put an end to "the misinformation being spread by people trying to make money from e-cigarettes".
"Every week we're hearing growing community concern about e-cigarettes in schools, the health harms and the risks of smoking uptake among young people," Ms Dessaix said.
"These findings send a clear message to all governments: act now. Do more to protect the community, especially young people, from the harms of e-cigarettes."
Lung Foundation Australia has also urged the Federal Government to strengthen and launch the National Tobacco Strategy in 2022 with "an amplified focus on addressing the rising health concerns of e-cigarettes".
"[Tobacco] companies sold the world cigarettes with effective advertising and addictive ingredients, and it was a long time before the truth about their dangers came out," Lung Foundation chief executive officer Mark Brooke said.
"The government was forced into action, but it was too late for many.
"Now, the writing's on the wall for e-cigarettes and it's time for the Federal Government to step in to protect Australia's youth from lifelong health impacts, including lung disease."
With additional reporting by Sophie Scott and Alison Branley
