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Should we be worried about vaping? - Expert Q&A


Over a dozen people have died in the United States and another 800 have become seriously ill in an outbreak of lung injury that appears to be associated with vaping.

The US Centers for Disease Control and Prevention (CDC) has confirmed 12 deaths, although media reports suggest up to 17 people have died. The CDC is continuing to investigate the deaths and illnesses, and says all patients have reported using e-cigarettes, with three-quarters saying they vape THC-containing products.

While the investigation is ongoing, the CDC recommends people refrain from using e-cigarettes, especially those containing THC. So far, no single substance has been identified in all the samples tested, though Vitamin E acetate has been found in many of the samples containing THC.

The SMC asked experts about the current situation and the benefits of vaping for smoking cessation. Below is an excerpt, the full Q&A is available on our website.

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Dr Penny Truman, School of Health Sciences, Massey University


Following a number of deaths in the United States linked to vaping, what do we know about the possible cause? Should New Zealand vape users be concerned?

“New Zealand vapers using nicotine (or the nicotine-free equivalent) should not be concerned by the problems in the USA. People have been vaping as a smoking cessation tool with no obvious problems for around 10 years now all around the world.

“In contrast, the lung damage that is appearing in the USA develops over a very short time-frame, is localised as to where it is happening and is almost certainly related to vaping cannabis. Thus it is likely to be linked to a supplier, or to a recent development in how the vape solutions are made up by a group of suppliers, that has had tragic consequences.

“Cannabis vape solutions are oil based, whereas nicotine ones are water-based. They are quite different.

“The strongest contender to be the cause is the addition of vitamin E acetate as a carrier oil to the cannabis vaping oil. Until we know more, it would be sensible for anyone wanting to vape cannabis (illegal in New Zealand, at present) not to use liquid vape devices.”

How have different countries approached regulation of e-cigarettes and their liquids? Would further regulation help protect vape users against these potential risks?

“Regulation in different countries is changing very rapidly, and ranges from encouraging vaping for smoking cessation under light regulatory control (in the UK) to having no controls at all – frequently followed by restrictions on vaping, of varying types, as governments start to worry when they see vaping becoming more and more common.

“In New Zealand, we started with banning the sale and supply of nicotine-containing solutions, but have listened to the evidence from overseas showing that many of the initial concerns were groundless. The government plans to introduce regulations around contents, packaging, advertising etc, to create a regulated market, which I hope will look very like what has been so successful in the UK.

“At the moment it is a free-for-all here in New Zealand, although the local vape manufacturers are acting ahead of regulation to comply. I think having ‘light touch’ regulations will give New Zealand consumers a layer of protection as to the type and quality of ingredients allowed in vape fluids which they do not have at present. I hope that can happen very soon.”


Conflict of interest statement:

I am a member of End Smoking New Zealand, which advocates for harm reduction solutions (such as e-cigarettes) to be encouraged within tobacco control policies.

I have been part of the MoH technical advisory group on e-cigarette regulation (2018).

I have an MBIE-funded Endeavour grant to work towards developing better smoking cessation therapies.

I have no other conflicts of interest to declare - I am not and never have been funded by the tobacco industry or the vaping industry, either directly or indirectly.

________________________________________

Dr Natalie Walker, Associate Professor in Public Health, The National Institute for Health Innovation (NIHI), School of Population Health; Director, Centre for Addiction Research, Faculty of Medical and Health Sciences, The University of Auckland

Following a number of deaths in the United States linked to vaping, what do we know about the possible cause? Should New Zealand vape users be concerned?

"The US outbreak of severe, acute respiratory failure (including deaths) related to vaping is certainly of concern. An investigation into the cause of these events is on-going so nothing is as yet certain.

"Whilst the investigation is underway, government agencies in the US are recommending consumers avoid buying vaping products from the black-market, and to refrain from vaping THC oil (THC is Tetrahydrocannabinol - the main psychoactive ingredient of cannabis) or 'modifying/adding any substances to products purchased in stores'.

"We need to put these events into context. First, e-cigarettes have been around for more than a decade, with no indications of harm. Second, the recent US events appear to be acute, that is they don’t appear to be related to long-term vaping. Finally, in the USA, 480,000 people die each year from smoking-related diseases (that’s 1,300 deaths every day) – it’s a pity these deaths don’t also make the world news.

"Should NZ vapers be concerned about the serious vaping events in the US? At this stage there is no evidence of the issue occurring in New Zealand, but I would suggest vapers make sure they buy their vaping products from reputable retailers and should not vape THC oil."

Is vaping a useful tool for people trying to quit smoking? What do we know about possible harm compared to smoking?

"Not all people find vaping helps them quit smoking, but for some vaping is the only thing that works. The most important thing is to stop tobacco smoking, as it's incredibly harmful. Nicotine e-cigarettes and nicotine replacement therapy (NRT) are reduced-harm nicotine products. These products are not without harm, but they are less harmful than continued use of tobacco."

No conflict of interest.

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Professor Julian Crane, Director, Wellington Asthma Research Group, University of Otago Wellington

Should New Zealand vape users be concerned about the recent deaths in the United States?

"Yes but not so much that they return to smoking. It is important only to use standard e-cigarettes and their specific solutions without adding anything to them. In general it is much better not to use flavourings if possible. Some 6000 are now used in e-cigarettes and while most pass food standards none have ever been tested on the lung – this is a tragedy waiting to happen – and it looks like it has!"

Do we have enough evidence to know how vaping may affect users’ lungs?

“No, obviously the long-term effects will take a long time to appear and hopefully the acute lung problems will be clarified and the offending agents removed.”

No conflict of interest.

________________________________________

Dr Sommer Kapitan, senior lecturer of marketing, Auckland University of Technology


Are there any current restrictions – in New Zealand or elsewhere – about how vaping products can be marketed? How should marketing of these products be managed?

“In New Zealand, the marketing, promotion, sales and use of vapes is unregulated. This means that advertising and promotion material can be targeted at everyone, whether they are smokers or not. That is dangerous, and highly worrisome. We have seen these tactics before. Clouds of vape, vapes held in hands by young professionals, vapes in use at youth-driven music festivals. Replace this imagery with a lit cigarette, and this looks like big tobacco all over again.

“Unlike other highly-regulated nicotine-delivery devices such as cigarettes, vape advertising and promotion material is aired on public television commercials, shown on billboards along busy streets, found on posters inside cinema toilet stalls, and plastered all over Instagram and other social media. It is clear that the lack of regulation around vape marketing efforts has resulted in the promotion of vaping not merely as a smoking cessation tool, but as a lifestyle choice. Vape marketing materials on websites and social media shows women dancing, people on boats enjoying cool flavours, a vape in hand while waiting for the train, a sleek vape alongside a morning coffee (#morningsmade). Commercials show sleek, stylish and high-tech vape pens with bright colours and catchy, upbeat music. Influencers on social media blow vape rings or exhale big clouds of vapour, and Rhythm & Alps festival-goers pose topless or in big groups around life-size frames with vape logos, sharing imagery of a vaping lifestyle to all their friends, followers, and the general public.

“None of this marketing and advertising emphasises ‘smoking cessation’. The job of marketers is to cultivate an audience, convince them to try their product, and ultimately to sell. Marketers of vape products in New Zealand are just doing their jobs. They are operating as they should in aiming to grow profits – and they are targeting nonsmokers as well as smokers who might like their nicotine products. Yet regulators in New Zealand are not yet doing their jobs to protect the public from a lifestyle choice that involves highly-addictive nicotine and otherwise questionable or unknown side effects.

No conflict of interest

________________________________________

Combined responses from:
– Professor Janet Hoek, Professor of Public Health and Marketing, University of Otago, Wellington
– Anaru Waa, Senior Research Fellow, Te Rōpū Rangahau Hauoraa Eru Pōmare, Department of Public Health, University of Otago Wellington
– Professor Richard Edwards, Professor of Public Health, University of Otago Wellington

How have different countries approached regulation of e-cigarettes and their liquids? Would further regulation help protect vape users against these potential risks?

“Regulation of electronic nicotine delivery systems (ENDS) and vaping products varies across countries. In the UK, these products are regulated by the Tobacco Products Directive (TPD). Among other things, the TPD restricts the size of ENDS tanks to 2ml, restricts the nicotine content of e-liquids to no more than 20mg/ml, regulates specific ingredients, and sets out labelling and warning requirements. Regulation in the US is outlined here. Australia has more restrictive regulation.

“Within New Zealand, vaping regulation is pending and the content of the legislation has not yet been released. There are different views on how we can put in place policies that support smokers wanting to switch to vaping and ensure they can use their vapes effectively while also preventing uptake among children and young people and adults who are not smoking or vaping. Measures that may help vape users avoid the illnesses observed in the US could include:

• Developing, implementing and enforcing product safety standards and an effective adverse reaction monitoring scheme.

• Requiring licensing of ENDS retailers and allowing only people knowledgeable about ENDS and smoking cessation to sell ENDS and other vaping products.

• Making all licensed ENDS retailers R18 outlets that cannot be established near schools (i.e., to deter youth exposure and uptake).

“While people using ENDS and vaping products need to be confident the items they purchase and use are safe and fit-for-purpose, ENDS are still widely regarded as presenting fewer risks to users than smoked tobacco. The regulatory regime should reflect this difference so that measures applied to smoked tobacco are more restrictive than those applied to regulate the sale and availability of ENDS. The introduction of measures to regulate ENDS is an opportune time to remedy deficiencies in smoked tobacco regulation. Such measures should include reducing availability by introducing licensing and controls on the number and type of outlets selling smoked tobacco and to reduce the addictiveness, palatability and appeal of these products by greatly reducing nicotine content and prohibiting flavours and additives.”

Given the current state of knowledge, is it recommended that smokers use vaping to quit tobacco? What about non-smokers?

People who smoke could use recommended and approved smoking cessation treatments, such as the many types of Nicotine Replacement Therapy (NRT), or medicines such as Zyban or Champix, which their doctor can prescribe, if appropriate. These treatments have been demonstrated to be effective and have had to undergo a rigorous approval process, and hence are likely to be the safest aids for quitting smoking. However, not everyone is able to quit smoking using these approaches and people who have not been able to quit using existing treatments may wish to try ENDS; however, they should buy their device and e-liquid from a specialist outlet. They should also aim to quit using ENDS as soon as they feel they would not relapse to smoking.

“Non-smokers should neither smoke nor vape; doing either will increase the risk of harm they face. People who are addicted to nicotine typically dislike the hold it has over them and resent the loss of control they experience. For them, the struggle to rid themselves of nicotine is not worth the short-term sensations that led to their addiction.”

Conflict of interest statement: We co-direct ASPIRE, a University of Otago Research Centre, and have undertaken several studies designed to inform smokefree policies. We have received funding from the Health Research Council of New Zealand, the Royal Society Marsden Fund, the New Zealand Cancer Society, the New Zealand Ministry of Health, and other NGOs. We have never received funding from the tobacco, vaping or pharmaceutical industries (or related commercial interests), nor from the Foundation for a Smokefree World.


ends

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