Vaping Policy FAQ

What is the purpose of tobacco and nicotine policy?

The primary public health policy goal is to reduce disease and death from smoking tobacco.

“People smoke for the nicotine, but they die from the tar.”
Professor Michael Russell

New Zealand has implemented the full range of WHO recommended tobacco control policies, and still 387,000 New Zealanders smoke. We must now concentrate on the goal of smoking cessation, and at the same time, prevent uptake of smoking. To reach the Smokefree 2025 goal, over 60,000 people need to quit smoking permanently each year in New Zealand, of whom almost half need to be Maori.

What is ‘tobacco harm reduction’?

Tobacco harm reduction is a key public health strategy. In areas where “abstinence-only” approaches are ineffective, harm reduction is widely practised in public health. An example is the reduction of the harms of illicit drugs by providing syringe exchange of methadone.

In the case of tobacco harm reduction, the aim is to provide less harmful alternatives to cigarettes by use of regulation, fiscal measures, communications and support services to reduce the harms associated with tobacco or nicotine use, including the secondary harms of smoked tobacco. In practice, this primarily means encouraging smokers or would-be smokers to adopt non-combustible nicotine products such as e-cigarettes rather than combustible, smoking products such as cigarettes. The rationale is that these products are a lot less harmful than the alternative.

What products are involved?

There are four broad categories of non-combustible consumer nicotine products:

In New Zealand, our main focus is on vaping products, but in Scandinavia snus (a form of smokeless tobacco) has driven smoking cancer death rates down to the world’s lowest level.

Shouldn’t we aim for a nicotine-free society?

We need to focus on smoking as it is uniquely harmful and kills.

Nicotine is not benign but as a recreational drug, it is relatively innocuous. Unlike alcohol, which is linked to serious health risks, nicotine is not a cause of serious disease in its own right.

Ultimately, New Zealand could be nicotine free, but the urgent public health issue remains smoking. Good policy can use nicotine as a tool to reduce smoking.

Safety and relative risk – what are the risks?

Are e-cigarettes less harmful than cigarettes?

Yes. Beyond any reasonable doubt, e-cigarettes are much less harmful than smoked cigarettes. People smoke cigarettes to access nicotine. Almost all the harm from cigarettes arises from the smoke, inhaling the products of high-temperature combustion of dried and cured tobacco leaf. The smoke is the sticky smoke particles and hot toxic gases that are drawn into the lung.

E-cigarettes can produce vapour, but do not produce smoke because there is no combustion and no burning organic material, just heated tiny droplets of nicotine-carrying liquid. Combustion or burning is the key difference and this creates completely different physical, chemical and biological effects.

How much less harmful are e-cigarettes than cigarettes?

It is clear that e-cigarettes are much less harmful than cigarettes.

“Vaping is not harmless, but it is much less harmful than smoking.”
The New Zealand Ministry of Health

Compared to cigarettes, e-cigarettes are “likely to be far less harmful.”
The US National Academies of Science Engineering and Mathematics

“... the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.”
The British Royal College of Physicians

“…stating that vaping is at least 95% less harmful than smoking remains a good way to communicate the large difference in relative risk.”
Public Health England

None of these bodies, or the experts advising them, has any connection to the e-cigarette or tobacco industries. In each case, the experts based their view on a comprehensive published review of the evidence.

Is it fair to say that e-cigarettes are likely to be at least 95% less harmful than smoking?

Yes. The statements above are the expert estimates of the long-term risks based on what we know of the toxicology of cigarette smoke and vape aerosol and also what we know of the exposure to toxicants in the body as measured in blood, saliva and urine.

"... it is reasonable to work on the basis that e-cigarettes are likely to be … at least 95% lower risk than cigarette smoking and substantially lower than that. In the short to medium term, there does not appear to be any significant risks given the experience of tens of millions of users over 10 or more years.”
Public Health England and the Royal College of Physicians

Public Health England have regularly updated their original estimate and have found no new evidence to revise it.

In practice, we will not be able to directly determine the actual health effect of vaping for many decades, if ever, given that most vapers have also been smokers. But importantly, knowledge of systems toxicology is far advanced from the early days of smoking and health research; it is unnecessary to wait many decades to understand risk. Even if some risks emerge, long term effects are likely to be negligible; technology improvements or regulation will allow us to tackle any risks that do emerge.

Do the recent US cases of severe lung injury prove that e-cigarettes are very harmful?

No. As of February 2020, there have been nearly three thousand hospitalisations and over sixty deaths from a severe lung injury condition in the USA. This has been given the misleading name EVALI (electronic-cigarette or vaping product use–associated lung injury).

The cases occurred in users of cannabis vaping products and were caused by the use of a particular illegal additive used for thickening cannabis (THC) oils – Vitamin E Acetate. It is possible other additives were also involved.

In the UK, where more than 3.5 million people vape, there have been no cases of EVALI.

There is no evidence that people are using these additives in New Zealand and no deaths associated with e-cigarettes.

Should we be concerned about the long-term effects of vaping?

While it is impossible to have 50-year studies of a product that has only been in use for about 10 years, that does not mean we have no data on which to base concerns about long-term effects of vaping.

There is extensive data on the toxicants in the vapour and measurements of ‘exposure biomarkers’ in the blood, urine and saliva of users. All of these suggest very much lower risks than smoking.

It took years before the harmful effects of smoking emerged in the 1950s, so won’t it be the same with vaping?

No. With the knowledge we have now, we would know immediately that smoking is extremely harmful. We would not have to wait decades for epidemiology to show that smoking was causing cancer, heart disease and other chronic conditions. This is because the discipline of systems toxicology has hugely advanced since the mid-twentieth century. We also know a lot more about the risks of particular exposures, and can draw on findings from other disciplines such as occupational health and the limits that are imposed on exposure in the workplace.

Quitting smoking – do vaping products displace smoking?

Do e-cigarettes help people quit smoking?

There are now four strands of evidence that suggest e-cigarettes are effective in helping people to quit smoking:

Randomised controlled trials

A New Zealand randomised controlled study showed that combining reduced-harm nicotine products, such as nicotine patches with a nicotine e-cigarette, can lead to a modest improvement in smoking cessation over and above that obtained from using patches plus a nicotine-free e-cigarette (or patches alone), with no indication of any serious harm in the short-term ( Walker et al, 2019).

Other randomised controlled trials have shown vaping to be about twice as effective as NRT.

“E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support.“
Hajek et al 2019,

Observational studies (watching what happens when people use e-cigarettes).

“Use of e‐cigarettes and varenicline are associated with higher abstinence rates following a quit attempt in England.“
Jackson et al 2019.

Population data (unusually rapid reductions noted in smoking prevalence or cigarette sales visible in market data)

“The substantial increase in e-cigarette use among US adult smokers was associated with a statistically significant increase in the smoking cessation rate at the population level. These findings need to be weighed carefully in regulatory policy making regarding e-cigarettes and in planning tobacco control interventions.“
Zhu S-H et al, 2018.

Thousands of testimonials of users who have struggled to quit smoking using other methods and have successfully used e-cigarettes.

None of these is decisive in its own right, but all four strands point towards e-cigarettes displacing smoking.

Do most vapers use both e-cigarettes and cigarettes?

The proportion of dual users is about 50% of all vapers in NZ.

Many dual users are in transition from smoking to vaping over a period of months or even years. Dual-use is part of a behavioural pathway that evolves over time, not something this is static and fixed. Vaping may start with no intention to quit smoking, but as the user becomes more familiar and finds the product they like they gradually make more use of the product in more situations.

Almost all attempts to quit smoking using established methods involves continuing to smoke, often by a series of quitting efforts, followed by relapse.

Is there a difference between NRTs, smoking cessation pharmaceuticals and vape products?

Yes, but from a public health perspective, we should support the use of whatever options we can to reduce smoking, which is the primary driver of disease.

The impact of any approach to quitting smoking is a product of two things – (1) how effective it is and (2) how willing people are to use it. In the UK and the US, e-cigarettes are the most used product by smokers trying to quit smoking, more than any of the officially-approved smoking cessation medications.

The great strength of the vaping approach is that it is effective at replacing cigarettes because it replicates many aspects of smoking(for example, nicotine effects, sensory experience, hand-to-mouth movement, and a behavioural ritual) but without the harm. But it also does this in a way that appeals to smokers – it is fun and interesting and there is a sub-culture to go with it. Vaping has the combination of effectiveness and appeal. There may be occasions when it makes sense for a vaper to use NRT – for example, while learning to vape, on long flights, perhaps even overnight. The consumer market is developing diverse nicotine products – for example, oral nicotine pouches – which may also help.

What is the cost of vaping?

In New Zealand, the average smoker consumes 10 cigarette equivalents per day in 2018. In early 2019, the cheapest tax-paid cigarettes were approximately $25 for 20 cigarettes, meaning an average smoker buying the cheapest tax-paid budget cigarettes would spend NZ$4,517 per year.

But these averages obscure much higher overall cost for more dependent smokers; a pack-a-day budget cigarette smoker would spend over NZ$9,000 per year on smoking.

Vaping is much cheaper than smoking. If people can afford to smoke, they can certainly afford to vape!

However, for the economically disadvantaged, there are issues at the point of transition:

There are upfront costs for a vaping device – the user may save money in the medium term
The user may worry about ending up paying for both cigarettes and vaping equipment if the latter doesn’t work for them – and this is a barrier to experimentation

Youth – how should we address the uptake of adult products by young people?

Are e-cigarettes for young people?

No. E-cigarettes are a harm reduction tool for those who smoke to help them quit smoking.

The ASH advice for anyone who does not smoke, particularly youth: Do not vape

What can be done to protect young people?

There are three main evidence-based policy approaches to protect young people:

Control access by setting age limits and restricting where and how products can be purchased.
Control marketing, packaging and branding to prevent marketing targeted at adolescents.
Provide credible reality-based campaigns, information and warnings targeted at young people.

Despite ASH asking for regulation for over a decade, the New Zealand government only regulated vaping late 2020 to control access, marketing, packaging and branding. The unregulated market has meant we have experienced an uptake of youth vaping.

Do e-cigarettes appeal to adolescents?

Unfortunately most illicit products or behaviours will appeal to at least some adolescents – this applies to alcohol, drugs, gambling, pornography etc. Vaping is the latest thing. There is no doubt that vaping has attracted some adolescent use. Daily and experimental vaping by youth are clearly increasing.

However the most important indicator of youth dependence is daily use. Reports of youth vaping often cite data that includes ever use, or monthly use. This often includes experimentation such as sharing a vape, or a single device being passed around several young people at a party. However, it is a not an indicator that young people are dependent on nicotine.

Whilst daily use is increasing, more than 90% of 14-15 years olds do not use vapes daily and most have not even tried a vape.

Is vaping a gateway to smoking?

There is no compelling evidence for this gateway theory. However, there is a quite strong association between young people who vape and then subsequently smoke. They are about four times as likely to smoke if they have vaped. This has allowed some to claim a gateway effect. But this approach is flawed – you would need to know what the person would have done in the absence of vaping, and many would have progressed straight to smoking. It is most likely that ‘common liability’ explains the associations. This means that the same factors that incline young people to smoke, also incline them to vape. [i] In other words young people who like risks, takes risks.

Should flavours be banned to stop youth vaping?

Youth, when asked, do not say they primarily vape because of flavours. Rather daily vapers say they vape primarily because they enjoy it and experimental vapers say they primarily vape to give it a try.

Banning all or most flavours would be like banning all or most toppings on pizzas – it would effectively prohibit all or most of the products, leaving only the unattractive tobacco-flavoured liquids. This would make e-cigarettes nearly useless as alternatives to smoking for adults, promote a black market and may even increase risks to young people if it encourages them to smoke or to access black markets. It makes more sense to ban certain flavour descriptors that are designed to appeal to youth. This is what we have done in New Zealand.

Does nicotine damage the developing adolescent brain?

No. The evidence for this hypothesis comes only from a few rodent studies. These are an unreliable guide to human risk because the rodent brain does not offer a reliable proxy for the human brain and it is difficult to design experiments that are controlled to give a mouse equivalent exposure to a human.

But this is not the main reason for doubt. Over the last 60 years, millions of adolescent nicotine users have grown up as smokers and either continue to use nicotine or have quit. There is no sign of any cognitive impairment in the population of former teenage smokers and many of today’s finest adult minds were once young smokers. If a detrimental cognitive effect of nicotine existed in the human population, it is inconceivable that we would not already have seen extensive evidence of it from the study of smokers, non-smokers and ex-smokers over several decades.

How should government handle reduced risk products?

We should use ‘risk proportionate’ regulation to encourage switching from cigarettes to e-cigarettes while controlling safety risks and preventing youth uptake of all tobacco and nicotine products.

Should e-cigarettes be treated like cigarettes?

No. Cigarettes are far more harmful than e-cigarettes and e-cigarettes can help people quit smoking. For these two reasons alone, the policy needs to take account of difference in risk and the potentially large benefits of e-cigarettes.

Should e-cigarettes be regulated as smoking cessation medicines with pharmaceutical regulation?

No. These products are not medicines. They work as consumer products – effective competitors to cigarettes rather than medicinal therapies for tobacco dependence. They are not medicines. The people using them do not usually see themselves as sick and many do not want to enter a healthcare setting. They are using these products as a lifestyle consumer choice and as a better alternative to cigarettes.

Should regulation of e-cigarettes be based on risk?

Yes. Regulation of tobacco and nicotine products should be “risk-proportionate” – with more stringent controls placed on the highest risk products. This means a regulatory agenda as follows:

Relatively high taxes on cigarettes, but low or no taxes on less harmful products including e-cigarettes;
Bans on cigarette advertising, but controls on content and placement of e-cigarette advertising to prevent marketing to teens;
Large graphic health warnings on cigarettes, but messages encouraging switching on e-cigarettes;
Regulation of product formulation that makes switching to vaping relatively more attractive than continuing to smoke;
Regulation that addresses electrical, chemical, thermal and mechanical product risks where these benefit consumers;
Regulation of containers to make them child-resistant;
Differential age restrictions, for example, age 21 for cigarettes, but 18 for e-cigarettes;
Bans on internet sales of cigarettes, but not on e-cigarettes;
Vaping-friendly stop-smoking services
Campaigns to discourage smoking, but to encourage switching to vaping.

Are there potential unintended consequences of excessive vaping regulation?

The danger is that excessive regulation will make vaping less attractive to nicotine users compared to cigarettes. Poorly designed regulation has the potential to shift the calculations of users in favour of more harmful products. We need the right balance in protecting youth, ensuring safe products and helping people to switch to less harmful alternatives ot smoked tobacco. that is what the New Zealand Government has tried to do with its vaping legislation.

Vaping in public places – should it be permitted?

Is e-cigarette vapour and second-hand smoke from cigarettes the same thing?

No. Three things are very different between vapour from e-cigarettes and second-hand (or environmental) smoke from cigarettes. Any toxic exposure to bystanders depends on all three:

The quantity emitted. Most of the inhaled vapour is absorbed by the user and only a small fraction is exhaled (15% or less, depending on the constituent). In contrast, about four times as much environmental tobacco smoke comes directly from the burning tip of the cigarette than is exhaled by the smoker. There is no equivalent of this “sidestream smoke” for vaping.
The toxicity of the emissions. Tobacco smoke contains hundreds of toxic products of combustion that are either not present or present at very low levels in vapour aerosol. Vapour emissions do not have toxicants present at levels that pose a material risk to health. Exposure to nicotine, itself relatively benign, is unlikely to reach a level of pharmacological or clinical relevance.
The time that the emissions remain in the atmosphere. Environmental tobacco smoke persists for far longer in the environment (about 20-40 minutes per exhalation). The vapour aerosol droplets evaporate in less than a minute and the gas phase disperses in less than 2 minutes.

Should vaping be banned by law in public places and workplaces?

There is no robust evidence of harm from second-hand vapour whereas second-hand cigarette smoke, especially the smoke generated when a user is holding a lit cigarette, has been associated with cancer and heart disease in passive smokers.

In the absence of material risk to the health of bystanders, there is a very weak justification for a general prohibition.

Marketing – what marketing constraints are appropriate?

Are vaping products aggressively marketed to teens?

Yes. We have seen “lifestyle” marketing of vaping products to youth and this type of marketing is thankfully now banned in New Zealand.

Should advertising for reduced-risk products be banned?

No, but it should be carefully regulated to ensure products are not attrcative to youth.

Regulated advertising can function as anti-smoking advertising – promoting a smoking cessation pathway, and at no expense to the taxpayer. It allows the new ‘entrant’ products to gain the attention of smokers and compete with cigarettes, the dominant incumbent’. Advertising and promotion is key to the disruption of the cigarette industry. It works by informing consumers, developing confidence in brands, creating a buzz around an alternative “value proposition” to smoking. To ban the advertising of low-risk alternatives has the effect of protecting the cigarette trade.

Is there a way to maximise the benefit to smokers and would-be smokers, while minimising the potential to recruit non-users of nicotine?

Yes. Controls on access, marketing and information should be used for targeting any particular sub-populations.

Rather than ban vape advertising, a good policy would control content (what sort of messages) and placement (where and when the advertiser can advertise).

Retailing – who should sell and under what conditions?

Where should e-cigarettes and other reduced-risk products be sold and not sold?

Alternatives to cigarettes should be at least as widely available as cigarettes and other combustible tobacco products. It makes no sense to withdraw the much safer nicotine products from certain retail environments while leaving cigarettes in place.

A recent 4-country study of where vapers purchase their vaping products found that whilst 41% purchased from specialist shops, 31.1% used other retail locations. In England, where vaping is being encouraged as a smoking cessation tool, non-specialist retail locations were the major source of vaping products for vapers[4].

Should vaping products be available on-line?

Yes. Particularly in areas of sparse population, specialist vape shops selling diverse products are not be viable and many people also like the convenience and wide choice of online shopping and bargain hunting. Again, this is an area where vaping can and should out-compete smoking. Online sales present barriers to youth access through the requirement to make card payments and stronger systems of age verification at purchase, and on delivery of products. This system is already used for other online sales like lotto and alcohol.

The place of the tobacco industry

Are e-cigarettes a tobacco industry ploy to keep people smoking?

Modern e-cigarettes were not invented by the tobacco industry and most suppliers are not part of the tobacco industry.

The tobacco industry realised that its customers want to switch to these products and entered the market when they saw the impact on their shares of increased vaping. There are now over 40 million vapers world-wide and this is projected to reach 70 million by 2022.

The tobacco industry deserves to be treated with great scepticism and should always be handled with caution. However, a long-term transition of the industry from selling combustible products to non-combustible is in the interests of public health and could be the most likely and rapid way to end the worldwide epidemic of smoking-related disease and achieve a smoke-free world.

If tobacco companies want to reduce the harm caused by cigarettes, why don’t they just stop selling cigarettes?

This is more of an empty campaigning posture than a plausible way to make progress. No public company could do this unilaterally.

The management of any company has a legal duty to its shareholders not to destroy the value of their equity (shares). If a management team tried it is likely it would be fired and replaced by the board or shareholders. If somehow they succeeded, the company would be taken over or its profitable assets and brands would be sold to another company. Somebody would end up selling the cigarettes.

There are two other ways in which it could happen: (1) a government-led legal ban on cigarettes or its equivalent (reducing nicotine levels to near-zero). (2) a technology transition, reinforced by risk-proportionate regulation, in which cigarettes become an obsolete product.

Where can I find out more about vaping?

Ministry of Health. Click HERE

Health Promotion Agency. Click HERE

A Surge Strategy for Smokefree Report. Click HERE

Lancet Article. Click HERE

With grateful thanks to Clive Bates for his input into this FAQ.

[1] ASH year 10 smoking survey www.ash.org.nz/research

[2] Ministry of Health. 2019. Annual Data Explorer 2017/18: New Zealand Health Survey [Data File]. URL: https://minhealthnz.shinyapps.io/nz-health-survey-2017-18-annual-data-explorer

[3] Walker et al. Use of e-cigarettes and smoked tobacco in youth aged 14-15 years in New Zealand: findings from repeated cross sectional studies (2014-19). Lancet Public Health. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30241-5/fulltext

[4] Braak DC, Cummings KM, Nahhas GJ, et al. Where Do Vapers Buy Their Vaping Supplies? Findings from the International Tobacco Control (ITC) 4 Country Smoking and Vaping Survey. Int J Environ Res Public Health. 2019;16(3):338. Published 2019 Jan 26. doi:10.3390/ijerph16030338

[i] The factors might include genetics, family smoking history, home circumstances, mental health and personal efficacy, delinquency, educational attainment, social group etc. Statisticians can try to eliminate these ‘confounding’ factors from the association to show that what is left of the association can be attributed to trying vaping. The trouble is that they can never do this completely – they will never have enough data or accurate models for confounding, and therefore never be able to eliminate these factors completely.