Vaping Policy FAQ

1.  Strategy – what is the purpose of tobacco and nicotine policy?

1.1 What are the goals of tobacco and nicotine policy?

1.2 What is ‘tobacco harm reduction’?

1.3 What products are involved?

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

2. Safety and relative risk – what are the risks?

2.1 Are e-cigarettes less harmful than cigarettes?

2.2 How much less harmful are e-cigarettes than cigarettes?

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

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

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

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

3. Quitting smoking – do vaping products displace smoking?

3.1 Do e-cigarettes help people quit smoking?

3.2 Do most vapers use both e-cigarettes and cigarettes?

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

3.4 What is the cost of vaping?

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

4.1 Do e-cigarettes appeal to adolescents?

4.2 Is there a ‘youth vaping epidemic’ in New Zealand?

4.3 Is vaping a gateway to smoking?

4.4 Should flavours be banned to stop youth vaping?

4.5 Does nicotine damage the developing adolescent brain?

4.6  What can be done to protect young people?

5. How should government handle reduced risk products?

5.1 Should e-cigarettes be treated like cigarettes?

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

5.3 Should  regulation of e-cigarettes be based on risk?

5.4 Are there potential unintended consequences of excessive vaping regulation?

5.5 Should regulators impose limits on the strength of nicotine in e-liquids?

6.  Vaping in public places – should it be permitted and who should decide?

6.1 Do e-cigarette vapours pose the same risks to bystanders and family members as second-hand smoke from cigarettes?

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

7.  Marketing – what marketing freedoms or constraints are appropriate?

7.1 Are vaping products aggressively marketed to teens?

7.2 Should advertising for reduced-risk products be banned?

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

8.  Retailing – who should sell and under what conditions?

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

8.2 Should e-cigarettes be available only through pharmacies or on prescription or over-the-counter everywhere?

8.3 Should vaping products be available on-line?

9.  The place of the tobacco industry

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

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

10.  Where can I find out more about vaping?


1.  Strategy – what is the purpose of tobacco and nicotine policy?

1.1 What are the goals 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 500,000 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.

1.2 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 using 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 reduced harm products such as e-cigarettes rather than combustible, smoking products such as cigarettes. 

 

1.3 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, with clear public health benefits.

 

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

If there is to be an overarching public health goal, it should be focussed on a ‘smoke-free society’ not a ‘nicotine-free society’. Smoking kills, whereas nicotine can be used without the harms of smoking.

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.


2. Safety and relative risk – what are the risks?

2.1 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.

 

2.2 How much less harmful are e-cigarettes than cigarettes?

Much Less harmful. 

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

 “Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, 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.

 

2.3 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.

Based on the available evidence on relative toxicity and human exposures to toxicants, independent experts making assessments for Public Health England in 2015 and the Royal College of Physicians in 2016 concluded that 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 have regularly updated their original estimate and have found no new evidence to revise it.

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. 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 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.

 

 2.4 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.

 

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

No.  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.

 

2.6 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 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. 


3. Quitting smoking – do vaping products displace smoking?

3.1 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.

 

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

 

3.2 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 should be properly understood as 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.  Unless “cold-turkey,” smoking cessation therapies or behavioural counselling are 100% and immediately effective, people who are trying to quit will continue to smoke over the course of quitting.

 

3.3 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. At least in the UK and the US, e-cigs are now 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.

 

3.4 What is the cost of vaping?

In New Zealand, the average smoker consumed 10 cigarette equivalents per day in 2018.  In early 2019, the cheapest tax-paid cigarettes were approximately $25 for 20, 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 afford to vape. 

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

  1. There are upfront costs for a vaping device – the user may save money in the medium term
  2. 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
  3. Some sort of inducement to try vaping might be necessary and be highly cost-effective for the provider

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

4.1 Do e-cigarettes appeal to adolescents?

Most illicit products or behaviours will appeal to some adolescents – this applies to alcohol, drugs, gambling, pornography etc. 

There has been much talk of a recent increase in e-cigarette use by New Zealand adolescents. But the definition used includes anyone taking one puff in the past 30 days. Drilling down into this data shows that most teen vaping in New Zealand is infrequent. Among frequent users, the vast majority had already smoked; for them, e-cigarettes may be beneficial. There is little sign of adolescent vaping causing addiction in users with no prior tobacco use.

The most important indicator of youth dependence on nicotine 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. Daily use by those who have never smoked is the best indicator that vaping is recruiting a new generation of addicts. In New Zealand this consistently remains under 1% of those who have never smoked.

Year 10 use of e-cigarettes or vaping according to susceptibility to smoking

4.2 Is there a ‘youth vaping epidemic’ in New Zealand?

No.  There are no surveys anywhere in the world of youth vaping prevalence  that supports the notion of a youth vaping ‘epidemic’. 

There has been a high-profile media debate about an “epidemic” and this has largely focused on observation and anecdotes from high socially economic status schools rather than available and current data.

So far, there is no scientific evidence of a youth vaping epidemic.

Three independent surveys of young people have found consistent findings on youth vaping prevalence. The ASH year ten survey of 14-15-year olds, New Zealand Health Survey that includes 15-17 years olds, and the HPA Health and Lifestyles survey which includes 12-24 year olds.

 

Daily Vaping by underage users (<18 years)[1],[2]

Graph of daily youth vaping from the New Zealand health Survey and ASH year 10 survey from 2014 - 2019.  Daily vaping for 15-15 years olds is 3.1% nm 2019, and 1.7% for 15-17 years olds.

Detailed analysis of 4 years of data from the ASH year ten survey was published in the Lancet Public Health in early 2020. The survey is completed by around 30,000 students each year, half the eligible year 10 population. The findings concluded that there was no vaping epidemic, and vaping may be displacing smoking in young people[3]. If this is correct, then it would have a net health gain. 

 

4.3 Is vaping a gateway to smoking?

Unlikely.  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 academics or activists 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]

 

4.4 Should flavours be banned to stop youth vaping?

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 may make sense to ban certain flavour descriptors (the names given to flavours), if these are designed to appeal to youth.

 

4.5 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.

 

4.6  What can be done to protect young people?

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

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

5. How should government handle reduced risk products?

The aim should be to 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.

5.1 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.

 

5.2 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. 

 

5.3 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:

  1. Relatively high taxes on cigarettes, but low or no taxes on much safer products including e-cigarettes;
  2. Bans on cigarette advertising, but controls on content and placement of e-cigarette advertising to prevent marketing to teens;
  3. Bans on smoking in public places, but indoor vaping policy should be a decision for the owners or managers of buildings;
  4. Large graphic health warnings on cigarettes, but messages encouraging switching on e-cigarettes;
  5. Plain-packaging for cigarettes, but not e-cigarettes;
  6. Regulation of product formulation that makes switching to vaping relatively more attractive than continuing to smoke;
  7. Regulation that addresses electrical, chemical, thermal and mechanical product risks where these benefit consumers;
  8. Regulation of containers to make them child-resistant;
  9. Differential age restrictions, for example, age 21 for cigarettes, but 18 for e-cigarettes;
  10. Bans on internet sales of cigarettes, but not on e-cigarettes;
  11. Vaping-friendly stop-smoking services
  12. Campaigns to discourage smoking, but to encourage switching to vaping.

 

5.4 Are there potential unintended consequences of excessive vaping regulation?

Yes.  The danger is that excessive regulation will make vaping (or heated, smokeless or oral nicotine products) relatively 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:

However, if [a risk-averse, precautionary approach to e-cigarette regulation] also makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking. Getting this balance right is difficult. (Section 12.10 page 187)

Royal College of Physicians 2016 report, Nicotine without smoke: tobacco harm reduction

But there is an important fact to consider when striking this balance, the possible unintended consequences (more smoking) are much more serious than almost all of the conceivable harms that the regulation of low-risk products is designed to prevent. 

 

5.5 Should regulators impose limits on the strength of nicotine in e-liquids?

No.  The danger of limiting nicotine is that it leaves cigarettes in place as the most rapid and effective way of delivering nicotine. Such limits will make e-cigarettes ineffective alternatives for heavier smokers or those struggling to convert from smoking to vaping.

Nicotine content is a highly unreliable predictor of nicotine delivery and absorption by the user because product design and use variability is so wide. For example, a vaper who is trying to cut down may increase nicotine content in their vape liquid or device in order to manage their withdrawal for longer between puffs. Lower nicotine content requires more frequent vaping to achieve the same withdrawal.

It also may be a block on current and future innovation (e.g. to make products safer, smaller, easier to use) and make them more dangerous by forcing users to consume more liquid for a given dose of nicotine. Limits should only be set for poison-safety reasons (for example 7.2% or approximately 72mg/ml is a poison threshold in the UK) and not to limit nicotine uptake as this would provide an advantage to cigarettes.


6.  Vaping in public places – should it be permitted and who should decide?

6.1 Do e-cigarette vapours pose the same risks to bystanders and family members as second-hand smoke from cigarettes?

No, far from it. Bystanders are exposed to far lower levels of toxicants and for much less time.

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:

  1. 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.
  2. 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.
  3. 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.

Many studies have misunderstood the risks; it is not sufficient to detect agents in the indoor air to declare a risk, the risk depends on exposure. It is possible to compare exposures with second-hand tobacco smoke or by reference to an indoor air quality standard – for example, standards set in workplaces for occupational exposure.

 

6.2 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.

The appropriate compromise is to allow vaping in R18 venues subject to the owner’s discretion.


7.  Marketing – what marketing freedoms or constraints are appropriate?

7.1 Are vaping products aggressively marketed to teens?

Yes.  We have seen “lifestyle” marketing of vaping products to youth and this type of marketing should be banned.

 

7.2 Should advertising for reduced-risk products be banned?

No, but it should be regulated.

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.

 

7.3 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, such as youth.

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


8.  Retailing – who should sell and under what conditions?

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

In New Zealand the latest generation of pod systems are largely purchased where people buy cigarettes. This level of access is important as it both presents an opportunity to divert a person to a safer alternate when they are vulnerable to purchasing their nicotine in cigarettes, and providing convenience to access their preferred safer alternate when experiencing withdrawal.

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].

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. Of course, a government cannot force retailers to stock particular product lines, but it should not use its powers or influence to make cigarettes more available in some environments.  In addition, there is a case for making effective alternatives available in settings where there may be an opportunity for behaviour change – for example, in hospital shops.

 

8.2 Should e-cigarettes be available only through pharmacies or on prescription or over-the-counter everywhere?

No. The latest generation of products are very easy to use, have closed nicotine refil pods, are not user customisable.  They are as easy, if not easier to use than a cigarette. They should therefore be available everywhere cigarettes are – convenience stores, petrol stations, supermarkets etc. 

As alternatives to smoking need to be just as easy to access as the harmful dominant product, cigarettes. It is important not to place barriers in the way of easy access: if people cannot access them easily there is less chance they will try and more chance they will fail and relapse back to smoking. 

Vape shops are especially important as they combine diverse personalised product options with expert advice – offering what amounts to a smoking cessation service. They can also cater to customers who want more advanced and complex devices.

Vaping products are now available in some hospital shops in England – this is to encourage patients, visitors and staff to try a permanent switch from smoking.

 

8.3 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.


9.  The place of the tobacco industry

9.1 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.

 

9.2 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. 


10.  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.