Letter to the Editor regarding ‘Smoke and mirrors: Support from psychiatrists for nicotine e-cigarette availability in Australia’

The article by McKeon and Scott argues for urgent review of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) 2018 position statement on e-cigarettes due to concerns about health effects, effectiveness and youth use (McKeon and Scott, 2022). However, the evidence they outline does not justify their concerns and crucial evidence is omitted.

The RANZCP guidelines support the use of vaping nicotine as a second-line treatment for people living with mental illness who smoke, when other treatments have failed. Vaping is a tobacco harm reduction tool and is a safer alternative for those who would otherwise continue to smoke.

The authors acknowledge that ‘It is widely accepted that ECs [e-cigarettes] are safer than cigarettes’. However, they are concerned about the uncertain long-term safety. As with all new products, the precise long-term risks will not be established for decades. However, vaping is likely to be considerably less harmful than smoking due to the substantial reduction in toxicants, biomarkers of exposure and clinical improvements seen in smokers who switch. Some ex-smokers have vaped nicotine for over a decade, and to date, reports of serious adverse effects are very rare.

The authors raise caution about dual use (concurrent smoking and vaping), citing observational studies that found an association between increased cardiovascular and respiratory risk for dual users compared to exclusive vapers. These cross-sectional studies cannot infer causation. A more likely explanation is, as the authors state, that dual users have higher tobacco dependence and are more likely to have smoking-related harms from past heavier smoking.

Dual use is often a transitional phase to quitting. Most studies have found that dual users substantially reduce their cigarette intake. Dual use is associated with reduced biomarkers and clinical improvements and is preferred to exclusive smoking (Hartmann-Boyce et al., 2022).

The authors’ disquiet about the ongoing use of nicotine appears to misunderstand the role of vaping as a harm reduction treatment. Continued nicotine vaping is not harmless but can help prevent smoking relapse, which is far more harmful.

The serious lung disease Electronic cigarette or Vaping-Associated Lung Injury (EVALI) is presented as a potential risk of vaping nicotine. The EVALI outbreak in 2019 was strongly linked to vitamin E acetate (VEA) added to black market tetrahydrocannabinol (THC) vaping oils. There is no evidence that nicotine vaping caused EVALI and no causal agent has been detected in nicotine liquids. The EVALI outbreak resolved when VEA was removed from the Illicit THC supply chain in early 2020.

The authors question the role of vaping when other effective treatments are available. However, quit rates from conventional therapies are very low, at around 8% at 12 months in randomised controlled trials and even lower in real-world settings. Quit rates are lower still for smokers with mental illness. Vaping is significantly more effective than nicotine replacement therapy (Hartmann-Boyce et al., 2021). More studies in smokers with mental illness are needed, but there is no reason to believe that similar outcomes would not apply to smokers with mental illness.

The authors claim without good evidence that vaping is not an effective population health measure. However, numerous population studies in the United Kingdom, United States and Australia have found that smokers who vape are significantly more likely to quit than those using other methods.

Simulation modelling studies have concluded that the overall public health benefits of vaping are likely to be considerably greater than the harms under all plausible scenarios. One study modelled the impact of relaxing regulations in Australia so nicotine vaping products would be as widely accessible as in the United States. Assuming an excess risk for vaping of 5% that of smoking, 104,200 smoking-attributable deaths and 2.05 million life years lost would be averted during 2017–2080 (Levy et al., 2022).

Concerns are also raised about the possible role of vaping as a gateway to smoking. Cross-sectional studies have found that those who first try vaping are more likely to smoke later. However, there is no good evidence of a causal relationship. The most plausible explanation for this association is a common liability for risk taking.

Evidence from population studies suggests that vaping diverts more young people from smoking than encourages them to smoke. Indeed, declines in youth smoking rates in the United States accelerated from around the time vaping became popular. This population finding is the opposite of that predicted by the gateway hypothesis.

Psychiatrists’ first and foremost responsibility is to the welfare of their patients. If a smoker is unable to quit with first-line therapies, it is mandatory to consider tobacco harm reduction, in the same way that methadone is used for heroin users who are unable to quit.

While we wait for more evidence, psychiatrists have an ethical responsibility to minimise the harm from smoking in any way possible, including nicotine vaping, as advised by the RANZCP guidelines.