27 Aug 2016

E-cigarettes: do the benefits outweigh the risks?

From This Way Up, 12:01 pm on 27 August 2016

New Zealand is about to change its laws governing the sale and marketing of e-cigarettes - but how safe are the vaping products and e-liquids currently being sold? And what would a regulated vaping industry look like?

Image 4: Courtesy of Vaping 360

The Ministry of Health is collecting submissions on a plan to allow people to legally buy e-cigarettes containing nicotine, before recommending law changes to the government by the end of this year.

E-cigarette liquids containing nicotine are currently banned under the Medicines Act, although people can buy products containing nicotine online from overseas for personal use. In practice, current rules aren't being enforced so if you want to you can buy nicotine e-liquids over the counter just about anywhere in New Zealand.

According to vaping advocates and some public health experts, vaping technology offers a safe and effective way to help people stop smoking and could be a valuable measure to save some of the 6 million lives lost worldwide to tobacco smoking every year.

But questions remain over the safety of inhaling flavoured e-liquids over the long term. Meanwhile there are concerns about a potential 'gateway effect' – that vaping could be introducing children and non-smokers to nicotine.

Others question the efficacy of vaping as a smoking cessation tool, saying its effectiveness isn't supported by the robust evidence behind other therapies such as patches and nicotine-replacement gum.

“It is probably reasonable to say there is no scientific consensus on how the total potential benefits of e-cigarette availability compare to the total potential harms in the longer term” - Richard Edwards, et al (The NZ Medical Journal, Nov 2015).

Vaping 101

E-cigarette components

E-cigarette components Photo: (FDA)

An electronic cigarette or e-cigarette is a handheld electronic device that was invented by a Chinese pharmacist back in 2003. It vapourises a flavoured liquid by drawing it over a heated coil and the user inhales this vapour. That's why using an e-cigarette is often called vaping.

Today vaping units look more like an MP3 player or a smartphone than a cigarette; they've morphed into personal vapourisers, modular, hi-tech, fully customisable products that can even connect to the internet.

No one is quite sure how many people are using e-cigarettes in New Zealand today. Estimates suggest that anywhere from 13 percent to 20 percent of the population have tried them, with a far smaller proportion using them regularly: the Ministry of Health estimates that about 30,000 adults are using them every month.

And it isn’t just ex-smokers who are vaping to help them kick tobacco. A new generation of consumers are embracing these sleek devices as a lifestyle choice, experimenting with flavoured e-liquids (and making their own), customising their vaping units, and doing smoke tricks that attract millions of views on YouTube.



Does vaping work to stop people smoking?

The BBC journalist Michael Mosley recently took up vaping for a month to explore the latest science around e-cigarettes for a BBC documentary called 'E-cigarettes: Miracle or Menace?'

He said it’s already clear that vaping is far safer than smoking tobacco, and that some evidence would already have appeared if their use was linked to serious health concerns.

“I started off feeling quite cynical about e-cigarettes and I ended up being quite convinced that with the right controls, particularly advertising controls, they do have the potential to deliver benefit” - Michael Mosley.

Dr Michael Mosley

Dr Michael Mosley Photo: Supplied

One of the leading studies looking at how effective e-cigarettes are as a way to help smokers kick the habit was conducted here in New Zealand by Professor Chris Bullen of the University of Auckland. Published in The Lancet in 2013, the researchers tracked 657 people and found that e-cigarettes, with or without nicotine, seemed to be just as effective as nicotine patches at helping smokers to quit.

Professor Bullen said that recent advances in the technology should mean that e-cigarettes would be an even more efficient nicotine delivery mechanism today.

Professor Chris Bullen of The University of Auckland

Professor Chris Bullen of The University of Auckland Photo: Supplied

“I think the weight of evidence now is that they certainly do help some people both in terms of quitting smoking but also in cutting down the numbers of cigarettes they smoke. The problem is we haven’t had a whole lot of time to do this research yet so the science of e-cigarettes is in its infancy although the number of publications that have been coming out about e-cigarettes seems to have gone exponential in the last 12 months to the point where it’s very, very hard to keep up” - Professor Chris Bullen.

The Ministry of Health's spokesman Professor Hayden McRobbie accepted that people are using e-cigarettes to help them stop smoking, but said there is not enough evidence they are effective. “We have only got two studies so far and that is certainly not enough for the Ministry of Health to make recommendations that people should go out there and use e-cigarettes, ” he said.

He said further research is needed before e-cigarettes can be accepted as an approved treatment to stop smoking. Although short-term use appeared to be safe, he said the results of long-term exposure to e-cigarette vapour remain unknown.

Professor Hayden McRobbie, spokesman for the Ministry of Health

Professor Hayden McRobbie, spokesman for the Ministry of Health Photo: Supplied

E-liquids: what’s in them and are they safe?

The e-cigarette market is unregulated in New Zealand. With no testing or product labelling regime in place, there is a lot that consumers don’t know and can’t tell about what's in some of the e-liquids they are buying, including where and how they're produced.

We bought a range of e-liquids and found that some revealed little or no information about what was in them and where they were made. And it’s not easy to do this research yourself. When we approached two local labs to see if we could get some e-liquids currently on sale in New Zealand tested, they both said they couldn't do the work.

It's not an ideal state of affairs - a fact acknowledged by the industry group the New Zealand Vaping Alliance, which is calling for stricter safety, labelling and testing rules so that e-liquids sold here have to comply with tougher British standards.

E-liquid ingredients close-up

E-liquid ingredients close-up Photo: Flickr user Lindsay Fox http://ecigarettereviewed.com (CC BY 2.0)

Although propylene glycol, for example, is widely used by the food industry we still don’t fully understand what gets produced when you heat these ingredients up and inhale them. And if you look online there seems to be no shortage of stories and studies claiming that personal vapourisers can release harmful chemicals.

These include known carcinogens like formaldehyde, respiratory irritants like acrolein, and also diacetyl - a compound linked to a potentially deadly lung condition called 'popcorn lung' that's affected some workers in microwave popcorn factories in the US. So some e-liquids are sold and marketed as being 'diacetyl free'.

But this is where things start getting murky because some of these studies have been criticised as they involve burning rather than vapourising the various chemical constituents, making them unreliable. There have even been claims that some of these unfavourable studies are backed by the tobacco industry to make vaping seem more risky than it really is.

Professor Ian Shaw is a toxicologist based at The University of Canterbury. He said that the big challenge is to measure what happens to ingredients when they are heated, because what you inhale could be quite different to the base ingredients in isolation.

Propylene glycol, for example, was an approved food additive widely used as a preservative and anti-drying agent to stop baked products becoming dry and stale. Ian Shaw said it's also used as ‘dry ice’ in theatres, so the health and safety effects of being exposed to it and even inhaling it are fairly well understood.

“Most of the studies are saying that the effects are far less than cigarette smoke so the studies are looking at e-cigarettes as a way of stopping smoking” - Professor Ian Shaw.

Future regulation

With the Ministry of Health reviewing current laws and deciding how it is going to regulate e-cigarettes, what could the market for e-cigarettes and vaping products look like in New Zealand in the future? Do we treat these products like medicines to be dispensed at a pharmacy, or make them available in a similar way to tobacco or alcohol?

The Ministry of Health said it doesn’t yet have a position on who should be responsible for the better testing and labelling requirements that many accept should be applied to e-liquids and vaping devices. For Nell Rice of Cosmic, one of the country’s biggest retailers of vaping products, responsibility for selling safe products should lie with retailers, overseen by the Ministry of Health.

Meanwhile any stricter testing and labelling requirements will come at a cost. If experience overseas is any guide, then these costs are likely to be passed onto consumers, making vaping products more expensive to buy. It might also reduce the range of products on offer and this could stifle innovation and the development of better, safer products in the future.


Photo: 123rf

According to Professor Richard Edwards of the University of Otago's Department of Public Health, higher compliance costs and regulatory hurdles also tend to favour the tobacco industry, increasing concerns about its involvement in the emerging (and rapidly growing) e-cigarette market as an alternative revenue source.

Professor Edwards has been reviewing how e-cigarettes could be controlled here in New Zealand based on what's happening overseas. He said it will be difficult to find the right approach and suspected we will follow overseas practice, meaning that only e-liquids and devices that have been approved for use in the United States or the European Union will be able to be sold here.

He could also foresee a situation where vaping products would be sold on a restricted basis at pharmacies and at specialist vape shops, with trained staff maximising the chances that the products are being used to help people quit smoking. But he recognised that this is a delicate balancing act.

“We shouldn’t have a situation where the regulations on e-cigarettes are much stronger than on cigarettes. That would seem to make no sense. Cigarettes are much more dangerous”- Professor Richard Edwards.

Final thoughts

With vaping technology relatively new and still developing, and the science underpinning it still in a state of flux, what messages can would-be vapers extract?

Although there is widespread acceptance that inhaling e-vapour is substantially safer than smoking cigarettes, no-one is prepared to say that vaping is entirely risk-free, with the long-term effect of vapourising and inhaling e-cigarette ingredients as yet unknown.

That situation isn't helped by the lack of a robust and coherent system of testing and labelling e-liquids here in New Zealand. Perhaps a law change will provide more certainty for consumers, and hopefully more solid research is on its way.

In the meantime, the best advice seems to be: only start vaping if you're doing so to help you quit smoking, and not as a lifestyle choice.

Also do your research online, and ask questions of the retailers you're buying from about their products - how they're made, what they contain and where they are produced. And if they can't, or won't, answer your questions then consider taking your business elsewhere.

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Photo: Supplied