In recognition of the disproportionately high smoking prevalence, and low quit rates, among people living with mental illness, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) supports the legalisation and regulation of nicotine-containing e-cigarettes and other vaporised nicotine products to facilitate their use as harm reduction tools. The RANZCP also recognises the potential harm which use of such products may entail and therefore encourages further research to clarify the nature and extent of harm associated with e-cigarettes, as well as the role they may play in smoking cessation.
- People living with mental illness are more likely to smoke tobacco and smoke more heavily than the general population. This is the leading cause of the poorer health and mortality outcomes suffered by this group.
- Tobacco harm reduction is an essential component of any framework that aims to improve health outcomes for people who smoke tobacco.
- Tobacco smokers should have ready access to a broad range of harm reduction and smoking cessation tools.
- Smoking cessation rates are lower for people living with mental illness. Tobacco harm reduction strategies may therefore provide particular benefits for this population group.
- E-cigarettes and vaporisers may provide a less harmful way to deliver nicotine to those who are unable or unwilling to stop smoking tobacco. However, there are no long-term studies recording the magnitude of the effects of long-term vapour inhalation on people’s health.
- Further research is required to ascertain the effectiveness of e-cigarettes and vaporisers as tools for smoking cessation and whether they may provide a novel route into smoking initiation. This does not justify withholding what is, on the current evidence, a lower-risk product from existing smokers while such data is collected
Addictions, including nicotine dependence, are associated with significant morbidities and mortalities across both physical and mental health dimensions; as such, they are a core concern for psychiatrists. People living with mental illness suffer disproportionately from the harm of tobacco smoking. Research in Australia shows that 70% of people with schizophrenia and 61% of people with bipolar disorder smoke compared to 16% of those without mental illness (Cooper et al., 2012). People living with mental illness are not only more likely to smoke, but they also tend to smoke more heavily than the general population (Ratschen, 2014) and are less likely to succeed during a smoking cessation attempt (Cather et al. 2017). People with mental illness experience significantly poorer physical health outcomes too, including increased comorbidities and reduced life expectancy (RANZCP, 2015); smoking is the leading cause of this health gap (Sharma et al., 2017).
Tobacco harm reduction is an essential component of any policy framework that aims to improve health outcomes for people who smoke and is endorsed in Australia's National Tobacco Strategy (ICD, 2012). Although smoking rates of the general population in Australia have decreased significantly in the past 20 years, the smoking rate did not significantly decline between 2013 and 2016, for the first time in two decades (AIHW, 2017). Furthermore, the rates of smoking in people with severe mental illness have not decreased at all (Cooper et al., 2012). The situation in New Zealand is likely to be similar. This population group would greatly benefit from policies focussed on tobacco harm reduction. The RANZCP is concerned that policies with an unduly narrow focus on abstinence risk exacerbating health and financial disparities and perpetuating the discrimination which this group continues to experience.
The RANZCP supports a multi-pronged approach to reducing tobacco-related harm encompassing a wide range of clinical interventions and public policy initiatives, based on an appropriate balance between smoking cessation and tobacco harm reduction approaches. A comprehensive approach should include the legalisation and regulation of e-cigarettes and vaporisers proportionate to the associated risks, as is the case in New Zealand. This is consistent with a preventive precautionary approach which encourages ‘the replacement of dangerous substances and activities with less dangerous substances or technologies where suitable alternatives are available’ (Martuzzi and Tickner, 2004). Considering the complex legal status of cigarettes in Australia (ATHRA, 2018), there would be benefits in having a uniform approach to regulation across the country.
Harm reduction strategies are designed to reduce rather than eliminate the harm associated with particular activities. Although complete abstinence from tobacco smoking is preferable, the RANZCP recognises that many people living with mental illness face difficulties abstaining. The RANZCP also acknowledges that e-cigarettes and vaporisers provide a less harmful way to deliver nicotine to people who smoke, thereby minimising the harm associated with smoking tobacco and reducing some of the health disparities experienced by people living with mental illness. It is on this basis that the RANZCP supports the legalisation and regulation of nicotine-containing e-cigarettes to facilitate their use as harm reduction tools. This may be relevant for both tobacco and cannabis smoking.
As e-cigarettes are a relatively new invention, there are no long-term studies on the nature and magnitude of the effects of long-term vapour inhalation on people’s health and the research which does exist isconflicting (Scollo and Winstanley, 2016). The long-term effects of vaping are unknown and possible health risks associated with the use of e-cigarettes and vaporisers include the inhalation of toxins in the vapour and the potential impact of the inhalation process on the respiratory system. However, it has been estimated that long-term use of e-cigarettes is up to 95% less risky to an individual’s health than smoking regular cigarettes (RCP, 2016; McNeill et al., 2015; Nutt et al., 2014). Although the level of risk is likely to be far less than from smoking,there should nevertheless be vigilance to any emerging evidence on e-cigarettes and vaporisers being linked to long-term health problems.
Internationally there is significant debate about the effectiveness of e-cigarettes and vaporisers as tools for smoking cessation. Data from large population-based surveys suggest that many people report quitting smoking using e-cigarettes (Farsalinos et al., 2016; Office for National Statistics, 2017; CDC, 2017). While few randomised controlled trials have been conducted in this area, a Cochrane review estimated the odds of smoking cessation using nicotine-containing e-cigarettes to be approximately doubled compared to placebo (Hartmann-Boyce et al., 2016). However, the effectiveness of e-cigarettes for smoking cessation continues to be disputed (Peters, 2017). The RANZCP recognises the potential of e-cigarettes and vaporisers as a smoking cessation tool, and supports further research to clarify the role of these products in smoking cessation.
Some international work suggests that the use of e-cigarettes and vaporisers may be associated with the development of nicotine dependence and subsequent tobacco smoking initiation in young people (Primack et al., 2018; Soneji et al., 2017). However, much of this is cross-sectional rather than longitudinal data and so cannot establish whether e-cigarette use preceded tobacco smoking initiation (Etter, 2017). Where longitudinal data do exist, they do not distinguish between occasional or experimental tobacco use and established smoking. As a result, e-cigarettes may not necessarily lead to the uptake of tobacco smoking among non-smokers. From a public health perspective, smoking rates continue to fall among young people in countries that have widespread access to vaping products (Warner, 2018) with increased usage of e-cigarettes among young people coinciding with continuing declines in youth tobacco smoking rates (Bauld et al., 2017).
Nevertheless, the potential that increased access to e-cigarettes and vaporisers may jeopardise continued progress in reducing smoking initiation in young people in Australia and New Zealand is of concern. The RANZCP recognises the need for balance in the regulation of e-cigarettes and vaporisers to reduce the incidence of new nicotine users through this route while still encouraging the harm reduction gains of smokers switching to these devices (see Warner and Mendez, 2018). This should include strong restrictions on all types of discounting, promotion, advertising and sponsorship relating to e-cigarettes and vaporisers, including prohibitions against advertisements which target children and adolescents.
The RANZCP supports a legislative framework where e-cigarettes and vaporisers are controlled proportionate to their risks while still allowing for individuals to have appropriate access to these products at a reasonable cost. Regulation is important as it can influence the health benefits of e-cigarettes and vaporisers (Yong et al., 2017).
The RANZCP also suggests a review of any legislation after five or 10 years to ensure that regulations reflect up-to-date research on the harm and benefits of these products.
The regulation of e-cigarettes and vaporisers should aim to achieve the following objectives:
- adherence to safety and quality standards including a minimum age of sale
- evidence-based health warnings to the public
- public education of the relative harmfulness of these products compared to cigarettes
- appropriate restrictions on advertising and display
- minimal taxation to encourage uptake of these devices over smokable tobacco products.
It is important that regulations strike an appropriate balance between competing public health priorities such as the need to encourage uptake of e-cigarettes and vaporisers among users of tobacco products while mitigating the potential risks, and ensuring that uptake among non-smokers and youth is minimised. The tobacco industry should not be involved in shaping regulations given the unavoidable conflict of interest, much like is the case for tobacco products currently.
The RANZCP recognises the potential harm reduction benefits presented by e-cigarettes and vaporisers for people living with mental illness, and the need for legislative reform for these to be realised. The RANZCP therefore recommends:
- exemption of nicotine-containing e-cigarettes and vaporisers from the restrictions imposed under the Poisons Standard so that they may be subject to stringent and suitable regulations as consumer products
- lower rates of taxation for e-cigarettes and vaporisers compared to smokable tobacco products to ensure affordability for low-income smokers, and to provide a financial incentive to switch
- further research into:
- the long-term health effects of vaping
- the effectiveness of e-cigarettes and vaporisers as a cessation tool
- monitoring of demographic patterns of use including rates of initiation by young people.