Electronic cigarettes, or e-cigarettes, have been growing in popularity in Australia and across the globe. While there has been significant interest in the direct health impacts of e-cigarettes, the potential for e-cigarettes to lead to tobacco smoking has also garnered much attention.
Accounting for more than 10 per cent of deaths worldwide, tobacco smoking is one of the greatest threats to health, known to cause cancer, diabetes and heart and lung disease. Due to the seriousness of the harms caused by tobacco smoking, helping smokers quit and preventing the uptake of smoking is a significant priority.
So, do e-cigarettes lead to smoking?
A recent review by researchers at the Australian National University found that non-smokers using e-cigarettes are, on average, three times as likely to take up smoking cigarettes than non-smokers who have never used e-cigarettes.
All 25 studies included in the review found a significantly increased likelihood of taking up smoking in non-smokers who had used e-cigarettes, however the degree to which people were more likely to take up smoking varied, ranging from approximately 1.2 to 12 times. E-cigarette use increased the chance that someone would try smoking, but also that they would go on to become a regular cigarette smoker. While the exact reason for this increased risk is not known, it is likely that nicotine addiction from e-cigarettes plays a role.
The ANU review also investigated whether e-cigarettes could influence relapse into tobacco smoking for ex-smokers. The results indicated that ex-smokers were almost 2.5 times as likely to relapse into smoking if they used e-cigarettes, compared to those that did not. Only three studies looked at this, and further research would provide greater certainty for this finding.
While e-cigarettes are used by individuals of all ages, their growing popularity in young people is worrisome. In the US, 5 per cent of middle and 20 per cent of high school students used e-cigarettes in 2020 - that's around 3.6 million youths. In 2019, the acting commissioner of the Food and Drug Administration, Ned Sharpless,conceded that the FDA "should have acted sooner" to halt the e-cigarette epidemic in adolescents.
Given the risk of smoking uptake with e-cigarette use, the high levels of use of e-cigarettes in youth could undermine declines in smoking rates. This is particularly true for Australia, where our success is increasingly driven by reduced smoking initiation in youth.
Australia is an acknowledged world leader in tobacco control and is now leading the world in evidence-based regulation of e-cigarettes. The strong evidence on uptake of smoking by non-smokers was a key consideration in the recent world-pioneering decision by the Therapeutic Goods Administration to restrict access to e-cigarettes to prescription-only.
This decision has the dual effect of restricting availability to non-smokers but allowing access for smokers wanting to quit, working with their health professional.