Rug #1: Vaping nicotine is a very successful way of quitting smoking – much better than all other ways

Two papers just published from the US PATH (Population Assessment of Tobacco and Health Study) have pulled a giant rug out from under one of the major pillars of vaping advocates’ claims about the benefits of vaping: that they are an excellent way to quit smoking. After trying to quit unaided (cold turkey), e-cigarettes are the most common method used by American smokers trying to quit.

The PATH study is a large cohort of smokers and vapers whose smoking and vaping use was recorded at baseline in 2013 and who have been followed up each year to monitor any transitions in and out of smoking and vaping. Prospective cohort studies recruited from the general population are arguably the most powerful ways of assessing the usefulness of different ways of quitting smoking over time in real world settings, outside of the artificiality of randomised controlled trials.

Two papers from the same group lead by long time Australian US resident John Pierce from the University of California, San Diego reported on two waves of follow-up after the initial base-line questionnaire. In the first paper, daily smokers were studied to compare methods of quitting used at their last quit attempt. 23.5% used e-cigarettes, 19.3% used pharmacotherapy only (including NRT) and 57.2% used no product. Cigarette abstinence for 12+ months at Wave 3 was approximately 10% in each group (meaning 90% were still smoking). Different methods had statistically comparable 12+ month cigarette abstinence, including quitting without any aids. So much for the unending hype that e-cigs are so much better than other ways of quitting and that all stops should therefore be pulled out to ensure as many smokers as possible can get unhindered access to this new wonder drug.

In the second paper by the Pierce group published in the high ranking American Journal of Epidemiology, the authors sought to allow for possible confounders in known differences between those smokers who self-select to use e-cigarettes and those who don’t. They identified 24 such potential confounders and statistically controlled for these using “propensity matching” to match each e-cigarette user with up to two closely matched control smokers and then compared their experience with quitting smoking.

12.9% of smokers who used e-cigarettes had quit long term but that there was no statistically significant difference when matched non-e-cigarette-users’ success was compared. The authors concluded “These results suggest that e-cigarettes may not be an effective cessation aid for adult smokers, and instead may contribute to continuing nicotine dependence.”

Rug #2: Australia, with far less vaping than nations like the USA, UK, Canada and New Zealand is falling behind these nations in reducing smoking

The USA and the UK have been awash with e-cigarettes for around a decade, with Canada and New Zealand more recently legislating their widespread availability.  Australia by contrast, has always banned the domestic sale of e-juice containing nicotine. More recently, Health Minister Greg Hunt  has announced his intention to legislate that vapable nicotine be made available by prescription.

Vaping advocates’ mantras invariably include claims that without open access to nicotine for vaping, smokers are severely disadvantaged and Australia’s smoking prevalence is falling behind that of our anglophone rivals in being at the front of the world’s lowest smoking prevalence.  Given this, they argue, we should follow the policies of these other nations. The implication here is that our vaping policy is retarding our ability to reduce smoking.

So let’s look at the latest data.

In July this year, the AIHW (Australian Institute of Health and Welfare) released data from its 2019 survey of Australians’ drug use, including smoking.  Below I set out the most recent official data released by Australia, Canada, New Zealand , the UK and the USA that allow us to check the truth of the vapers’ claims that Australia has fallen behind in reducing smoking.

The latest available data on smoking prevalence from these five nations which are often compared would appear to show that the UK has 14.1% of its  ≥18 population who smoke. Canada (14%) and New Zealand (14.2%) report their data from those aged ≥15years (not ≥18), and Australia from  ≥14years (14%). But as teenage smoking prevalence is less than that of ≥18 year olds, this acts to lower their total smoking prevalence. Australia’s ≥18 prevalence in 14.7%. These are important differences in how each of these nations count smoking.

Secondly, of these five nations, only Australia, Canada and the USA include all combustible tobacco products in their data on “smoking” prevalence. Canada also includes chewing tobacco use, but unlike the other four nations, only counts recent (past 30-day) smoking. The inclusion of chewing tobacco would inflate Canada’s “smoking” prevalence figure, while its “within-30-day” limit would reduce it, compared with all other nations which also count less-than-monthly smoking in their current smoking figures.

By not including all combustible tobacco product use (cigars, pipes, shisha), the “smoking” prevalence figures from the UK and New Zealand will thus underestimate the true prevalence of “smoking” in those nations. This point has previously been made about an earlier “headline” smoking prevalence figure of 15.1% for the USA (see extract below).

While the UK Annual Population Survey reported by the Office of National Statistics intends to cover RYO, it is possible that many respondents answering the question would not necessarily interpret it as doing so. As shown in the clips of the survey at the end of this blog, it asks specifically about cigarettes (after asking a lead in question about all tobacco products. Quite a few respondents might expect a follow up question just on RYO. If this was the case, the UK data may additionally underestimate “cigarette smoking” for this reason.

Taking into account all these factors, and noting the confidence intervals and margins of error noted in the data below, it is likely that Canada, Australia and New Zealand have almost the same smoking prevalence; that England may have slightly higher because of it not counting combustible tobacco other than cigarettes and roll-your-own tobacco, and that the USA has the highest smoking prevalence of the five nations.

• Australia:(2019 AIHW ages ≥14 and  ≥18): (all combustible tobacco users, at any smoking frequency –people who reported smoking cigarettes daily, weekly, monthly or less than monthly) ≥14yrs: 14.0% (margin of error 0.6); ≥18 yrs: 14.7% (margin of error 0.7%) Daily smoking by 11%.
• Canada:(2019 Canadian Tobacco and Nicotine Survey ≥15yrs  14% (Only past 30-day use of any tobacco product — including chewing tobacco)
• New Zealand:2018 Current smoking (smoke at least monthly, and have smoked more than 100 cigarettes in their whole life time) among persons aged  ≥15): 14.2%  (CIs: 13.4-15.0) (Māori adults 34% (31.1-37.1) (cigarettes & RYO only at any smoking frequency)
• UK:(2019 Office of National Statistics; ages  ≥ 18): 14.1%  “who smoke cigarettes nowadays”)
• USA: (2018 NHIS ages ≥ 18): 16.5% (CIs 15.9-17.2) (all combustible tobacco users at any smoking frequency “every day or some days”

With Australia having far less vaping prevalence that the other nations, and keeping in mind the unflattering track record of vaping in smoking cessation, as shown in the two PATH papers above, it is hard to argue that Australia is losing out in the race to have the lowest prevalence of smoking because it has not liberalised access to vapable nicotine.

As leading English smoking cessation researcher Robert West told the BBC in 2016