18.8 Population-level benefits and harms of increasing e-cigarette use

Decisions and debates about how best to regulate e-cigarettes have stemmed from assessments of their potential comparative risks and benefits.¹ The effects of e-cigarettes on population health can be informed by examination of: the health effects of vaping compared with smoking, vaping compared with use of neither product, and vaping in addition to smoking (i.e. dual use); and the behavioural effects of vaping for both people who smoke and those who don’t smoke (i.e. effects on uptake, cessation, and transitions between nicotine and tobacco products). Obtaining data to measure such effects is complicated by a range of factors, including the time lag needed—often decades following exposure—to identify health effects, difficulties reliably quantifying vape use, the often-complex exposure profiles of people who have a history of using multiple tobacco and nicotine products, differences in device and user characteristics, and rapidly changing regulations.^2,3

There is broad agreement that regulations on e-cigarettes should consider both potential benefits for people who smoke alongside risks for those who have never smoked or used nicotine, particularly young people.³ However, the weight each of these considerations is given varies depending on ethical frameworks, interpretations of evidence, and national contexts and histories.^1,4 Despite many thousands of publications on e-cigarettes, there is still no consensus regarding their safety and effectiveness.⁵ In light of the rapidly evolving evidence and uncertainty surrounding the products Australian researchers have attempted to develop a framework for assessing the public health impact of e-cigarettes and to inform the development of evidence-based policy. The framework comprises seven components: (1) characterisation of products under consideration; (2) definition of populations of interest; (3) characterisation of exposure to tobacco smoking, control and impacts on health and well-being; (4) review of evidence on patterns of e-cigarette use; (5) review of evidence on the relationship of e-cigarette use to health outcomes ; (6) assessment of likely risks, benefits and safety and (7) identification and assessment of policy options to optimise health outcomes. Consideration of each of these components—and reconsideration as more evidence becomes available—can guide high-quality decision making on e-cigarettes.⁶ Discussion of e-cigarettes in Tobacco in Australia follows this model. Section 18.1 characterises e-cigarette products and Section 18.2 describes how these are advertised and promoted to populations of interest. Section 18.3 sets out available data about extent of use of e-cigarette products in Australia. Section 18.4 summarises safety risks. Section 18.6 summarises the findings of a rapidly growing body of research on the potential health effects of use of e-cigarettes. Section 18.7 provides an overview of the evidence on the effects of e-cigarette use on smoking uptake and cessation. This section (Section 18.8) focuses on potential population-level impacts.

18.8.1 Modelling of net impact of use of e-cigarettes on smoking prevalence and tobacco-related disease

Using the evidence to date about effects of e-cigarette use on smoking behaviour and making varying assumptions about health risks of vaping, researchers have attempted to model possible outcomes of e-cigarette use on smoking behaviours and public health. The usefulness of such modelling is of course limited by the absence of data on long-term health effects, difficulties of precisely quantifying the effects of vaping on smoking uptake, and uncertainty about effects on smoking prevalence at the individual and population level (see Section 18.7). Conclusions therefore vary substantially depending on the assumptions and parameters used by researchers.

One early study noted that, based on patterns of vaping and smoking, smoking prevalence appears to be far more sensitive to e-cigarette effects on smoking cessation than on smoking initiation. Results from the model suggested that if e-cigarettes increase both uptake and quitting of conventional cigarettes, the effects on uptake would have to be extremely large (i.e., increase over 200%) to offset even small cessation effects on population smoking prevalence.⁷ It is not surprising then, that models that assume optimistic estimates of likely effects on smoking cessation tend to find high net positive benefits for increasing population use of e-cigarettes.

A modelling study of the health and cost impacts of e-cigarettes in New Zealand concluded that a fairly permissive regulatory environment achieves net health gain and cost savings. However, there was a large degree of uncertainty for this finding, given uncertainty about the impact of vaping on cessation rates and the relative health risk of vaping compared with smoking.⁸ Updated modelling in New Zealand using less optimistic estimates about cessation effects and less optimistic assumptions about potential reductions in health effects however found that while net health and cost-saving benefits were still likely from the liberalisation of access to e-cigarettes, the revised estimates suggest these gains and savings would be of smaller magnitude than previously thought, with a greater possibility of there being no net health gain or even net health harm.⁹         

US researchers have concluded that a substantial gateway effect (of vaping to smoking by never smokers) or an increase in the magnitude of harms from e-cigarettes relative to cigarettes (or both) would be required before the harms to public health outweigh the benefits of e-cigarette uptake. The authors estimate a net public health benefit associated with e-cigarettes resulting in 21% fewer smoking-attributable deaths and a 20% reduction in life years lost.¹⁰ A more recent modelling study by some of the same researchers concluded that, under an ‘optimistic scenario’, replacement of cigarette by e-cigarette use over a 10-year period would yield 6.6 million fewer premature deaths with 86.7 million fewer life years lost. Even under pessimistic assumptions regarding cessation, initiation and relative harm, they argue that replacing cigarette smoking with vaping would yield substantial life year gains, particularly among younger cohorts.¹¹

Additional studies that modelled smoking outcomes in England and the US concluded that e-cigarette use is associated with substantial reductions in smoking prevalence and smoking-attributable deaths.^12-14 A modelling study in Ukraine similarly concluded that e-cigarettes have the potential to reduce the burden of smoking.¹⁵ However, it is important to consider not just the outcomes for smoking, but also the health outcomes from vaping and uptake/gateway effects. While e-cigarette use was initially concentrated among people who smoked, the proportion of people who vape that have never smoked rose rapidly in the early 2020s, particularly among young people.¹⁶ When researchers have more broadly modelled the effects of e-cigarette use on public health in the US they found that it would translate to 1.8 million premature smoking-attributable and vaping-attributable deaths avoided and 38.9 million life-years gained during the period 2013–2060, but noted the uncertainty of future trends given unknown use behaviours and regulations.¹⁷ An Australian study published in 2023 concluded that more liberal access to vapes would likely yield a net public health benefit, though noted that the findings were sensitive to assumptions about the relative health risks of vaping and the rates of switching between products.¹⁸ Additional modelling studies in the US, Germany¹⁹ the Russian Federation,²⁰ and Mexico²¹ also found that e-cigarette use was likely to reduce smoking-attributable deaths;^22,23 however one study notes that this would only represent a small fraction of such deaths, and emphasises the importance of continued existing evidence-based tobacco control measures in order to reduce smoking-related harms.²³  

In contrast to the modelling studies that find net population benefits of e-cigarette use, modelling studies with less optimistic assumptions about cessation effects and more pessimistic assumptions about effects on uptake tend to find net population harm. A collaboration of researchers with expertise in youth smoking uptake have estimated that e-cigarette use in 2014 represents a population-level harm in the US of about 1.6 million years of life lost over the lifetime of all adolescent and young adult never-cigarette smokers and adult current cigarette smokers. If e-cigarette use confers long-term health risks, the model estimated even greater population-level harm. They argue that previous models—which reached more favourable conclusions about the public health impact of e-cigarettes—are based on faulty assumptions about uptake and smoking initiation among young people.²⁴

Another study that modelled the potential health effects of increasing e-cigarette use concluded that—in order for there to be any benefits to public health—most e-cigarette users need to be currently smoking and interested in quitting or people who would have otherwise gone on to smoke. Other scenarios, such as e-cigarette use renormalising smoking, dual use, or significant uptake by young people (those young people who would otherwise never have smoked tobacco cigarettes) have the potential to increase population-level harm. The authors suggest that the likelihood of negative scenarios eventuating will ultimately depend on the regulatory environment, with benefits to public health being more probable with strict regulations on the sale, promotion, and use of the products; i.e., regulations that encourage use only by people who smoke,²⁵ and only without simultaneous use of tobacco products. An Australian commentary published in 2024 concluded that e-cigarette use is likely to incur substantial avoidable costs to the healthcare system if users transition to smoking.²⁶

Researchers in Singapore modelled the potential impact of different e-cigarette and tobacco cigarette policies over 50 years, combining evidence from Singapore (where e-cigarettes are currently banned) with evidence from Japan, the UK and the US (where e-cigarettes are much more widely accessible). The study concluded that while a less restrictive e-cigarette policy could reduce smoking prevalence in the short term, it is not as effective as other policies in the long term. The most effective single policies were ‘smokefree generation’ and substantial tax increases; the most effective combination of policies was raising the minimum legal age plus moderate tax increases and e-cigarettes on prescription.²⁷

A review published in 2021 critically appraising modelling studies concluded that while most suggest that the introduction of alternative nicotine products would have a beneficial population health impact, the predictions are based on a number of factors and assumptions for which epidemiological evidence is lacking.²⁸ Another review similarly found that while the majority of modelling studies on the population impacts of e-cigarette use predicted favourable outcomes, almost half of the studies relied on the basis that e-cigarettes produce only 5% of the adverse health effects associated with smoking—an estimate that has been increasingly challenged due to mounting evidence on health risks of vaping. Models that assumed high rates of e-cigarette initiation among non-smokers and that e-cigarettes discourage smoking cessation predicted more negative population impacts from their use.²⁹ A recent systematic review found that many modelling studies had significant limitations in model structure, data quality, transparency, and handling of uncertainty, making it difficult to draw definitive conclusions. It concluded that current studies are not robust enough to reliably inform policymakers about the consequences of restrictive versus permissive e-cigarette policies.³⁰ Overall, any population-level effects may include some groups incurring harm (e.g., young people who would not otherwise have smoked who take up vaping or who start smoking), and some incurring benefits (e.g., people who smoke that quit). Changing cessation rates are seen earlier than the effects of changing initiation rates, due to the health effects of smoking taking many years to manifest. Conclusions of various models will therefore vary based on whether the projections are short- or long-term, with potential harms from increased initiation by youth occurring decades after the benefits of increased cessation are seen.³¹

18.8.2 The renormalisation of nicotine use 

Decades of successful public health campaigning have profoundly denormalised smoking.³² As evidence has accumulated about the hazards of tobacco, stronger public health measures—including restrictions on smoking in public places—have been widely adopted³³ and attitudes to tobacco use and the tobacco industry have become increasingly negative over time (see Section 10.17). With smoking and nicotine addiction having fallen drastically among teenagers over the past few decades, there is concern that the rapid increase in vape use and exposure could undermine these gains and  promote the normalisation of nicotine use, and subsequently lead to long-term use and addiction among those who would otherwise never have vaped or smoked.³¹ Research has found that exposure to e-cigarette use among young people increases their likelihood of vaping uptake—see Section 18.9.6.4. Along with being more susceptible to vaping, data from a nationally representative survey of US secondary school students showed that observation of e-cigarette use at school was associated with significantly higher odds of being susceptible to smoking cigarettes, especially among middle-school students.³⁴ Californian research similarly found that adolescents who had a family member or peer that used e-cigarettes reported more positive attitudes about and greater willingness to take up smoking.³⁵ Young people who vape who have never smoked also have a markedly increased risk of smoking uptake—see Section 18.7.1.

People who vape commonly report using the products to circumvent no-smoking policies,^36-38 and many users report using e-cigarettes discreetly in places where use is prohibited.³⁹ Such use has the potential to undermine hard won restrictions on smoking and vaping in public places and in the process contribute to the normalisation and uptake of vaping. British American Tobacco has promoted its e-cigarette products to investors as a means of increasing the frequency of nicotine use, including at home, commuting to work, at work, and in bars where smoking is now less acceptable.⁴⁰ Research in the US found that one in five high school students who had never used tobacco products reported exposure to secondhand e-cigarette aerosol in public, which was associated with overestimation of peer use for both e-cigarettes and conventional cigarettes, as well as increased curiosity and susceptibility to e-cigarettes and cigarettes.⁴¹ 

Norms among adults who vape or smoke towards e-cigarettes appear to reflect country regulations, such that people in countries with less restrictive policies (England, Canada and the US) are exposed to more e-cigarette use in public and are more likely to report that society and people important to them approve of e-cigarette use compared with people in countries with more restrictive policies (such as Australia).⁴² In 2022–23, about four in five Australians indicated that they would support restrictions on vaping in public places and on e-cigarette advertising (80% and 82%, respectively), and 86% supported restricting sales to people aged 18+. Support for these measures tended to increase alongside age, but all were supported by the majority, even among younger Australians.⁴³

18.8.3 Interference by the tobacco and e-cigarette industries in public health policy

Although e-cigarettes were originally developed and marketed independently from the tobacco industry, some of the world’s largest tobacco companies subsequently heavily invested in the market—see Section 18.1.2.3. Given its history of unethically promoting and defending tobacco cigarettes, the tobacco industry’s involvement in e-cigarettes is of great concern to public health experts.⁴⁴ While claiming to be working toward a ‘smoke free future’ with investments in vapes and other nicotine products, tobacco companies continue to heavily market combustible products and oppose tobacco control measures. Tobacco companies appear to be using investment in e-cigarettes to portray themselves as concerned about their customers’ health and strategically position themselves as legitimate stakeholders in research and policy debates.^45,46  A study that analysed New Zealand’s e-cigarette policy documents from 2015 to 2024 found that policy responses were delayed and often lacked the strength needed to prevent industry interference, allowing commercial actors to oppose, bypass, or weaken regulatory measures. Evidence also showed repeated engagement between the industry and public health stakeholders, which may have legitimised the industry’s role in tobacco harm reduction discussions.⁴⁷ An article by an international group of Indigenous advocates and researchers further argues that framing new nicotine products as safer alternatives often ignores structural inequities and the broader social determinants of health and serves to divert attention from industry accountability and ongoing harm.⁴⁸

Following decades of interference by the tobacco industry in tobacco control policy—see InDepth 10A—the tobacco and e-cigarette industries have been adopting a range of similar tactics to prevent or weaken e-cigarette regulations. Common strategies that have been reported include lobbying decision makers (see also Section 18.1.2.4), funding research (see below), running public relations campaigns, attempting to discredit those working in tobacco control,⁴⁹ filing lawsuits and using international trade and investment agreements to challenge regulations,^50,51 developing products that increasingly resemble pharmaceutical products to circumvent regulations and position themselves as part of the ‘solution’ to smoking,^52,53 and creating front groups.⁴⁹ For example, the Foundation for a Smoke-Free World (now called ‘Global Action to End Smoking’), while claiming its mission is to eliminate smoking and encourage a shift to ‘reduced harm’ products, has been largely funded by Philip Morris International who continue to oppose and undermine effective tobacco control policies.^54,55 Philip Morris has also funded retail groups in Australia that have lobbied for weaker e-cigarette regulations,⁵⁶ and Philip Morris and Imperial Brands have also reportedly sent pro-e-cigarette messages and/or requested meetings with Australian MPs in recent years.⁵⁷ While the Australian Labor Party, Liberal Party, and Greens do not accept donations from the tobacco industry, the Nationals and Liberal Democrats have continued to receive donations—see Section 10A.7.3. There are also reports of donations from vaping lobby groups to the Liberal Party during debates over legislative reforms.⁵⁸ 

Another common tactic employed by the tobacco and e-cigarette industries is participation in parliamentary inquiries and consultations. An analysis of submissions to the UK’s proposed 2023 generational ban on tobacco sales and new youth nicotine product restrictions found that about two in five (42%) submissions came from transnational tobacco companies and actors with known current links to these companies, who framed themselves as responsible public health stakeholders while opposing the measures claiming they would harm the economy, fuel illicit trade, and increase risks to retailers.⁵⁹ A content analysis of vaping industry actors’ submissions to Australian vaping legislation consultations (2017–2023) found that nearly all submissions misused evidence (96%), most commonly through unsupported factual assertions (92%) and weak evidence (79%). Almost all denied the effectiveness of e-cigarette control strategies, with 85% making unsubstantiated claims about adverse effects from restrictions and 85% promoting industry-favoured regulations.⁶⁰ In 2020, the Australian Therapeutic Goods Administration (TGA) held a public consultation on proposed changes to the regulation of vaping products. An analysis of the 1405 submissions made by self-reported e-cigarette users revealed that about one quarter (26%) contained text copied from a template provided by a vaping industry-led organisation as part of an ‘astroturfing’ campaign (i.e. publishing opinions that appear to come from members of the public but come from a political group or company).⁶¹ A review of submissions to a New Zealand consultation on e-cigarettes found that industry submissions were less likely to cite peer-reviewed evidence and more likely to cite sources with industry connections compared with health organisations.⁶² One paper notes that the extensive resources of these industries means that they can disproportionately influence processes and outcomes and can far outweigh input from health and policy actors.⁶³ Researchers have suggested that government bodies should require a conflict of interest statement on all submissions prior to consideration of the evidence or arguments.⁶⁴

Concerns have also been raised regarding the quality of research on e-cigarettes, with one systematic review finding many serious methodological shortcomings. In 34% of the papers reviewed, the authors had a conflict of interest. Most studies were funded or otherwise supported/influenced by manufacturers of e-cigarettes (including the tobacco industry), which appeared to influence the conclusions of the papers.⁶⁵ Another analysis found that while almost all papers published on e-cigarettes and health without a conflict of interest found potentially harmful effects, less than eight per cent of tobacco industry-related studies reported potential harm. Tobacco industry papers were cited more often than papers written by independent researchers.⁶⁶ Others have highlighted examples of flawed study designs and analyses and misleading conclusions within studies funded by the e-cigarette industry.⁶⁷ Several reviews have found that research funded by the e-cigarette, tobacco, or pharmaceutical industry was significantly associated with a supportive stance on tobacco harm reduction and positive results toward vaping compared with non-industry funded articles,^68,69 with one finding that reporting a conflict of interest with the tobacco industry increased the odds of favourable results by 29 times.⁶⁹ A 2021 review of public health recommendation documents from the WHO, UK, Australia and the US found that many drew on evidence that contained substantial conflicts of interest, including funding from e-cigarette and tobacco companies.⁷⁰ Comprehensive, well-defined and transparent conflict of interest policies from public heath bodies can help to minimise corporate influence and promote public trust.^71,72 An additional concern is the selective or non-reporting of trial outcomes, with an analysis finding that Juul Labs had not completely reported the findings from its registered clinical trials.⁷³ One paper also notes that compared to non-industry-sponsored authors, authors with industry sponsorship may have greater influence on the scientific discourse due to higher numbers of publications and collaborators.⁷⁴

As well as enjoying commercial gains from investing in e-cigarettes, it has been argued that tobacco companies are likely to be keen to exploit opportunities for advertising and promotion that will promote tobacco and/or e-cigarette use.⁷⁵ Many e-cigarette advertisements resemble traditional tobacco advertising.⁷⁶ By becoming involved in alternative nicotine delivery products, companies may be able to evade current restrictions on engagement in policy imposed by Article 5.3 of the Framework Convention on Tobacco Control (FCTC).⁷⁵ In response to concerns regarding the possibility of e-cigarettes interfering with existing tobacco control efforts, the WHO has invited FCTC Parties to “protect tobacco-control activities from all commercial and other vested interests related to [electronic nicotine delivery systems], including interests of the tobacco industry”.⁷⁷

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References  

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