Last updated: January 2019
Suggested citation: Greenhalgh, EM, & Scollo, MM. InDepth 18B: Electronic cigarettes (e-cigarettes). In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from: http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes
A number of authoritative Australian and global health agencies have issued position statements on e-cigarettes. Excerpts from some of these are included below: it is not practicable to provide an exhaustive list, or to reproduce them in full. Readers should refer to the original position statements for further detail.
Some overseas organisations have also published position statements, and a selection of these, with web links, is listed in Section 18B.10.3, below. The preponderance of these statements have been issued by agencies based in the UK or the USA, where usage of the products is comparatively widespread and the market largely unregulated compared with Australia. Regulation of e-cigarettes in other countries is discussed in Section 18B.9.
For the most part, position statements express caution about e-cigarettes, generally acknowledging that while they could have the potential to benefit public health, there is currently insufficient evidence to be sure that e-cigarettes assist smokers in quitting, do not cause some level of physical harm, and will not serve to undermine long-standing and effective tobacco control measures.
In 2018, the Australian Medical Association, Cancer Australia, Cancer Council Australia, National Heart Foundation of Australia, and the Thoracic Society of Australia and New Zealand released a joint statement,1 concluding:
Based on current evidence, the potential benefit of e-cigarettes on smoking cessation is not established, and there is increasing evidence of health harms. Accordingly, the undersigned health and medical organisations support a precautionary approach to the promotion and availability of e-cigarettes in Australia. This is in line with recommendations from the World Health Organization and the World Federation of Public Health Associations.
These organisations, and others, have also released individual position statements, as summarised below.
The Therapeutic Goods Administration (TGA) is part of the Australian Government Department of Health, and is responsible for regulating therapeutic goods, including prescription medicines. This includes regulating supply, import, manufacturing and advertising of therapeutic goods; and ensuring that therapeutic goods meet required standards of safety, quality and efficacy.2
The TGA notes that:3
Unlike Nicotine Replacement Therapy (NRT) products, which have been rigorously assessed for efficacy and safety and, therefore, approved by the Therapeutic Goods Administration for use as aids in withdrawal from smoking, no assessment of electronic cigarettes has been undertaken and, therefore, the quality and safety of electronic cigarettes is not known.
The Australian Government is concerned about the use of electronic cigarettes in Australia. The impact of wide-scale use of these devices on tobacco use is not known, and the outcome in the community could be harmful.
Among other roles, the National Health and Medical Research Council (NHMRC) has responsibility for developing health advice for the Australian community, health professionals and government.4 The CEO of the NHMRC released a statement on e-cigarettes in 2017,5 noting that:
The Public Health Association of Australia stated in 2018:6
Based on current evidence, and in line with recommendations from the WHO, the World Federation of Public Health Associations, the Cancer Council, Heart Foundation, Cancer Australia and other leading evidence-based organisations, the PHAA strongly supports a precautionary approach to the use, promotion and availability of e-cigarettes in Australia.
These agencies issued a joint position statement in 2015.7 In their Overview, the agencies state that:
...based on past experience in tobacco control and early research on electronic cigarettes, there is sufficient information to act on three particular regulatory gaps in order to prevent uptake and use of electronic cigarettes by young people and other risks to public health. Areas in need of priority attention for this purpose include the proper regulation of: (a) non-nicotine electronic cigarettes; (b) use in smoke-free environments; and (c) advertising.
The agencies make the following recommendations:
The Australian Medical Association (AMA) released Tobacco smoking and e-cigarettes in December 2015.8 The statement notes that ‘the AMA has significant concerns about e-cigarettes. E-cigarettes and the related products should only be available to those people aged 18 years and over and the marketing and advertising of e-cigarettes should be subject to the same restrictions as cigarettes. E-cigarettes must not be marketed as cessation aids as such claims are not supported by evidence at this time.’ Elsewhere in the document, they state that:
The evidence supporting the role of e-cigarettes in cessation is mixed and low level, and e-cigarettes are not currently recognised as cessation aids by the National Health and Medical Research Council, the Therapeutic Goods Administration or the World Health Organisation. In fact, using an e-cigarette may significantly delay the decision to quit smoking. In addition, there is uncertainty about the longer term health implications of inhaling the vapours produced by the illegally imported (and unregulated) solutions.
There are legitimate concerns that e-cigarettes normalise the act of smoking. This has the potential to undermine the significant efforts that have been dedicated to reducing the appeal of cigarettes to children, young people and the wider population. These concerns are supported by research findings that young people using e-cigarettes progress to tobacco smoking. Currently there is no medical reason to start using an e-cigarette.
In its statement of June 2014, Lung Foundation Australia declared that:9
There is currently not enough evidence to suggest the use of e-cigarettes as an effective smoking cessation tool over current recommended strategies including pharmacotherapy and clinical counselling. This could change as more research is published on this subject.
While the number of toxins in an e-cigarette is fewer than those in traditional cigarettes, there are no long-term studies on the safety of e-cigarettes and concern has been expressed about the small particles inhaled when “vaping” and their health impact, particularly on youth.
Lung Foundation Australia strongly urges relevant government agencies to further regulate access to e-cigarette devices and components, nicotine-filled cartridges, and non-nicotine cartridges.
In contrast to the above organisations, in its October 2018 position statement,10 the RANZCP stated its support for the legalisation and regulation of nicotine-containing e-cigarettes and other vaporised nicotine products to facilitate their use as harm reduction tools. It recommends:
In response to the increase in e-cig use, in 2009 the WHO Study Group on Tobacco Product Regulation reviewed the evidence to date, and recommended that ENDS should be ‘regulated as combination drugs and medical devices and not as tobacco products.’11
At the Fifth Session of the Conference of the Parties to the WHO Framework Convention on Tobacco Control (FCTC) in November 2012, the WHO was invited to report on the ‘control and prevention of smokeless tobacco products and electronic nicotine delivery systems, including electronic cigarettes’,12 and to present this report to the Sixth Session of the Conference of Parties, to be held in 2014.
In the lead-up to the release of this report, Dr Margaret Chan, Director-General of the WHO, was sent a letter signed by 53 ‘specialists in nicotine science and public health policy,’ urging the WHO to consider the potential for tobacco harm reduction products to reduce the burden of smoking-related disease.13 In the following weeks a second letter signed by 129 ‘public health and medical authorities from 31 countries’ was sent to Dr Chan, countering the arguments put forward in the first letter and encouraging the WHO to maintain its evidence-based approach to shaping an appropriate regulatory framework for ENDS.14
In October 2014, the WHO presented its report Electronic nicotine delivery systems to Sixth Session of the FCTC Conference of the Parties in Moscow.15 The report included the following clauses:
General considerations (clauses 33–38)
33. Smokers will obtain the maximum health benefit if they completely quit both tobacco and nicotine use. In fact, Article 5.2(b) of the Convention commits Parties not only to preventing and reducing tobacco consumption and exposure to tobacco smoke but also to preventing and reducing nicotine addiction independently from its source. Therefore, while medicinal use of nicotine is a public health option under the treaty, recreational use is not.
34. The rapid growth of ENDS use globally can neither be dismissed nor accepted without efforts to appropriately regulate these products, so as to minimize consequences that may contribute to the tobacco epidemic and to optimize the potential benefits to public health. Thus it is important to identify public health concerns and to consider these concerns when undertaking regulation and surveillance.
35. Regulation of ENDS is a necessary precondition for establishing a scientific basis on which to judge the effects of their use, and for ensuring that adequate research is conducted, that the public has current, reliable information as to the potential risks and benefits of ENDS, and that the health of the public is protected. Public health authorities need to prioritize research and invest adequately to elucidate evidentiary uncertainties as soon as possible. However, the greater responsibility to prove claims about ENDS scientifically should remain with the industry.
36. When designing a regulatory strategy for ENDS, governments should bear in mind the following general regulatory objectives:
(a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth;
(b) minimize potential health risks to ENDS users and non-users;
(c) prohibit unproven health claims from being made about ENDS; and
(d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry.
37. Because the product, the market and the associated scientific evidence surrounding ENDS are all evolving rapidly, all legislation and regulations related to ENDS should be adaptable in response to new scientific evidence, including evaluation of different models for ENDS regulation, as evidence accumulates.
38. Governments should consider that if their country has already achieved a very low prevalence of smoking and that prevalence continues to decrease steadily, use of ENDS will not significantly decrease smoking-attributable disease and mortality even if the full theoretical risk reduction potential of ENDS were to be realized.
The Conference of the Parties accepted the WHO report and requested that the WHO be further invited to prepare ‘an expert report, with independent scientists and concerned regulators… with an update on the evidence of the health impacts of ENDS/ENNDS, potential role in quitting tobacco usage, impact on tobacco control efforts, and to subsequently assess policy options’ for the prevention and control of ENDS.16 The updated report was presented to the Seventh Session of the Conference of the Parties,which took place in India, in November 2016.17 As to the potential role of e-cigarettes in tobacco control, it concludes that:
If the great majority of tobacco smokers who are unable or unwilling to quit would switch without delay to using an alternative source of nicotine with lower health risks, and eventually stop using it, this would represent a significant contemporary public health achievement. This would only be the case if the recruitment of minors and non-smokers into the nicotine-dependent population is no higher than it is for smoking, and eventually decreases to zero. Whether ENDS/ENNDS can do this job is still a subject of debate between those who want their use to be swiftly encouraged and endorsed on the basis of available evidence, and others who urge caution given the existing scientific uncertainties as well as the performance variability of products and the diversity of user behaviour.18
The decision following the report:
Invites Parties to consider applying regulatory measures such as those referred to in document FCTC/COP/7/11 to prohibit or restrict the manufacture, importation, distribution, presentation, sale and use of ENDS/ENNDS, as appropriate to their national laws and public health objectives.19
The World Federation of Public Health Associations (WFPHA) has announced its support for the recommendations provided by the WHO in their 2014 report, Electronic nicotine delivery systems.15 In their position statement, the WFPHA:20
In support of the WHO approach, the WFPHA calls for regulations to:
The International Union Against Tuberculosis and Lung Disease (the Union) recognises tobacco use as a global public health challenge. The Union issued a position statement on ECs/ENDS in 2013,21 and an update in October 2014.22
Key messages of the updated statement include that:
The Forum of International Respiratory Societies (FIRS) is composed of professional organisations and experts in respiratory disease. Member societies include Asociacio´n Latinoamericana del To´rax, the American College of Chest Physicians, the American Thoracic Society, the Asian Pacific Society of Respirology, the European Respiratory Society, the International Union Against Tuberculosis and Lung Disease and the Pan African Thoracic Society. FIRS’ position on electronic nicotine delivery devices includes the following statements:23
The FIRS released a further position statement in 2018,24 specifically addressing e-cigarette use in youth. It concludes:
There can be no argument for harm reduction in children. To protect this vulnerable population from electronic cigarettes and other nicotine delivery devices, we recommend that electronic cigarettes be regulated as tobacco products and included in smoke-free policies. Sale of electronic cigarettes should be barred to youths worldwide. Flavouring should be prohibited in electronic cigarettes, and advertising accessible by youths and young adults be banned. Finally, we recommend greater research on the health effects of electronic cigarettes and surveillance of use across different countries.
The World Medical Association (WMA) is an independent federation of 111 national medical associations, including the Australian Medical Association.25 In their 2012 statement Electronic cigarettes and other electronic nicotine delivery systems,26 the WMA recommended:
Many overseas agencies have issued position statements. Some of these include:
Use of e-cigarettes as a device for harm reduction is more widely supported by health agencies in the UK than in most other countries (see also Section 18B.9).
1. Statement on e-cigarettes in Australia. Australian Medical Association, Cancer Australia, Cancer Council Australia, National Heart Foundation of Australia, Thoracic Society of Australia and New Zealand, 2018. Available from: https://canceraustralia.gov.au/sites/default/files/statement_on_e-cigarettes_february_2018_0.pdf.
2. Therapeutic Goods Administration. TGA basics. Canberra: Department of Health, 27 November 2015. Available from: https://www.tga.gov.au/tga-basics.
3. Therapeutic Goods Administration. Electronic cigarettes. Canberra: Department of Health, 30 March 2015. Available from: https://www.tga.gov.au/community-qa/electronic-cigarettes.
4. National Health and Medical Research Council, NHMRC home page. Canberra: NHMRC; 2015. Available from: https://www.nhmrc.gov.au/.
5. NHMRC CEO statement: Electronic cigarettes (e-cigarettes). Australia 2017. Available from: https://nhmrc.gov.au/about-us/publications/ceo-statement-electronic-cigarettes.
6. Public Health Association Australia. E-cigarettes: Policy position statement. 2018. Available from: https://www.phaa.net.au/documents/item/2949.
7. Cancer Council Australia and Heart Foundation, Position statement - electronic cigarettes. Cancer Council Australia; 2015. Available from: http://wiki.cancer.org.au/policy/Position_statement_-_Electronic_cigarettes.
8. Australian Medical Association. Tobacco smoking and e-cigarettes. 2015. Available from: https://ama.com.au/position-statement/tobacco-smoking-and-e-cigarettes-2015
9. Lung Foundation Australia, E-cigarettes. Brisbane: Lung Foundation Australia; 2014. Available from: http://lungfoundation.com.au/wp-content/uploads/2014/05/Lung-Foundation-Australia-E-Cigarettes-Position-Statement-18-June-2014.pdf.
10. The Royal Australian and New Zealand College of Psychiatrists. Position statement 97: E-cigarettes and vaporisers RANZCP, 2018. Available from: https://www.ranzcp.org/News-policy/Policy-submissions-reports/Document-library/E-cigarettes-and-vaporisers
11. World Health Organization. Who study group on tobacco product regulation: Report on the scientific basis of tobacco product regulation: Third report of a who study group. Who technical report series no. 955. Geneva: World Health Organization, 2009. Available from: http://whqlibdoc.who.int/publications/2009/9789241209557_eng.pdf.
12. Conference of the Parties to the WHO Framework Convention on Tobacco Control. FCTC/cop5(10). Control and prevention of smokeless tobacco products and electronic nicotine delivery systems, including electronic cigarettes. Fifth session, seoul, republic of korea, 12–17 november 2012. Geneva: WHO, 2012. Available from: http://apps.who.int/gb/fctc/PDF/cop5/FCTC_COP5(10)-en.pdf.
13. Abrams D, Axello T, Bartsch P, Bauld L, Borland R, et al. Reducing the toll of death and disease from tobacco - tobacco harm reduction and the Framework Convention on Tobacco Control 2014. Available from:https://nicotinepolicy.net/documents/letters/MargaretChan.pdf
14. Aktan O, Alexanderson K, Alleback P, de Araujo AJ, Arora M, et al., Letter to dr margaret chan, director general, World Health Organization, signed by 129 public health and medical authoroities from 31 countries urging evidence-based approach to ecigs. 16 June 2014. Available from: https://tobacco.ucsf.edu/129-public-health-and-medical-authorities-31-countries-write-who-dg-chan-urging-evidence-based-appro.
15. World Health Organization. Electronic nicotine delivery systems. Report by who to the conference of the parties to the who Framework Convention on Tobacco Control. Geneva: World Health Organization 2014. Available from: http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10-en.pdf?ua=1.
16. Conference of the Parties to the WHO Framework Convention on Tobacco Control. FCTC/cop6(9). Decision. Electronic nicotine delivery systems and electronic non-nicotine delivery systems. Sixth session, moscow, russian federation, 13–18 october 2014. Geneva: WHO, 2014. Available from: http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6(9)-en.pdf?ua=1.
17. WHO Framework Convention on Tobacco Control, India to host the seventh session of the conference of the parties (cop7) and the first session of the meeting of the parties (mop1). Geneva: WHO; 2016. Available from: http://www.who.int/fctc/news/cop7tobehostedinindia/en/.
18. Conference of the Parties to the WHO Framework Convention on Tobacco Control. FCTC/cop/7/11. Electronic nicotine delivery systems and electronic non-nicotine delivery systems (ends/ennds). Seventh session, Delhi, India 2016. Available from: https://www.who.int/fctc/cop/cop7/FCTC_COP_7_11_EN.pdf?ua=1.
19. Conference of the Parties to the WHO Framework Convention on Tobacco Control. Decision FCTC/cop7(9) electronic nicotine delivery systems and electronic non-nicotine delivery systems. Seventh session. Delhi, India 2016. Available from: https://www.who.int/fctc/cop/cop7/FCTC_COP7_9_EN.pdf?ua=1.
20. World Federation of Public Health Associations, Statement by the world federation of public health associations on electronic cigarettes. Geneva: World Federation of Public Health Associations; 2015. Available from: http://www.wfpha.org/images/events/141218_WFPHA_ECig_Statement_FINAL.pdf.
21. International Union Against Tuberculosis and Lung Disease. Position statement on electronic cigarettes (ecs) or electronic nicotine delivery systems (ends). October 2013. Paris: International Union Against Tuberculosis and Lung Disease, 2013. Available from: https://www.theunion.org/what-we-do/publications/official/body/E-cigarette_statement_FULL.pdf.
22. International Union Against Tuberculosis and Lung Disease. Summary position statement on e-cigarettes (ecs) and electronic nicotine delivery systems (ends) 2014. Paris: International Union Against Tuberculosis and Lung Disease, 2014. Available from: https://www.theunion.org/what-we-do/publications/technical/english/The-Union-Summary-Position-Statement-ECs-ENDS-Update-2014-dec-2015.pdf.
23. Schraufnagel D, Blasi F, Drummond M, Lam D, Latif E, et al. Electronic cigarettes. A position statement of the forum of international respiratory societies. American Journal of Respiratory and Critical Care Medicine, 2014; 190:611–18. Available from: http://www.atsjournals.org/doi/pdf/10.1164/rccm.201407-1198PP
24. Ferkol TW, Farber HJ, La Grutta S, Leone FT, Marshall HM, et al. Electronic cigarette use in youths: A position statement of the forum of international respiratory societies. European Respiratory Journal, 2018; 51(5). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29848575
25. World Medical Association, World medical association members' list. Geneva: World Medical Association; 2016. Available from: http://www.wma.net/en/60about/10members/21memberlist/index.html.
26. World Medical Association, Statement on electronic cigarettes and other electronic nicotine delivery systems. Geneva: World Medical Association; 2012. Available from: https://www.wma.net/policies-post/wma-statement-on-electronic-cigarettes-and-other-electronic-nicotine-delivery-systems/.
27. Brandon T, Goniewicz M, Hanna N, Hatsukami D, Herbst R, et al. Electronic nicotine delivery systems: A policy statement from the American association for cancer research and the American society of clinical oncology. Journal of Clinical Oncology, 2015; 33(8):952–63. Available from: http://jco.ascopubs.org/content/33/8/952.long
28. American Cancer Society. American cancer society position statement on electronic cigarettes. Stay Away from Tobacco, 2018. Available from: https://www.cancer.org/healthy/stay-away-from-tobacco/e-cigarette-position-statement.html.
29. Livingston CJ, Freeman RJ, Costales VC, Westhoff JL, Caplan LS, et al. Electronic nicotine delivery systems or e-cigarettes: American college of preventive medicine's practice statement. American Journal of Preventive Medicine, 2019; 56(1):167-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30573147
30. Bhatnagar A, Whitsel LP, Ribisl KM, Bullen C, Chaloupka F, et al. Electronic cigarettes: A policy statement from the American heart association. Circulation, 2014; 130(16):1418–36. Available from: http://circ.ahajournals.org/content/130/16/1418.short
31. British Medical Association's Board of Science and Occupational Medicine Committee, Bma calls for strong regulation of e-cigarettes. London: British Medical Association; 2014. Available from: https://www.bma.org.uk/collective-voice/committees/board-of-science/publications.
32. Canadian Cancer Society, Our perspective on e-cigarettes. Toronto: Canadian Cancer Society; 2014. Available from: http://www.cancer.ca/en/about-us/news/national/2014/perspective-on-e-cigarettes/?region=on.
33. Cancer Society of New Zealand, Position statement on electronic cigarettes. 2011. Available from: https://auckland-northland.cancernz.org.nz/assets/Positions-Statements/E-cigarette-Position-statementFINALJul13.pdf.
34. European Public Health Association. Facts and fiction on e-cigs 2018. Available from: https://eupha.org/repository/advocacy/EUPHA_facts_and_fiction_on_e-cigs.pdf
35. New Zealand Ministry of Health. Ministry of health position statement – vaping products. NZ 2018. Available from: http://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/e-cigarettes.
36. McNeill A, Brose LS, Calder R, Bauld L, and Robson D. Evidence review of e-cigarettes and heated tobacco products 2018: A report commissioned by public health England. Public Health England, London: Public Health England, 2018. Available from: https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review .
37. Royal College of Physicians and others, Joint statement from public health bodies. E-cigarettes: An emerging public health consensus. London: RACP; 2015. Available from: https://www.rcplondon.ac.uk/news/joint-statement-public-health-bodies-e-cigarettes-emerging-public-health-consensus.
38. US Department of Health and Human Services. E-cigarette use among youth and young adults. A report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/index.htm.
39. US Food and Drug Administration, Electronic cigarettes (e-cigarettes). Silver Spring, MD [USA]: US Department of Health and Human Services; 2015. Available from: http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm.
40. National Institute on Drug Abuse, Drugfacts: Electronic cigarettes (e-cigarettes). Bethesda [MD]: National Institute on Drug Abuse; 2015. Available from: http://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes.
41. US Preventive Services Task Force, Final recommendation statement. Tobacco smoking cessation in adults and pregnant women: Behavioral and pharmacotherapy interventions. Rockville [MD]: US Preventive Services Task Force; 2015. Available from: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1.