I have been involved in drug harm-reduction debates in Australia since the early 1980s. Every new harm-reduction intervention met fierce resistance, often lasting years. This happened with methadone treatment for problem heroin users, needle syringe programs to slow the spread of HIV, and drug consumption rooms to reduce drug overdose deaths.
Each debate was nasty, personal and dishonest. The current debate about vaping unfortunately fits this pattern. Harm-reduction approaches eventually win because they are much more effective, safer and cheaper than the alternatives. Needle syringe programs in Australia from 2000 to 2009 cost taxpayers $200 million, but every $1 spent saved $27.
Vaping opponents are suspicious of any attempt by cigarette companies to reduce harm, with justification. Decades ago tobacco companies introduced low-nicotine and low-tar cigarettes, as a top-down, disingenuous attempt to improve their image.
However, the story of vaping has a very different trajectory. The first commercially successful vaping device was invented in 2003 by a chain-smoking Beijing pharmacist who had failed to quit despite trying all conventional methods many times. It has grown to be a global industry dominated by ex-smokers grateful to have been freed from their cigarette addiction. Cigarette companies own no vaping companies in Australia and less than 20 per cent of global vaping. Vaping competes with smoking.
Successful harm reductions have taken a bottom-up approach. Early in my harm-reduction career I learnt that to be effective I had to work closely with the people who use drugs. When advocating for needle syringe programs, senior people told me that those who injected drugs would never use sterile needles. Yet I knew from talking to people who injected drugs that sharp, unused needles hurt much less than needles blunted from use many times, so-take up rates would be high.
Vaping is similarly a bottom-up approach, and therefore likely to succeed. As digital cameras are to film cameras and smartphones are to landlines, vaping is a disruptive innovation that has significantly undermined the cigarette industry. In the past few years since vaping and other harm-reduction options began to eat into the lucrative cigarette market, the market capitalisation of tobacco companies has fallen steeply. Heated tobacco products, another form of tobacco harm reduction, were introduced to the Japanese market in April 2016. Three years later, cigarette sales were down 31 per cent.
Greg Hunt, the Australian health establishment and the World Health Organisation are deeply entrenched in their positions against tobacco harm reduction and this disruptive innovation. Yet they will eventually lose. It is nonsensical to make vaping, the less risky nicotine option, hard to get while cigarettes, the much more risky option, can be bought easily from 20,000 outlets across the country. And when there is strong demand for a commodity and the legal supply is closed or becomes exceedingly difficult, other illegal sources inevitably emerge.
The critics argue that vaping hasn’t been around long enough for all its negatives to be known. Yet cigarette smoke contains 7000 chemicals at high concentration, whereas vaping aerosol contains fewer than 300 chemicals, mostly at trace concentration. Surely this has to be a much lower risk. Even with unknown risks, the Royal College of Physicians estimates that the long-term risks of vaping are likely to be no more than 5 per cent of the risk of smoking.
Would the same critics also oppose the Ebola vaccine? Will they wait 20 years before accepting a new COVID vaccine?
Australia should make it as easy as possible for our 2.7 million smokers to switch from high-risk cigarettes to much lower-risk vaping, while also minimising the uptake of all nicotine products by youth through regulation.
Alex Wodak, a retired physician, is an emeritus consultant at St Vincent’s Hospital, Sydney, and a director of the Australian Tobacco Harm Reduction Association.