Generation Vape: Australia’s new public health crisis

With their tell-tale clouds of white smoke, e-cigarettes – or vapes – are a common sight on our streets. But concern is rising about their use, especially amongst young people. Stories abound of high school students vaping within the school grounds, prompting the NSW branch of the Australian Medical Association to conduct a study into students’ use of vapes.

Earlier this year, the Federal health minister, Mark Butler, announced action to “stamp out vaping – particularly among young Australians”, with the Federal Budget including funding to address illegal vaping.

How did young Australians become so addicted to these flavoured nicotine hits, and what can be done about it?

Truly a public health crisis

Generation Vape is a first-of-its-kind, long-term study operated as a partnership between Cancer Council NSW, the Daffodil Centre and the University of Sydney. It began in 2021 in NSW before expanding its reach nationally in 2022.

“It’s an ongoing study where we’re looking at attitudes, beliefs and behaviours of young people, parents, teachers and young adults about vaping because we do not have a lot of data,” says Dr Becky Freeman, chief investigator of the Generation Vape study and Associate Professor in the School of Public Health at the University of Sydney.

The research uses both quantitative and qualitative approaches, including interviews, surveys and focus groups. What it’s found so far is that young people find it easy to get vapes, whether through friends, ‘dealers’ or at places outside of school. In fact, 80 per cent of young people said they found it easy to get hold of vapes in NSW.

According to the findings so far, 53 per cent of young vapers who took part in the research had used a vape that they knew contained nicotine.

The study has provided crucial insights into vaping behaviours amongst young Australians, Freeman says: “Now we have a lot of data to back up that vaping is truly a public health crisis in Australia.”

Commercial interests vs public health

Vaping has been positioned as a tool that could help wean people off harmful cigarettes. Now it seems they’re creating similar problems to their cancer-causing counterparts.

“I think it’s really important to interrogate who was saying that it was going to be a smoking cessation aid and why it was being positioned that way,” Freeman says.

“The tobacco industry, which is part of the vaping industry as well, has always said that vaping products, e-cigarettes, whatever you want to call them, are smoking cessation products. But when you look at how they’re marketed and packaged and designed and sold, and who they’re sold to, they’re primarily used by young people who have never smoked.”

Data from the Australian Institute of Health and Welfare (AIHW) supports this sentiment: 65 per cent of those aged 14–17 had never smoked before when they first tried vaping, while 34 per cent were smokers. For those aged 18–24, 58 per cent were current smokers when they tried vaping for the first time, and 39 per cent had never smoked.

And the Institute’s data also reveals some of the reasons young people engage in vaping:

• 22 per cent of those aged 18–24 thought they were less harmful than traditional cigarettes
• 21 per cent said they tasted better than cigarettes
• 6 per cent said they tried e-cigarettes to help quit smoking.

The AIHW notes its concerns about this trend, due to the “hazardous substances” in some vapes and the presence of addictive nicotine. Quoting a US study, the AIHW states: “E-cigarette liquid flavours have played a marketing role in promoting the perceived attractiveness of e-cigarettes and in encouraging people to start smoking them.”

Generation Vape’s research also provides insights into why young people choose to vape; in its February to May 2023 NSW findings summary, young people listed “flavours and taste” as their main reason for using e-cigarettes.

An unhelpful distinction

Freeman says the prevalence of vaping, especially amongst young people, is due to a variety of factors, and “there’s a lot to unpack.”

“It’s sort of a confluence of the fact that we’ve got these inexpensive, flavoured, disposable vaping devices on the market [and] they contain a high concentration of nicotine salts. We’ve got aggressive online marketing [and] a whole bunch of misinformation about product safety. We have this very unhelpful distinction between nicotine and non-nicotine, which allowed retailers to claim they were legally selling non-nicotine products when we know they were selling nicotine.

“And you put all those together with the commercial interests at play – there’s a lot of money to be made in selling a highly addictive product to young people, and the inability to enforce these laws because of this non-nicotine loophole,” she adds.

All of this means the “dramatic increase in vaping” has become “normalised” amongst young people.

The commercial imperative behind the sale of vapes means prohibition, or banning, is tricky. Nevertheless, in May the Federal Government announced a ban on non-prescription vaping.

The Federal Government’s approach is for more stringent regulation and enforcement of vapes, including:

• Stopping the importation of non-prescription vapes
• Increasing minimum quality standards for vapes
• Requiring that vapes come in pharmaceutical-like packaging
• Reducing the amount of nicotine allowed in vapes, and
• Banning single-use disposable vapes.

Also, the Federal Government pledged to end the sale of vapes in places like convenience stores, limiting their availability to pharmacies; and both vaping products that do contain nicotine and those that don’t will require a prescription.

A ‘fiddle around the edges’ approach

“These products can be regulated and they will still be available. They’re not being, quote-unquote, banned to everyone. There will be nicotine-containing vaping devices and liquids will be available by prescription from pharmacies,” Freeman says.

A paper published in The Lancet in November, ‘Recreational vaping ban in Australia – policy failure or masterstroke?’, considered the Federal Government’s plan and placed it in the context of vaping regulations around the world. It noted that nicotine vapes are used as a “first-line treatment for smoking cessation” in the UK, with the prevalence of vaping in 11-18 year-olds at 8.6 per cent.

A charity known as UK Action on Smoking and Health has recommended that the UK government take action to “reduce the accessibility, affordability and appeal of vapes to children” through things like taxation and marketing and packaging regulation. Regulation of vapes is also a hot topic in other countries, according to the study, including across Africa and Asia.

The paper concluded that debate is ongoing around the world as to how best to deal with vaping, especially amongst young people, and as a smoking cessation aid, and asked: “Who is right? Will we debate forever? Or will we unite – across nations, societies and health-care systems – against the tobacco industry in working towards a common goal of long-term tobacco cessation?”

Freeman believes the current prevalence of vaping is at a critical juncture, and compares it to tobacco control several decades ago.

“I think we made a huge mistake in tobacco control 50 years ago when we knew these products were so dangerous. We decided 50 years ago to take a sort of ‘fiddle around the edges’ [approach],” she explained.

This approach included “demand reduction strategies” like increasing the price of cigarettes through taxation, ending advertising for smoking, putting graphic health warnings on cigarette packs and banning smoking in public places.

And they worked, she concedes – but it took time.

“All those small incremental changes over a long period of time have worked really well to bring smoking rates down – but it’s taken decades for that,” she says.

Instead, Freeman believes now is the time to tackle vaping head-on by addressing what has caused them to become so popular.

“We know it’s the easy access – we heard [that] from young people in our Generation Vape study. It’s the fact that they’re sold on every street corner. They’re dirt cheap, they smell good, they’re readily available. We have to address access – and that’s what these new laws are about.”

Regulating vaping

Freeman says the current regulatory framework is built around nicotine, which is classified as a poison in Australia at both federal and state levels. Exceptions are provided for tobacco products prepared for smoking. This, Freeman says, is how cigarettes and other combustible tobacco products can be sold legally. Smoking cessation aids that contain nicotine and that have been approved by the Therapeutic Goods Association are also excepted.

“E-cigarettes are currently an unapproved medicine. They fall under the poison standards. But instead of having gone through the approval channels [for] being a safe and effective cessation device … they are an unapproved medicine that you must have a prescription to access now,” Freeman says.

Meanwhile, non-nicotine vapes are not subject to a regulatory framework, she says, although NSW has regulated them through its state-level tobacco control laws. Under the Public Health (Tobacco) Act 2008 (NSW), it’s illegal to sell vapes to people under the age of 18. Non-nicotine vapes are legal and can be purchased by adults, but those containing nicotine are prescription-only and available at pharmacies. It’s also illegal to display, advertise and promote the devices.

Freeman says the proposed federal regulations will eventually mean that importing vaping products will be banned, with the distinction between non-nicotine and nicotine products removed. Disposable vapes will be taken off the market, and the prescription model will remain.

“The vaping products that will be available on prescription will be very different from the ones that you can buy from convenience stores and petrol stations. It’s proposed that they will only come in mint and tobacco flavour; and they will be sold in pharmaceutical-like packaging,” she says.

She believes the importation ban will be of particular importance to solving the vaping problem.

“The market is flooded with these things. They’re everywhere. Enforcement is going to be so much easier with this non-nicotine/nicotine distinction removed because, at the border, we’ll be able to just seize products that aren’t destined for a pharmacy.”

“This is going to fundamentally change the market,” Freeman says, “and get rid of this open season market. I think it is unfair to say that this will fix everything – of course, it won’t, but it’s going to be a heck of a lot better than what we’ve got.”

No magic bullet

Although there are changes on the horizon, the current public health issue – the number of young people addicted to vapes – remains. But Freeman is optimistic that this too can be addressed.

“Nicotine is highly addictive. But … we have a real window of opportunity to act here,” she says.

The Federal Government’s vaping action package includes support for those looking to quit vaping, with $63 million set aside for a public health information campaign to discourage vaping and smoking. Another $30 million will be put towards quit support programs.

“We already have really good infrastructure for quit smoking support that we can add vaping to,” Freeman explained.

Schools will also need to be involved, offering support and help for students caught with vapes rather than penalising them, she added.

Education will be a vital part of any legal and regulatory reforms designed to tackle vaping, but Freeman says it can’t be relied upon as a magic bullet, given the might of the commercial engine driving the use of tobacco products.

“Education is a support for regulatory processes. Regulation is the backbone of what we do in tobacco control, and then you beef that up with really supportive education and cessation initiatives,” she says.

“But to expect [education] to be enough to push back against the commercial interests involved here … these are very powerful commercial forces at work. Legislation is so necessary.”

Schools should not take a “punitive approach”, Freeman says.

“We don’t want kids being suspended or missing out on school activities because they were caught with a vape at school. Again, expecting your average 14-year-old to be able to push back against the enticing marketing of big tobacco or vape retailing is unfair. So [we should be] taking a really supportive approach, offering those quit supports, but at the same time being really clear and firm that vaping is not acceptable at school. It’s not giving permission to vape; it’s taking a non-judgemental, supportive view.”