Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697634107289.pdf (Australia)
Tobacco Harm Reduction Senate Select Committee on Tobacco Harm Reduction SUBMISSION November 2020 1 Tobacco Harm ReductionSubmission 292 About NACCHO NACCHO is the national peak body representing 143 Aboriginal Community Controlled Health Organisations (ACCHOs) Australia wide on Aboriginal and Torres Strait Islander health and wellbeing issues.
NACCHO’s work is focussed on liaising with governments, its membership, and other organisations on health and wellbeing policy and planning issues and advocacy relating to health service delivery, health information, research, public health, health financing and health programs.

Our Members provide about 3.1 million episodes of care per year for around 350,000 people across Australia, which includes about 800,000 episodes of care in very remote and outer regional areas.
Sector Support Organisations, also known as Affiliates, are State based and also represent ACCHOs offering a wide range of support services and Aboriginal and Torres Strait Islander health programs to their Members including advocacy, governance training and advocacy on State and Territory Government health care policies and programs.

Affiliates also support ACCHOs to deliver accessible, responsive, and culturally safe services for Aboriginal and Torres Strait Islander people.
The leadership and support provided by Affiliates strengthens governance and financial expertise in the Aboriginal and Torres Strait Islander community-controlled health sector.

Affiliates provide a strong interface for the Aboriginal and Torres Strait Islander community-controlled health sector with the national reform agenda occurring in the health system.
Together NACCHO and Affiliates harness better coordinated, more cohesive and cost-effective mechanisms for stakeholder and community engagement on Aboriginal and Torres Strait Islander health issues, and providing advice to Federal, State and Territory Governments.
ACCHOs range from large multi-functional services employing several medical practitioners and providing a wide range of services, to small services which rely on Aboriginal Health Workers/Practitioners and/or nurses to provide the bulk of primary care services, often with a preventive, health education focus.

Our 143 ACCHOs operate approximately 700 facilities, including about 450 clinics.
ACCHOs and their facilities and clinics contribute to improving Aboriginal and Torres Strait Islander health and wellbeing through the provision of comprehensive holistic primary health care, and by integrating and coordinating care and services.
Many provide home and site visits; provision of medical, public health and health promotion services; Allied Health; nursing services; assistance with making appointments and transport; help accessing childcare or dealing with the justice system; drug and alcohol services; and providing help with income support.
Across the sector we employ about 6,000 staff, 56 per cent of whom identify as Aboriginal or Torres Strait Islander, which makes us the second largest employer of Aboriginal and Torres Strait Islander people in the country.
Any enquiries about this submission should be directed to: NACCHO Level 5, 2 Constitution Avenue Canberra City ACT 2601 Telephone: 02 6246 9300 Website: naccho.org.au 2 Tobacco Harm ReductionSubmission 292 Introduction We thank you for the opportunity to make this response to your Inquiry into Tobacco Harm Reduction.
We make this submission with input from Aboriginal Medical Services Alliance Northern Territory (AMSANT), Aboriginal Health and Medical Research Council of NSW (AH&MRC) Victorian Aboriginal Community Controlled Health Organisation (VACCHO) and Aboriginal Health Council Western Australia (AHCWA) Although the use of nicotine vaping products (vaping), including electronic cigarettes and smokeless tobacco, has increased in recent years in attempts to reduce traditional tobacco smoking (conventional smoking), their effectiveness and benefits remain unclear.
Emerging evidence suggests that, like conventional smoking, vaping has an adverse impact on lung and heart functioning, respiratory health, fertility, immunity and brain development.

Aboriginal and Torres Strait Islander people, who experience disproportionate levels of chronic health conditions and co-morbidity as compared to other Australians, are particularly susceptible to the harmful effects of not only conventional smoking but also vaping.
Vaping is not only practiced by people wanting to stop conventional smoking; people who have never previously engaged in conventional smoking, particularly youth, are increasingly vaping.

More so, evidence suggests vaping can readily lead to conventional smoking.

Aboriginal Community Controlled Health Organisations (ACCHOs) have contributed significantly to reduced smoking rates, but the harm caused by vaping and its gateway to conventional smoking is of significant concern to our sector.
ACCHOs and other Aboriginal and Torres Strait Islander community representatives and primary healthcare experts need to be central in the continued development of policy and programs aimed at reducing conventional smoking, as well as vaping, among Aboriginal and Torres Strait Islander people.

Key points • Conventional smoking is responsible for one in five Aboriginal and Torres Strait Islander deaths and is the most preventable causes of poor health and early death.
There is insufficient evidence to understand how many deaths vaping is potentially responsible for.

• Emerging evidence suggests that although vaping is not as harmful as conventional smoking, its health effects are similar, including on lung and heart functioning, respiratory health, fertility and immunity, and impedes brain development among youth.
• Like conventional smoking, vaping before, during and after pregnancy adversely impacts the health and wellbeing of mother as well as her child.1 • Aboriginal and Torres Strait Islander people, who experience chronic health conditions and co-morbidity at higher levels compared to other Australians, are particularly susceptible to the harmful effects of conventional smoking and (although to a lesser degree) vaping, as are Aboriginal and Torres Strait Islander people living in overcrowded housing exposed to inhalation.
• ACCHOs continually demonstrate creativity and innovation in effective public health awareness campaigns, including recently during community closures as a result of COVID-19, and with allocated funding, including funded tobacco control positions, can contribute to effective tobacco harm reduction messaging.
• Following the tireless and successful work of ACCHOs to reduce conventional smoking among Aboriginal and Torres Strait Islander people, particularly youth, there are strong concerns as to the health effects of vaping and the risk of it leading to conventional smoking.
1 Tackling Indigenous Smoking, 2020, Mothers and Babies, https://tacklingsmoking.org.au/introduction-to-activities/mothers-and-babies/ 3 Tobacco Harm ReductionSubmission 292 • Public awareness raising about the harms of vaping and strategies to reduce vaping among Aboriginal and Torres Strait Islander people must be developed in genuine partnership and shared decision-making between the Australian Government and Aboriginal and Torres Strait Islander community representatives, including ACCHOs, as outlined in the new National Agreement on Closing the Gap2 (the National Agreement).
Recommendations That the Australian Government work with ACCHOs and other Aboriginal and Torres Strait Islander community representatives in genuine partnership and shared decision-making as outlined in the National Agreement, to: 1. increase ACCHOs’ funding to: a. expand the Tackling Indigenous Smoking (TIS) and other tobacco reduction programs and services, including funded positions and with a greater focus on reducing the use of vaping products.
b. produce and circulate innovative, localised public health awareness campaigns around the harms of vaping, in the preferred language/s of the targeted communities c. train and educate TIS workers about the harms of vaping, who can effectively communicate the message to clients and review and continuously improve the public health awareness campaign.
2. further invest in research and increase ACCHO’s and other Aboriginal and Torres Strait Islander health providers’ access to its findings into: a. the harms of different nicotine and non-nicotine vaping products b. best approaches (if any) to using vaping products and other approaches to reduce conventional smoking, and c. the need for and best practise approaches to reduce vaping, such as those outlined by the National Best Practice Unit at TIS.3 Background Vaping products containing ‘e-liquids’ that comprise varying levels of nicotine, heavy metals and other harmful substances have become increasingly popular in Australia.4 Around 30% of Australian conventional smokers and around 21% of Aboriginal and Torres Strait Islander smokers have tried e- cigarettes.
Aboriginal and Torres Strait Islander people who have tried e-cigarettes tend to be under 30 years of age, living in urban areas, daily smokers and wanting to quit or having made attempts to quit in the past year.5 Recent research has found that over half of all people using vaping products are under 35 years of age, and slightly over 9% are 18-24 years of age.6 The number of Aboriginal and Torres Strait Islander people in urban locations who are regular smokers has dropped by 12%, whereas there has been no change in rural and remote regions.7 ACCHOs across urban, rural and remote Australia in recent years have delivered services and programs aimed at reducing tobacco use among Aboriginal and Torres Strait Islander people.
The Tacking Indigenous Smoking (TIS) and other programs have successfully reduced tobacco use in a 2 National Agreement on Closing the Gap, 2020, https://www.closingthegap.gov.au/national-agreement-closing-gap-glance 3 Tackling Indigenous Smoking, 2019, About the National Best Practice Unit at TIS, https://tacklingsmoking.org.au/about-nbpu-tis/ 4 Cancer Australia, 2018, Statement on e-cigarettes in Australia, Canberra, https://www.canceraustralia.gov.au/sites/ 5 HealthInfoNet, 2019, Tackling Indigenous Smoking: E-cigarettes, https://tacklingsmoking.org.au/e-cigarettes/ 6 Thomas, D., Lusis, N., van der Sterren, A., Borland, R., 2019, Electronic cigarette use and understanding among a national sample of Australian Aboriginal and Torres Islander smokers.
Nicotine & Tobacco Research, 21(10), 1434-1440, https://doi.org/10.

7 Thomas, D., & Calma, T., 2020, Tackling Indigenous smoking: a good news story in Australian tobacco control https://www.phrp.com.au/wp 4 Tobacco Harm ReductionSubmission 292 range of locations, including the Australian Capital Territory (see case study), but there is need and opportunity to expand the work of ACCHOs to promote and counter the harms of vaping.
The regionalised distribution of TIS funding has also resulted in ACCHOs missing out on much needed funding.

The effects of vaping The health risks and effects of vaping are largely determined by the chemical compositions contained in the vaping product.8 The vape liquid is an unregulated product and may contain harmful substances such as heavy metals and nicotine even when labelled free of these ingredients.
With the composition of content in each vaping product varying, including differing levels of nicotine and changeable concentrations and forms of heavy metals, the nature and extent of harm on users also varies from product to product.

Also, the frequency of use also determines health effects.

Like other vaping products, e-cigarettes typically contain a range of chemicals, including solvents and flavouring agents, and may or may not contain nicotine and heavy metals.
Many users, including young people, prefer e-cigarettes containing nicotine and heavy metals, including chromium, nickel and lead in greater quantities than in conventional cigarettes, which have an adverse impact on the users’ health.9 Case Study: Tackling Indigenous Smoking Tackling Indigenous Smoking (TIS) is a national program aimed at improving life expectancy among Aboriginal and Torres Strait Islander people by reducing tobacco use.
The TIS health promotion program delivers a range of activities including information sessions and stalls at events, schools and workplaces to provide education and information on the harms of smoking.

The TIS program has a range of free promotional merchandise that communicates the impact of smoking during pregnancy, the health benefits of avoiding uptake of smoking (especially among younger people) and the dangers of second-hand smoke.
While the TIS program recognises the harmful impacts of vaping, inadequate funding prevents ACCHOs from sharing information as to the harms of vaping with some Aboriginal and Torres Strait Islander communities.

The TIS program is run by most of the 143 ACCHOs across Australia, including Winnunga Nimmityjah Aboriginal Health & Community Services (Winnunga), located in Canberra.
Smoking cessation support is delivered by Winnunga’s No More Boondah quit smoking program and the Aboriginal Quitline.10 Though the AH&MRC Nicotine Replacement Therapy Project consistent feedback has been received that many ACCHOs do not have staff funded for tobacco control.

For this reason its important to expand the scope of TIS and not just provide additional funding to those already receiving it.
Initial indications suggest that vaping is less harmful than conventional smoking, but this does not mean it is harm-free.

Vaping is different but not necessarily better than existing harm-free quit smoking methods.11 The impacts of vaping are largely unknown due to it being a relatively new trend and it not being around long enough for longer-term health effects to show.

Until there is more conclusive evidence as to the exact harms of vaping it should be considered as harmful as conventional smoking.
Compounding the difficulty, many people using vaping products are current or recent conventional smokers, which makes it difficult to separate the effects of vaping use from 8 Cancer Australia, 2018, Statement on e-cigarettes in Australia, Canberra, https://www.canceraustralia.gov.au/sites/ 9 Jongenelis, M., Kameron, C., Brennan, E., Rudaizky, D., Slevin, T., Pettigrew, S., 2018, E Australian young adult e 10 Winnunga, 2020, Tackling Indigenous Smoking, https://winnunga.org.au/services/social-health/tobacco-cessation-services/ 11 Tackling Indigenous Smoking, 2019, About the National Best Practice Unit at TIS, https://tacklingsmoking.org.au/about-nbpu-tis/ cigarette users.
Cancer Prevention and Control, 42(6), 572-574.

10.1111/1753-6405.12842 cigarette product preferences among ‐ ‐ 5 Tobacco Harm ReductionSubmission 292 long-term tobacco use.
Emerging evidence12 indicates that, like conventional smoking, vaping products containing nicotine: could lead to the irreversible lung disease bronchiolitis obliterans (‘popcorn lung’) increases risk of cardiovascular disease causes changes to lung functioning and respiratory health problems • • • may be associated with an increased risk of heart attack and cancer • • adversely affects fertility • • • impedes brain development among young vapers, and can cause brain damage, and is harmful to a baby or infants, if vaping occurs before, during and after pregnancy.
lowers immunity, meaning users have a higher risk of catching the flu or other infections Due to the harm of conventional smoking and also vaping caused to babies and infants before, during and after pregnancy, public health campaigns from a prevention lens should extend their message to the need for smoke-free and vape-free homes and cars.

Chronic health problems and co- morbidity are experienced by a disproportionate number of Aboriginal and Torres Strait Islander people compared to other Australians.
As a consequence, they are more susceptible to the effects of conventional smoking and vaping.13 Many Aboriginal and Torres Strait Islander people face the additional issue of living in overcrowded housing which makes them susceptible to second-hand toxins from vaping, further aggravating existing chronic health conditions such as asthma or chronic obstructive pulmonary disease (COPD).14 Vaping as a tobacco harm reduction strategy There is mixed evidence around the effectiveness of vaping for reducing or ceasing conventional smoking.15 International studies have found that many people who use vaping products will continue or even commence smoking tobacco, whereas other studies suggest e-cigarette users maintain a tobacco-free status at one-year follow-up.16 More research is required into the effects of vaping and its effectiveness or lack thereof in reducing tobacco consumption.
Vaping as a harm reduction strategy has been the position of many vaping/tobacco lobbyists.

Research is required to determine the legitimacy of this approach from an evidence based perspective.
Research has found that some people who use vaping products, including those containing nicotine and heavy metals, had never previously been conventional smokers, which suggests many users do not use e-cigarettes to quit conventional smoking.17 Also, it is not uncommon for people who have never previously smoked conventional cigarettes and who start vaping to progress to conventional smoking, making vaping a gateway to first-time conventional smoking.
Emerging evidence suggests that whereas adults usually reduce their tobacco smoking when they increase vaping, when young people increase vaping they also increase their tobacco smoking.18 Even if vaping does not lead to conventional cigarette use, initial research shows that vaping is addictive and harmful.19 Vaping not only has its own harmful effects on users’ health similar to (but to a lesser degree as) the effects of conventional smoking, but can result in dependence and cessation from vaping is difficult.20 With tobacco use among Aboriginal and Torres Strait Islander people being lower than ever before, including for younger Aboriginal and Torres Strait Islander 12 Ibid, Thomas et al., 2018 13 Ibid, HealthInfoNet, 2019 14 Ibid, HealthInfoNet, 2019 15 Cancer Australia, 2018, Statement on e-cigarettes in Australia, Canberra, https://www.canceraustralia.gov.au/sites/ 16 Ibid, HealthInfoNet, 2019 17 Ibid, HealthInfoNet, 2019 18 Ibid, HealthInfoNet, 2019 19 Ibid, HealthInfoNet, 2019 20 Ibid, Thomas et al., 2018 6 Tobacco Harm ReductionSubmission 292 people, the risk of vaping leading to tobacco use is a large concern.21 While there is a great need for Australian governments, health authorities, health professionals and e-cigarette regulations should provide clearer messages that vaping is less harmful than conventional smoking, but still harmful.22 Conclusion To reduce all forms of harmful tobacco use among Aboriginal and Torres Strait Islander people and communities, it is essential that there is genuine partnership and shared decision-making between the Australian Government and Aboriginal and Torres Strait Islander community representatives (including ACCHOs), as outlined in the National Agreement.
There is significant need for an increased investment in research into: the harms of different vaping products; the effects of other tobacco harm reduction strategies; best approaches (if any) to using vaping products to reduce conventional smoking; and best approaches to reducing vaping products.

Increasing public awareness in Aboriginal and Torres Strait Islander and other communities on the harmful impacts of vaping is also imperative.
ACCHOs require additional funding to expand the Tackling Indigenous Smoking and other tobacco reduction programs to increase the focus on reducing the use of vaping products.

21 Ibid, HealthInfoNet, 2019 22 Ibid, Thomas et al., 2018 7 Tobacco Harm ReductionSubmission 292