Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697642031584.pdf (Australia)
The George Institute for Global Health Level 5, 1 King Street Newtown NSW 2042 AUSTRALIA PO Box M201 Missenden Road NSW 2050 AUSTRALIA info@georgeinstitute.org.au www.georgeinstitute.org SENATE SELECT COMMITTEE ON TOBACCO HARM REDUCTION PUBLIC SUBMISSION About this submission The George Institute for Global Health is pleased to contribute a public submission to the Senate Select Committee on Tobacco Harm Reduction.
The George Institute believes e-cigarettes and other vaping products do not constitute smoking cessation tools that are appropriate for general distribution.

Short-term health consequences are well documented and longer-term consequences are still emerging, making these products unsuitable for widescale use in their current form.
We strongly recommend that e-cigarettes and other vaping products be put through the same rigorous consumer safety assessments that the Therapeutic Goods Administration (TGA) applies to all other products before they are made available to the Australian public.

The temporary decision to allow doctors to prescribe e-cigarettes does not mean that they have been fully tested by the TGA, and these safety processes must be undertaken.
If clear evidence existed that suggested e-cigarettes and other vaping products were a safe and heathy option to constitute smoking cessation, The George Institute would support amendments to the current regulatory frameworks.

Currently there is a lack of clear evidence, and therefore we do not support any amendments.
The George Institute notes that the House of Representatives Standing Committee on Health, Aged Care and Sport released the report, Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia in March 2018.

It recommended the TGA continued to oversee the classification of nicotine and relevant exemptions, and the assessment of any electronic cigarette product as a therapeutic good.
The Senate Select Committee on Tobacco Harm Reduction will influence the regulatory decisions on e-cigarettes and other vaping products that will impact generations of Australian consumers.

The George Institute’s submission, therefore, will directly address the Committee’s terms of reference C,D,E,G and H, while also providing specific information on the known and unknown harms of e-cigarettes and other vaping products for the Australian public.
The George Institute welcomes the opportunity to further engage with the Senate Select Committee on Tobacco Harm Reduction on this important issue.

Affiliated with Tobacco Harm ReductionSubmission 267 About The George Institute for Global Health The George Institute is a leading independent global medical research institute established and headquartered in Sydney.

It has major centres in China, India and the UK, and an international network of experts and collaborators.
Our mission is to improve the health of millions of people worldwide by using innovative approaches to prevent and treat the world’s biggest killers: non-communicable diseases (NCDs) and injury.

Our work aims to generate effective, evidence-based and affordable solutions to the world’s biggest health challenges.

We research the chronic and critical conditions that cause the greatest loss of life and quality of life, and the most substantial economic burden, particularly in resource-poor settings.
We also focus on the risk factors associated with these conditions, especially lifestyle behaviours relating to tobacco, alcohol, and unhealthy food.

commercial determinants of health, including the actions.

The George Institute’s work on tobacco covers the aspects of smoking cessation interventions (including nicotine replacement therapy and counselling), smoking care in primary health contexts, and the development of anti-smoking campaigns.
We advocate for the provision of affordable and effective cessation tools, especially for those experiencing various forms of disadvantage.

Affiliated with Tobacco Harm ReductionSubmission 267 C. The established evidence on the effectiveness of e-cigarettes as a smoking cessation treatment.

There is little established evidence that e-cigarettes and other vaping products are effective smoking cessation treatments, despite repeated claims by the industry.
Additionally, the potential health impacts of these products are still under investigation.

The George Institute would like to emphasise the following points to the Committee:  Public safety: It is crucial that before e-cigarettes and other vaping products are put on the market as smoking cessation treatments, scientists and the TGA are given ample time and funding to conduct rigorous assessments of their safety.
There is currently inadequate evidence of their known or unknown harms to enable informed decision-making.

According to the National Health and Medical Research Council (NHMRC), “e-cigarettes may expose users to chemicals and toxins such as formaldehyde, heavy metals, particulate matter and flavouring chemicals, at levels that have the potential to cause adverse health effects”.
In addition, the NHMRC states, “there is currently insufficient evidence to conclude whether e-cigarettes can assist smokers to quit”.

 Additional harms: Even ‘nicotine free’ e-cigarettes are known to contain harmful cancer-causing chemicals.

This poses an unacceptable risk for Australian consumers that they will trade one harmful product for another in an attempt to quit smoking, and with a tool of unknown efficacy.
According to the Australian Department of Health, e- cigarettes should not be considered safe.

 Industry influence: Despite many manufacturers marketing their e-cigarettes and other vaping products as smoking cessation tools, it has been reported that “…no e- cigarette manufacturer or company has made an application to the TGA".

This has resulted in misinformation to the public about the benefits, or potential harms, of the products they are purchasing.
Industry must be accountable for the health impacts of e-cigarettes and other vaping products, and these processes should not be rushed.

D. The established evidence on the uptake of e-cigarettes amongst non-smokers and the potential gateway effect onto traditional tobacco products.

While there is little evidence that e-cigarettes constitute an effective smoking cessation treatment, there is growing evidence of alarming levels of uptake by non-smokers and ex- smokers, especially among young people.
The George Institute notes the following research:  Gateway to tobacco: E-cigarette use is “associated with greater risk for subsequent cigarette smoking initiation and past 30-day cigarette smoking”.

This is particularly troublesome when we consider that e-cigarette companies target young people, normalising use through the addition of flavoured e-liquids that contain carcinogenic chemicals.
 Risks of exposure: Exposure to e-cigarettes can significantly increase desire for tobacco products in young adult smokers.

It is now understood that “electronic cigarette exposure may evoke smoking urges in young adult daily smokers”.

 Smoking relapse: Use of e-cigarettes is linked to smoking relapse for ex-smokers.
Affiliated with Tobacco Harm ReductionSubmission 267  Cost vs benefit: While it is inconclusive whether e-cigarettes and other vaping products are effective smoking cessation tools, “e-cigarette use currently represents more population-level harm than benefit” because of increased uptake among never smokers and relapse among ex-smokers.

The roll out of these products would undermine a generation of public health policy that has saved the lives of countless Australians.
Even if e-cigarettes and other vaping products were to be used for smoking cessation purposes, they constitute an unnecessary risk to human health.

E. Evidence of the impact of legalising nicotine vaping products on youth smoking and vaping rates and measures that Australia could adopt to minimise youth smoking and vaping.

Young Australians are at particular risk from the harms associated with the legalising of nicotine vaping products.
The George Institute would like to emphasise the following to the Committee:  Attractiveness: Around one-quarter of young people are curious about e-cigarettes, and these individuals have stronger intentions to experiment with and use the devices.

This highlights that availability needs to be heavily restricted to prevent wide-scale uptake among youth.

 Flavoured e-liquids: E-cigarette and other vaping products companies target young people by selling e-liquids in a range of flavours.
Amongst young adults, the vast majority of those who used e-cigarettes preferred flavoured varieties.

To minimise youth smoking and vaping, we recommend restricting the availability of these products to reduce their appeal.

 Policy in Australia: As above, there is significant evidence that e-cigarette and other vaping products lead to increased rates of youth uptake of tobacco products.

To minimise harm, strong regulation of e-cigarette and other vaping products is crucial.
G. Tobacco industry involvement in the selling and marketing of e-cigarettes.

It is widey recognised that the tobacco industry is playing an increasing role in the sale and marketing of e-cigarettes and other vaping products, both as cessation tools and as recreational devices.

As tobacco consumption continues to decrease, the tobacco industry must find new ways of targeting individuals and selling product.
The George Institute would like to emphasise to the Committee:  Changing tack: Although Australia’s efforts to date have been largely successful in protecting public health policies from tobacco industry interference, electronic nicotine delivery systems and other “smoke-free” products created by leading tobacco companies are a source of harm and a mechanism via which the tobacco industry is renewing its activities under the guise of “creating a smoke-free world”.
Such products are growing rapidly in popularity, even among non-smokers.

 Targeting youth: These companies are using pervasive marketing techniques to target young people to take up the use of e-cigarettes and other vaping products, Affiliated with Tobacco Harm ReductionSubmission 267 including through the sponsorship of youth-oriented events.
According to the Public Health Association of Australia, “there’s research to suggest that ads for e-cigarettes feature themes (including the expression of identity, friendship, sex and the attainment of social status) and use techniques (like animation, cartoons or attractive and young protagonists) that have known appeal to youth”.

H. Any other related matters.

All public health policy should be based on evidence.
As above, e-cigarettes and other vaping products are not appropriate smoking cessation tools based on best evidence of the known and unknown short- and long-term harms.

In addition to the points made above, The George Institute would like to emphasise to the Committee:  Taxation: Should e-cigarettes ever be legalised in any form, it will be critically important to develop a scale of taxation that is consistent with the taxation of tobacco cigarettes.
E- cigarettes should not become a low-cost alternative for perpetuating nicotine addiction.

 Groups experiencing vulnerability: Overall, smoking rates are on the decline in Australia.

However, groups experiencing vulnerability are particularly at risk of tobacco use and uptake of e-cigarettes and other vaping products.

These groups need to be supported to quit as safely and efficiently as possible using evidence-based methods and products approved by the TGA.
Contact Professor Simone Pettigrew Program Head, Food Policy The George Institute for Global Health Chelsea Hunnisett Policy and Advocacy Adviser, Global Advocacy & Policy Engagement The George Institute for Global Health Affiliated with Tobacco Harm ReductionSubmission 267