Policy Debates Regarding Nicotine Vaping Products in Australia: A Qualitative Analysis of Submissions to a Government Inquiry from Health and Medical Organisations

Feasibility of restricting e-cigarettes to prescription only for smoking cessation

E-cigarette use among youth in Canada has risen to epidemic proportions. E-cigarettes are also moderately useful smoking cessations aids. Restricting e-cigarettes to prescription only smoking cessation aids could help limit youth's access to them while keeping them available as therapies for patients who smoke conventional cigarettes. In Canada, drugs or devices must be approved by regulatory bodies such as Health Canada in order to become licensed prescription medications. A similar situation is underway in Australia, where e-cigarettes have been restricted to prescription only. This commentary explores the feasibility of a similar regulation for e-cigarettes in Canada as prescription smoking cessation aids.

E-cigarettes: A framework for comparative history and policy

BACKGROUND

England, Australia and the United States have approached the regulation of e-cigarettes in very different ways, yet all three countries have appealed to the concept of evidence as underpinning policy responses. We compared these policy responses using a combination of the methodologies of historians and policy scientists in order to elucidate the factors that had influenced policy in each country.

ARGUMENT/ANALYSIS

Each country's evidence and values intersected in different ways, producing very different responses within specific national contexts and histories. Our analysis accordingly emphasized the historical precursors of the policy issues raised by e-cigarettes and placed the policy debate within the context of regulatory bodies and the networks of researchers and advocates who influenced policy. Issues also of importance were the nature of the state; political context; the pre-history of nicotine for smoking cessation; the role of activism and its links with government; the influence of harm reduction ideas from drugs and HIV; and finally, whom policy was perceived to benefit. In the United Kingdom, based on this pre-history of the smoking issue, it was the existing smoker, while in the United States and Australia, protecting children and adolescents has played a central role.

CONCLUSIONS

Structural and historical factors appear to underpin differences in e-cigarette policy development in England, Australia and the United States.

An analysis of key stakeholder policy perspectives in the proposed e-cigarette regulations in New Zealand

ISSUE ADDRESSED

The use of e-cigarettes is increasing; New Zealand (NZ) has witnessed a rapid rise in consumption. Policymakers face a challenge to balance the impacts of regulation on those who use e-cigarettes as a smoking cessation tool while protecting people who do not smoke from the harms of e-cigarette use, particularly young people. Previous research has demonstrated varying perspectives on e-cigarette regulation according to different stakeholders and interest groups. This study examined key stakeholders' positions on the drafted legislation to regulate e-cigarettes in NZ.

METHODS

Using written submissions made during public consultation in 2020, we conducted a content analysis to determine levels of support for e-cigarette regulations. Submissions made by the e-cigarette industry and the health sector were included for analysis.

RESULTS

The tobacco industry is heavily invested in ensuring that e-cigarettes continue to be promoted and available in NZ with minimal restrictions. On the contrary, health organisations supported the introduction of regulations to reduce marketing to, and use of e-cigarettes by youth and people who do not smoke.

CONCLUSIONS

The industry opposes restrictions using similar approaches employed against tobacco control measures. Despite perceptions of division, the health sector is generally unified in support of e-cigarette restrictions. SO WHAT?: Policymakers must protect public health policies from commercial interests and be cautious of opposition framed as public health concerns.

Individual and Conjoint Factors Associated With Beliefs About the Harmfulness of Nicotine Replacement Therapies Relative to Combustible Cigarettes Among People Who Smoke: Findings From the 2020 ITC Four Country Smoking and Vaping Survey

INTRODUCTION

This study examined individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies (NRTs) relative to combustible cigarettes (CCs).

AIMS AND METHODS

Data analyzed came from 8642 adults (≥18 years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n = 1213), Canada (n = 2633), England (n = 3057), and United States (n = 1739). Respondents were asked: "Compared to smoking cigarettes, how harmful do you think nicotine replacement products are?" Responses were dichotomized into "much less" versus otherwise for analysis using multivariable logistic regression models, complemented by decision-tree analysis to identify conjoint factors.

RESULTS

Percentages believing that NRTs are much less harmful than CCs were 29.7% (95% CI = 26.2% to 33.5%) in Australia, 27.4% (95% CI = 25.1% to 29.8%) in England, 26.4% (95% CI = 24.4% to 28.4%) in Canada, and 21.7% (95% CI = 19.2% to 24.3%) in the United States. Across all countries, believing nicotine is not at all/slightly harmful to health (aOR = 1.53-2.27), endorsing nicotine vaping products (NVPs) as less harmful than CCs (much less harmful: aOR = 7.24-14.27; somewhat less harmful: aOR = 1.97-3.23), and possessing higher knowledge of smoking harms (aOR = 1.23-1.88) were individual factors associated with increased odds of believing NRTs are much less harmful than CCs. With some country variations, these nicotine-related measures also interacted with each other and sociodemographic variables to serve as conjoint factors associated with the likelihood of accurate NRT relative harm belief.

CONCLUSIONS

Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

IMPLICATIONS

This study demonstrates that despite past efforts to educate people who smoke about the harms of NRTs relative to CCs, misperceptions around the relative harmfulness of NRTs remain substantial. In all four studied countries, subgroups of people who smoke regularly who are misinformed about the relative harmfulness of NRTs, and who may be reluctant to use NRTs for smoking cessation can be reliably identified for corrective interventions based on their understanding of the harms related to nicotine, NVPs and smoking along with sociodemographic markers. The identified subgroup information can be used to prioritize and inform the development of effective interventions to specifically address the gaps in knowledge and understanding of the various subgroups identified. Our results suggest these may need to be tailored for each country.

Nursing students' attitudes, behaviour, and knowledge toward smoking cessation: Results from a descriptive survey at a regional university

BACKGROUND

Smoking is the largest single cause of lifestyle-related preventable morbidity and mortality. Nurses form the largest cohort of health professionals and are strategically placed to implement smoking cessation interventions. However their capacity is underutilised, particularly in rural and remote areas in countries such as Australia where the incidence of smoking in is higher than average and access to healthcare is limited. One strategy to address the underutilisation of nurses in smoking cessation interventions is to include training in the university/college nursing curriculum. To effectively implement this training, it is vital to have an in-depth knowledge of student nurses' attitudes towards smoking including the role of healthcare professionals in smoking cessation, their smoking behaviour and that of their peers, and knowledge regarding smoking cessation techniques and resources.

OBJECTIVES

Investigate nursing students' attitudes, behaviour, and knowledge towards smoking cessation, determine the impact of demographics and educational experienced on these, and develop recommendations for future research and educational practice.

DESIGN

Descriptive survey.

PARTICIPANTS

Non-probability sample of undergraduate nursing students (n = 247) from a regional Australian university.

RESULTS

Significantly more participants had tried smoking cigarettes than had not (p = 0.026). There were no significant relationships between gender and smoking (p = 0.169) or e-cigarette use (p = 0.200), but a significant relationship was found between age and smoking status where older participants (48-57 years) were more likely to smoke (p < 0.001). Most participants (70 %) were supportive of public health measures to reduce cigarette smoking but felt that they lacked specific knowledge to assist their patients to cease smoking.

CONCLUSIONS

Within education there needs to be an emphasis on the central role that nurses play in smoking cessation with a greater focus on training nursing students about smoking cessation strategies and resources. There is also a need to ensure that students know it falls within their duty of care to address smoking cessation with patients.

Use of supporting evidence by health and industry organisations in the consultation on e-cigarette regulations in New Zealand

Objectives

Scientific evidence to support the development of appropriate policy for electronic cigarette use is limited by rapidly changing technology and a lack of long-term data. Perceptions of risk and benefits determine diverse framings of the e-cigarette debate and complicate policy decisions. E-cigarette use by smokers who are attempting to quit may result in improved health outcomes, while their use among young people and non-smokers may lead to adverse health consequences. The purpose of this study was to identify the types of evidence used during public consultations on proposed revisions to New Zealand’s e-cigarette legislation in 2020.

Methods

Using submissions to parliament made by the tobacco/e-cigarette industry and the health sector, we assessed the cited evidence for quality and independence measured by publication type and tobacco industry connections. We identified themes from a sub-sample of frequently cited evidence to understand how stakeholders and organisations used evidence.

Results

The sample consisted of 57 submissions from the e-cigarette and tobacco industry (n = 21) and health organisations (n = 36). A total of 442 pieces of evidence were cited at least once. Health organisations were more likely to cite peer-reviewed evidence (OR = 2.99). The industry was more likely to cite evidence outside of peer review and sources with tobacco industry connections (OR = 4.08). In the sample of frequently cited evidence, youth prevalence and flavours were the most common themes. In some cases the same evidence was used by both groups to support opposing policy positions.

Conclusions

The industry continues to rely more heavily on evidence published outside of the peer-review process, which is, therefore, subjected to less scientific scrutiny. By using a smoking-cessation or harm-reduction narrative, the industry could be seen as a legitimate stakeholder in policy development.

A first pass, using pre-history and contemporary history, at understanding why Australia and England have such different policies towards electronic nicotine delivery systems, 1970s-c. 2018

AIMS

The United Kingdom and Australia have developed highly divergent policy responses to electronic nicotine delivery systems (ENDS). To understand the historical origins of these differences, we describe the history of tobacco control in each country and the key roles played in setting ENDS policy in its early stages by public health regulations and policy networks, anti-smoking organizations, 'vaper' activist networks and advocates of harm reduction policies towards injecting drug use.

METHODS

We analysed key government reports, policy statements from public health bodies and non-government organizations (e.g. cancer councils and medical organizations) on ENDS; submissions to an Australian parliamentary inquiry; media coverage of policy debates in medical journals; and the history of tobacco control policy in Australia and England. Key discourses about ENDS were identified for each country. These were compared across countries during a multi-day face-to-face meeting, where consensus was reached on the key commonalities and divergences in historical approaches to nicotine policy. This paper focuses on England, as different policy responses were apparent in constituent countries of the United Kingdom, and Scotland in particular.

RESULTS

Policymakers in Australia and England differ markedly in the priority that they have given to using ENDS to promote smoking cessation or restricting smokers' access to prevent uptake among young people. In understanding the origins of these divergent responses, we identified the following key differences between the two countries' approaches to nicotine regulation: an influential scientific network that favoured nicotine harm reduction in the United Kingdom and the absence of such a network in Australia; the success of different types of health activism both in England and in Europe in opposing more restrictive policies; and the greater influence on policy in England of the field of illicit drug harm reduction.

CONCLUSIONS

An understanding of the different policy responses to electronic nicotine delivery systems (ENDS) in England and Australia requires an appreciation of how actors within the different policy structures, scientific networks and activist organizations in each country and region have interpreted the evidence and the priority that policymakers have given to the competing goals of preventing adolescent uptake and encouraging smokers to use ENDS to quit smoking.

Cigarette smoking and e-cigarette use among university students in Queensland, Australia and New Zealand: results of two cross-sectional surveys

OBJECTIVES

Examine the patterns of cigarette smoking and e-cigarette use (vaping), the perceived harm of e-cigarettes compared with tobacco cigarettes, and associations between smoking and vaping with student characteristics.

DESIGN

Cross-sectional studies.

SETTING

The University of Queensland (UQ), Australia and eight New Zealand (NZ) universities.

PARTICIPANTS

Students at UQ: 4957 (70.8% aged <25 years, 63.0% women) and NZ: 1854 (82.5% aged <25 years, 60.1% women).

METHODS

Χ2 tests compared smoking by age and gender, and vaping by age, gender and smoking status. Two-sided p<0.05 was considered significant and 95% CIs reported where appropriate. Multinomial logistic regression examined associations between smoking and vaping (exclusive smoking, exclusive vaping, dual use and non-use) with age, gender and student type (domestic vs international).

RESULTS

Smoking (UQ vs NZ, 95% CI): ever 45.2% (43.8% to 46.6%) vs 50.0% (47.7% to 52.3%), current 8.9% (8.1% to 9.7%) vs 10.4% (9.1% to 11.9%) and daily 5.2% (4.6% to 5.8%) vs 5.6% (4.6% to 6.7%), and not smoking in indoor 98.3% vs 87.7% or outdoor smoke-free spaces 83.8% vs 65.3%.Vaping (UQ vs NZ, 95% CI): ever 20.9% (19.8% to 22.1%) vs 37.6% (35.4% to 39.9%), current 1.8% (1.5% to 2.2%) vs 6.5% (5.4% to 7.7%) and daily 0.7% (0.5% to 1.0%) vs 2.5% (1.9% to 3.4%), and not vaping in indoor 91.4% vs 79.6% or outdoor smoke-free spaces 84.4% vs 71.3%. Of respondents, 71.7% (70.3% to 73.2%) vs 75.3% (72.9% to 77.6%) perceived e-cigarettes as less harmful than tobacco cigarettes.Men were more likely than women to smoke and vape, and to believe that e-cigarettes are less harmful. Regression models containing all predictors for smoking and vaping were significant and the effect of gender was significant for dual use, exclusive smoking and exclusive vaping (all p<0.01). Men had higher odds for smoking, vaping or dual use.

CONCLUSIONS

Results suggest significant differences in patterns of smoking and vaping of university students in Australia and NZ, and a strong influence of gender on smoking and vaping.

How are nicotine vaping products represented to pharmacists? A content analysis of Australian pharmacy news sources

BACKGROUND

With the growing popularity and use of nicotine vaping products (NVPs), it is important that pharmacists have evidence-based information in order to provide guidance to their customers. The news media can play an important role in shaping how pharmacists think, feel and act regarding NVPs. This paper examines how NVPs are portrayed and framed in Australian pharmacy news sources.

METHODS

Four leading Australian online pharmacy professional news sources were searched for articles published between 2007 and August 2019. A combination of qualitative and quantitative methods was employed to explore how the safety, efficacy and regulation of NVPs was communicated.

RESULTS

We identified and analysed 103 relevant articles. Academic research findings and/or expert opinions were either cited or referenced most often, appearing in a total of 59% of articles analysed, followed by government sources quoted in 41% of articles. Health effects and safety issues of NVPs were the most frequently mentioned topic appearing in a total of 79% of the stories, followed by NVP-related regulatory issues (47%). The majority of NVP-related articles were framed in a loss rather than gain contexts, with more emphasis given to the concern that NVPs have the potential to addict youth to nicotine and undermine Australia's progress in tobacco control.

CONCLUSION

Australian pharmacy news media have more often reported the potential risks than the potential benefits of NVPs. Such portrayal is likely to contribute to misperceptions about the relative harm of NVPs. Pharmacy staff need access to unbiased and evidence-based guidance on how to handle customer enquiries regarding NVPs.

Framing and scientific uncertainty in nicotine vaping product regulation: An examination of competing narratives among health and medical organisations in the UK, Australia and New Zealand

AIMS

To compare the policy positions of health and medical organisations across Australia, New Zealand, and the UK as they relate to sale and supply of nicotine vaping products (NVPs) and evaluate factors that have informed the differences in policy recommendations among these countries.

METHODS

We used mixed methods to analyse data from position or policy statements published by health and medical organisations regarding NVPs (n = 30) and consultation documents submitted to government committees regarding policy options for the regulation of NVPs (n = 26). Quality assessment of included documents was conducted using the six-item Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers, and findings were presented narratively. Qualitative data were coded using NVivo 12 software and analysed using thematic analysis.

RESULTS

An overwhelming majority of health bodies, charities and government agencies in the UK and New Zealand portrayed NVPs as a life-saving harm reduction tool. In contrast, concerns about addicting non-smoking youth to nicotine, a perceived lack of clear and convincing evidence of safety and efficacy and the potential to undermine tobacco control progress continues to define attitudes and recommendations towards NVPs among Australian health and medical organisations. Although the profoundly divided views among stakeholders seem to arise from empirical uncertainties and disagreements over the level and credibility of evidence, the source of most of these disagreements can be traced back to the fundamental and irreconcilable differences in the framing of the NVP debate, and varied tolerability of risk trade-offs associated with NVPs.

CONCLUSION

Progress in resolving the controversy surrounding NVP policy requires stakeholders to be frame-reflective and engage in a meaningful dialogue of risk trade-offs, as well as both intended and unintended consequences of proposed policies.