Examining the evidence on the health risks of vaping with Professor Emily Banks

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Gretchen: Hello again. Welcome to Prevention Works, the podcast of The Australian Prevention Partnership Centre, recording here today on Darkinjung and Ngunnawal and Ngambri Lands. I’m Gretchen Miller, and on the show, a hot topic and an expert guest. Our subject is e-cigarettes and the practice of vaping and with us is Professor Emily Banks from the Australian National University.

Professor Banks is a public health physician, an epidemiologist and regarded as a trailblazer in tobacco and e-cigarette research. Her work on how smoking impacts the cardiovascular system and her world leading review of global evidence on the health effects of e-cigarettes released in March of this year [2023], has sparked national and international discussion. Her review, called simply Health Impacts of Electronic Cigarettes, incorporated multiple data sources and methods, and applied them to potential public health outcomes.

Professor Banks wears many hats, amongst other things she’s Head of the Centre of Epidemiology for Policy and Practice at ANU. Some of her other roles include Fellowship of the Australian Academy of Health and Medical Sciences, as well as Chair of the NHMRC Health Research Impact Committee, and she is also a Visiting Professor at Oxford University.

So, to vaping, the Australian federal government has recently introduced e-cigarette product legislation reform as part of its National Tobacco Strategy and this reform has brought international headlines for the proposed restrictions. But we know this is a complicated story. I have a personal interest in this area, both my husband and my brother as former smokers use vapes, and they swear by them as an alternative to the cigarettes they tried so hard to quit. But let’s be clear, it’s already illegal to sell e-cigarettes containing nicotine without a prescription, that is, Schedule 4 drugs. To date though, even the nicotine-free e-cigarettes sold over the counter frequently contain some nicotine, and these have slipped into mainstream consumption, particularly by children.

Having vanquished cigarettes to a degree, our public researchers and policy makers are now looking at an escalation of nicotine use across the country. So, are we back to square one?

Today, we’ll be discussing the likely impact of new legislative movements alongside the bigger picture of vaping practices in Australia and before we go into the details, I asked Emily what this proposed new federal legislation meant for the public health community?

Emily: Well, for a long time public health researchers and professionals and also people in the community have been concerned about e-cigarettes, the increasing use in young people and the targeting of the marketing to young people. So, I think when you talk about your brother and your husband, they’re really good examples of people who may well benefit from switching from tobacco smoking to e-cigarettes because they were smoking and smoking is one of the most harmful things that we can do as a community. It’s still our number one cause of burden of disease and disability and up to two-thirds of all smokers will die from their habit if they don’t quit. They are exposed to something very, very harmful and so e-cigarettes may well be a less harmful option for them but for people who are non-smokers, and particularly for young people, the option for them is breathing air. So, if you compare e-cigarettes with breathing air, they are not likely to be better for people.

One of the main things that we see is nicotine addiction. We tend to trivialize addiction. We say, I’m addicted to chocolate, or I’m addicted to this show on this streaming service, or whatever, but actually addiction is life-changing for an individual who’s affected. Nicotine is highly addictive but not only that, for someone who is addicted, they really only feel normal when they’ve had that hit of nicotine, and then they start to go into gradual withdrawal and that’s experienced as cravings, as an urge to vape or smoke, irritability, difficulty concentrating, and then having vape or having a smoke again. And you can imagine for school children, they are caught in that cycle of craving and withdrawal rapidly throughout the day. There are kids now who find it very difficult to go through a class without vaping.

Addiction is recognised by the WHO, or World Health Organization, as a harm. It’s not a benign thing and so what a lot of these companies are saying to us is, well look, this is really great for quitting smoking but what the community actually sees is like a cross between a Trojan horse and Pandora’s Box – a Pandora’s horse. It’s brought into the community as this will help someone quit smoking, you open it up, and out comes bubble-gum flavoured or fairy-floss flavoured vapes that are being used by kids in the toilets.

Gretchen: And how many flavours did you say the other day?

Emily: There are over 17,000 flavours. If we did a thought experiment about what would this really look like if it was purely targeting people quitting smoking – first of all, they wouldn’t be fairy-floss flavoured. Second, they would not be marketed to children and young people. The other thing is they would be available in consistent doses, but also, they would’ve been submitted and have gone through the approval process for smoking cessation products, and no products have been approved worldwide by regulatory authorities. So doing that thought experiment, you can see that the community is being told, “Well, this is to help people quit smoking”, but they have not signed up for widespread promotion and normalisation of these products among children and adolescents.

Gretchen: What’s your response to this legislation, which has made international headlines?

Emily: My job is really to provide the evidence as an epidemiologist and public health physician, and it’s really up to the community and the community’s representatives and policy makers to take that evidence and to take action. I try not to go too hard into whether a particular government or a particular group has done the right or the wrong thing and whether I’m pleased or not, but much more about whether I think that what has happened is consistent with the evidence.

Gretchen: And is it consistent with the evidence?

Emily: We reviewed the worldwide evidence about electronic cigarettes and we looked at over 25,000 studies down to 400 that we synthesized the evidence from. And that evidence really showed that e-cigarettes do carry a number of risks and what our findings showed is that e-cigarettes increase the risk of addiction. They also cause poisoning. They can cause toxicity from inhalation and that can lead to seizures. They’ve also been shown to increase the risk of lung injury and among non-smokers who use e-cigarettes, they have around three times the risks of taking up tobacco smoking than non-smokers who don’t use e-cigarettes. If you put those altogether then e-cigarettes are likely to cause harm in people who are non-smokers, particularly young people. And then for smokers, we do know that the majority of people who quit smoking actually do so unaided. And for the people who need support, there are registered products.

Gretchen: You and your community came together to inform the National Tobacco Strategy in response to this bolting horse, if you like, and I’ll get you to talk to bolting horses in a minute, that’s been a rapid response, how are research policy and practice playing a part in pushing back against tobacco companies?

Emily: It may look to the outside like a rapid response but Australia’s been a world leader in tobacco control for decades and we are always working incredibly hard behind the scenes, reviewing the evidence, working with our policy and practice partners to look at what is going to be the next problem and what’s on the horizon.

The so-called rapid response that happened recently, in fact our team was commissioned by the federal government in 2018 to review the worldwide evidence on health outcomes in relation to electronic cigarettes. Although we still have to do these sorts of sprints, where suddenly someone will say, look I really need a rapid response on this particular issue, we have already done a lot of the work in the background and so a lot of it is responding rapidly to more tailored needs. We are actually doing a huge amount of work behind the scenes every day to make sure that we are up to date with all of the research evidence, but we’re also looking at the policy horizon and I have multiple examples of that.

Gretchen: Could you give us an example?

Emily: Well, for example, we were already working on this review that was over a two-year period and then the TGA (Therapeutic Goods Administration) was wanting to change its policies fairly rapidly in late 2021, and there was a consultation prior to that. We actually managed to write up specific aspects of the review, which were about smoking behaviour, so smoking uptake in teenagers and smoking cessation in people who were using e-cigarettes to quit, and we were able to write those up fairly rapidly, get them out as preprints so they could be in the public domain at the time when the decision making was happening. I think every researcher would have similar stories, which is why we are going really deeply into the data constantly and also making sure we are responsive within the policy timeframes.

Gretchen: Can you talk to how the legislation has drawn on the evidence you and other researchers have presented?

Emily: Yes, so the upshot of our review is that e-cigarette use should be avoided in non-smokers, particularly young people, and the young people part of it is because they are particularly vulnerable to the adverse effects, as well as there being indirect evidence of adverse effects of nicotine on the developing brain. The one group who may benefit are smokers who are using it to quit completely and promptly.

Putting those things together we need policy measures which reduce use in young people and non-smokers and which target smokers and so latest legislative announcements, which are yet to pass through all of parliament, are really aiming to do that. They are about reducing imports and they are also about broadening the ability of GPs (general practitioners) to prescribe e-cigarettes. They are also about working with the states and territories to enforce some of the existing legislation.

Now, one of the things that is really important to note is that e-cigarettes were already banned outside of prescriptions in Australia, but there were some legal loopholes, meaning there were large volumes of e-cigarettes coming in, like a recent seizure of products in Queensland where there were 45,000 vapes at a particular shop, both in the shop and in storage. So, people are importing these in very large volumes, and one of the problems with young people is that they are actually in a kind of flood of product. They are getting all this promotion on social media and they’re incredibly widely available. The latest evidence is four-out-of-five teenagers would say it’s easy to get hold of e-cigarettes or vapes and other people are saying, oh, well we should just educate kids about the dangers, but that’s like someone being in a flood and saying, oh, by the way, don’t get wet.

We need to make sure with tobacco control that we have a comprehensive approach. It’s about reducing supply as well as addressing that demand side of it and making sure people are making informed choices, but informed choices alone won’t help when you’re up against a huge amount of social media and widespread availability. Those things are in a dynamic process together. Teenagers are interpreting the widespread availability of e-cigarettes as meaning they are safe and accepted and normal.

Gretchen: Will flavours be banned under this legislation, those thousands of flavours?

Emily: Yes, so another part of the legislation is to try and ‘medicalise’ or make things more like prescription medicines. When you look at your Ventolin inhaler, it is not available in 17,000 flavours, it has not got cartoon characters on the front of it. The idea is to ban a lot of the flavours and make sure that things are in appropriate pharmaceutical-style packaging.

I found a vape package outside my daughter’s school, it was pink, had lollies all over it, and was bubble-gum flavoured. So, it is clearly targeting children, but the product contained the nicotine equivalent of nine packets of conventional cigarettes. These are very, very strong. I do hear of people who are smokers who use e-cigarettes, or who’ve tried them, say that they actually find them very strong, and they also find that instead of it being that you smoke a cigarette and then you stop that, you can do it constantly. There are studies that show that adolescents who use e-cigarettes actually have higher blood nicotine levels than adolescents who smoke. So, there are differences between the products that mean we need to be particularly cautious about them.

I think one of the other things that comes up for me regularly in the media about this, particularly when I’m doing international media, is that this is a drastic measure and why is Australia doing something so extreme? What most of those people don’t appreciate is that actually over 30 countries already ban e-cigarettes as consumer products and around 41% of the world’s population lives in countries that ban the sale of e-cigarettes as consumer products. So it’s actually not a particularly unusual step. The prescription-only model is unusual because these are not approved products, but it’s trying to tread that middle ground.

Gretchen: That’s super interesting because the point you’re making here is that actually e-cigarettes haven’t yet gone through the TGA process, but because it’s taken off so rapidly there’s been a sort of a compromise on that. Is that unusual?

Emily: Well, it is unusual for doctors to be kind of encouraged to prescribe a medicine that is actually not approved. It’s an unapproved medicine and that’s part of why the College of General Practitioners has it as a kind of last-line therapy. Try everything, try the approved things first, but I think it’s also a sign of the rhetoric that the industry uses to try and push policy in particular directions. So, you use the term the horses bolted, the industry also coined the term, the genie is out of the bottle. So, they want to create this idea that it’s all completely out of control and really there’s not much you can do so you may as well let them sell them at the corner shop. First of all, those metaphors are really unhelpful because in public health we have controlled things that are much more common than this. You know, we’ve controlled so many things for the public benefit.

Gretchen: Such as seat belts, for example?

Emily: Seat belts, drunk driving, and smoking are really good examples. It used to be that the majority of adult men smoked. We are now down to 11% current daily smoking. It’s still too high. It’s still the terrible cause of premature death and disability but we’ve taken something that was completely normal and every time they say, oh, the horse is bolted, it’s too hard, you couldn’t possibly ban smoking at work, or you couldn’t ban smoking on airplanes. You know, that idea where you use this rhetoric that’s not actually an evidence-based thing. But the other thing to say is that although e-cigarettes are becoming common among young people, they’re actually not the majority of young people doing it.

So, the current data are in teenagers (14 to 17), about a third of teenagers have tried them and that doesn’t mean they’re keeping on going with it. We are looking at maybe 5% addicted, like 5% using them every day but that’s a very ropey figure, but the interesting thing is the industry’s managed to create an atmosphere that it is normal. Teenagers will, when you ask them, you’ll end up with about a third having tried them but then if you ask them, is everybody doing it? They say, yeah, everybody’s doing it, and that’s actually another thing the industry is doing is creating this sense that it’s normal, that everybody’s doing it and that to fit in, you’ll have to do it. We have to be really clear that we are not buying that, and our policies are based on evidence. They are not based on a catchphrase.

The industry is trying multiple things to manipulate the community. They’re saying, this is great for smoking cessation while marketing it to children. They’re saying the genie is out of the bottle, so we need to have it at the corner shop even though it’s not past the basic safety standards. That’s why our regulatory processes are really important. Cigarette smoking was probably the gravest public health mistake we made, allowing it to be widely available, but we did it before we knew what smoking did to people’s health. And also, we did it before we had mature safety assessment bodies. It was before the TGA existed. It was before the FDA (Food and Drug Administration) could assess things like that, so we can kind of understand why we let them be available. Our proponents are saying, well, cigarettes are really available – why aren’t e-cigarettes really available? And we can say, well our processes are actually better now. We don’t just let things that have been shown to have risks to our young people just be out there for sale. And if you think about what happens if you have a car where the brakes fail you know, in one in 10,000 cars, you have to recall those cars. You have to fix those cars. So, we have totally different safety standards to when cigarettes were available.

Gretchen: I’ve got a question for you. I mean, how did the COVID-19 pandemic and e-cigarettes intersect in Australia?

Emily: First of all, when we think about the places where the e-cigarette epidemic really started first, that was actually in the US and they had very widespread use in teenagers prior to the Covid pandemic. They had about a quarter to a third of high-school students using them regularly. And that was in 2017,  2018 and then in 2019 there was the epidemic of lung injury in the US particularly called EVALI, or e-cigarette or vaping-associated lung injury, and that was mainly to do with e-cigarettes that contained tetrahydrocannabinol or Vitamin E acetate, but it was also seen one-in-eight cases in the biggest case report. It was seen actually with regular e-cigarettes.

In Australia, e-cigarettes arrived slightly later, and they started an upswing in 2017 and 2018. Then we had the pandemic and in some ways that didn’t actually accelerate the use because kids weren’t getting together so much but what did happen was that all of the public health people who would’ve been enforcing this stuff, actually were pretty occupied, so there was a cynicism in it in that it was definitely making hay while the sun shines and getting around that. But the other thing is it’s being portrayed as this thing that these poor, lonely adolescents are using to comfort themselves, and certainly adolescents are vulnerable to being told you’ve got to do this, it’s the sort of social pressure, but particularly pressure from social media and they’re being told this can help with mental health problems, but they actually tend to generate mental health problems. So, there’s a very complex relationship with mental health problems, which is people might use them thinking it’s going to help their mental health problem, then they develop an addiction, and the withdrawal symptoms are anxiety and feeling terrible. So then you think, well, yes, this vape really does help me feel better, but it’s this mixture of the underlying problem. So it is true, I think the mental health issues that a lot of young people are facing now are exacerbating the issue with vapes with e-cigarettes and that there were a lot of problems with Australia’s public health response around the time because we were kind of otherwise occupied.

Gretchen: We could have gone down the New Zealand route. Can you describe how New Zealand has handled the e-cigarette phenomenon? What’s the evidence they draw on and why Australia hasn’t chosen that route?

Emily: It’s difficult to really comment on other countries’ policies because they’re steeped in a whole lot of other things, and New Zealand is a world leader in tobacco control. There’s absolutely no question about it.

Gretchen: Because they’re tracking to outlaw cigarettes, aren’t they?

Emily: Absolutely, their targets are similar to ours in terms of getting below 5% current daily smoking, which is a kind of denormalisation at the general population level. They are doing really innovative things like preventing sales of cigarettes to people born after a certain year, reducing the number of cigarette outlets, denicotinizing cigarettes, so making them with less nicotine than in the cigarettes, so less addictive. Alongside that, New Zealand did opt to say that e-cigarettes should be freely available and promoting them, actively promoting them as an alternative to smoking for the general population. Now what we are seeing is really quite rapid reductions in smoking in New Zealand alongside very rapid increases in e-cigarette use, including in people who are non-smokers. The latest data from their 13- to 15-year-olds is 9.6% of the general population (13 to 15) are current daily vapors and it’s about 18.6%, so nearly 20% of the age group above that are the 15- to 24-year-olds. So, they have got very widespread levels.

Gretchen: So, that’s higher than us?

Emily: Much higher than us, that is more than double us. In terms of that daily use, the other thing is that 19% of Māori 13- to 15-year-olds are vaping every day. So, I think that it’s really important to look at that and say, well, can Australia get to the same sorts of targets without having the issue of this really, really widespread e-cigarette use? And certainly, New Zealand is trying very hard to get those rates down. New Zealand’s conscious that that is a big problem. They’re not saying, oh, well that’s just acceptable collateral damage. So that’s also a message that has been really loud and clear from our health minister, he is putting in place a comprehensive tobacco control strategy.

We are not targeting e-cigarettes on their own. We are not targeting smoking on its own. We’re targeting tobacco products across the board, including smoking and e-cigarettes, and we are saying we don’t accept that trade off. We don’t accept this rhetoric that, oh, well if you’re going to help adult smokers to quit, you’re going to have to put up with unicorn flavoured e-cigarettes in the school toilets, we don’t accept that equation. We know that we can do both optimal levels of both.

If we look at the EU and the UK and Canada and a number of other countries, they limit their nicotine concentration in their vapes to 20 milligrams per mil or 2%. What New Zealand, most of the disposable products are 5%, which is a very high concentration, and most of the disposable products we see here, which are illicit, are also 5%. They are very, very strong.

Gretchen: Okay, so we have had positive international response. As you say, we are world leaders in our management of tobacco. How do the proposed models for Australia intersect with international action? How do we compare?

Emily: All the countries worldwide are really struggling with electronic cigarettes. We’re all struggling to deal with this essentially industry push. We have to be really clear that the responsibility for this lies with the industry. The tobacco industry is wanting to sell its products. The tobacco industry actually has a legal obligation to maximise profits for its shareholders and that’s by selling cigarettes and also by selling what they call alternative tobacco products. So, it isn’t just about e-cigarettes, there are also heated tobacco products and nicotine pouches, they’re innovating to try and keep their profits up, and they’re particularly targeting the next generation of users. So worldwide people are really trying to work out a good policy response.

At last count, 34 countries completely banned the sale of e-cigarettes as consumer products and about 80 countries have absolutely no regulations at all about e-cigarettes. And there is about 70 countries kind of in the middle who might have them available as consumer products but try and restrict the age. What we have seen is in countries that allow e-cigarettes as consumer products and then say, don’t sell these to people younger than 18. They have higher rates of youth use than the countries that ban them. That’s a broad-brush statement, but that is what we are seeing.

The other thing is that countries are moving to ban different aspects of e-cigarettes. So, China recently has banned all flavours except tobacco for its internal market, which is ironic because China is the main manufacturing place of these products which are sold worldwide with over 17,000 flavours. But you can see that from a policy point of view, they are concerned about their own youth epidemic and so they are banning those flavours. We also see that de facto the US bans flavours apart from mint, menthol, and tobacco. And the EU has had an announcement recently that it’s moving to ban disposable products and a lot of them are where young people are using these disposable products that they can hide very easily, and that’s often where the flavours are. So internationally, people are doing multiple different things to try and put a lid on what is essentially an industry-driven problem.

Gretchen: So, the proposed federal legislation needs then to be refined and worked out between the state and federal governments. Will the states work closely together for a national approach, do you think or will it be best to approach this with different communities and different populations in mind?

Emily: So once again, we are providing the evidence, and it’s really not for me to say how the states and territories and federal governments should work together. What has happened is there is a task force that’s being set up with states and the Commonwealth to try and deal with the issue and it is true that what we see works best in tobacco control is this universal comprehensive approach. And then with added kind of uplift for different priority groups and making sure that you’re dealing with all of those things together. So, it definitely is about making sure that you can chew gum and walk at the same time, but that’s because you’re also dealing with multiple kind of attacks from industry. So, industry has a very long history of using a huge range of tactics to undermine tobacco control. In fact, the World Health Organization has made a list, or a taxonomy, of all the different ways the tobacco industry tries to undermine control of its products. It’s things like constantly trying to evade or get around regulation by changing its products and flooding the market. So, the FDA has had to deal with literally millions of these products. So imagine you’re a regulatory agency and you’re trying to deal with that. They also create a moving target for when researchers are trying to understand the impacts of things. If that product is changing all the time, it makes it harder to kind of pin down what’s going on.

They also fund science, and they fund scientists, and they fund researchers to produce their own research to create doubt. So, they’re also known as the merchants of doubt. Like they actually try and create confusion and controversy where actually there’s a fairly reasonable consensus often.

Gretchen: Yes, it’s extraordinary, I remember seeing a research centre called Responsible Vaping Australia with this recent TGA review, which was open to the public saying that the government wants to hear from the public and a link to a petition calling on the government to exempt nicotine vaping products from the poison standard and so on and so forth. So Responsible Vaping Australia is one such front, correct?

Emily: That’s right, you won’t hear the tobacco industry saying, oh, this is terrible, you are ruining our profits. But you will hear groups like Responsible Vaping Australia, which is funded by British American Tobacco. Also, some of these front groups are people who have received money from tobacco, but also have stand to potentially lose money. So, convenience store operators, vape store operators and then there are also researchers who would see themselves as well intentioned but who have accepted money from e-cigarette companies before. For example, I have people who have been supported by industry questioning our work.

Our group actually has a policy of not engaging with people who are funded by industry in matters of science because there’s just no mileage in it. It legitimizes it, but also, you are never going to achieve any sort of consensus. You are never going to achieve any progress in science because they don’t have the same goals and the one thing that has been very important for tobacco control is to understand that the tobacco industry and related industries have no place at the table. You will never achieve good outcomes with them at the table. Their goals and the goals of public health are two different things. I for one, would believe them more if they said, right, we are phasing out all sales of combustible cigarettes and we’re not going to advertise to anyone. We’re not going to recruit any new smokers, and then we’re going to go to these harm-reduced products to wean those remaining smokers off. They have not done that.

Gretchen: I would assume that calling this a crisis, a health crisis, where does a term like that sit with us as public health professionals and in terms of the prevention of chronic disease?

Emily: In public health, we are often having to hold those two things in our head. We are often told this is a serious problem and for many people, they would view it as a crisis. When I talk to teachers, they actually say it’s their number one behavioural problem at the moment in schools and if you think about how many issues you have, dealing with a whole lot of kids and adolescents to say that this one thing, vaping, is your biggest problem is a pretty big deal, particularly when you think about having mental health issues, issues about consent, issues about other drug use, alcohol, and vaping being the number one.

I think that calling something a crisis, it’s probably something more the community needs to say, not public health professionals or researchers. We can say this is how big the problem is, and we can say it’s this magnitude, but it is the community who is really identifying whether this is a crisis, you know, and looking at that evidence. But we have to let that saying “it’s a crisis” galvanize us into evidence-based action.

The other thing is that there’s a huge amount of evidence about how to use words to help people to take action. It’s about saying, what will empower people to take action? And what kinds of words work in those circumstances? We saw with COVID although there were people initially saying, “Oh, well, you know, Australians will never lock down because that’s just too much to ask.” Where people who control high-risk pandemics on the ground repeatedly would say, “If the community understands the problem and they understand what to do, they will do what it takes.”

More than 80% of the community has said they want strong action on electronic cigarettes. They are concerned about themselves, they are concerned about their kids, they are concerned about future generations. Some of the most concerned people I’ve found about e-cigarette use in young people are older smokers who’ve used e-cigarettes to quit. They have said, I know what it’s like to be addicted to nicotine, I don’t want anyone else to go through this and I don’t want the price of my quitting to be people facing a lifetime of addiction to nicotine. That’s not what I want either.

Gretchen: It’s a very good point, and the thing is, as you’ve hinted at and pointed out, unlike the first nicotine wave, the establishment of actual cigarettes, which as you said, became socially and culturally ever present well before the health risks were realised, there’s clear public support for action on vaping. So, what does that support mean for the way that you handle proactivity on a research, policy, and on a legislative level?

Emily: Well, I can probably speak most to the research part. I think what is interesting is although there is widespread support as researchers in tobacco control, we are often the target of abuse. We’re often the target of efforts by researchers who are supported by industry to discredit our work. We are often targeted on social media. It’s not a comfortable place to work. I had worked for a long time in medication safety, cancer, cardiovascular disease, and Aboriginal and Torres Strait Islander health, but working in tobacco control, it is really unpleasant, a lot of the time in terms of the pushback you get. I actually want everybody to love me. I hate it when people say nasty things about me, but what I’ve had to do is to know that there is a thing called the scream test.

It means that if we are doing something which truly compromises tobacco control’s bottom line, then they will scream, they’ll scream through their front groups, they’ll scream through their scientists, they’ll scream through whoever. And they have virtually limitless resources and zero scruples so that combination is diabolical when you’re out there. But I’ve had to say, all right, we are releasing some new findings, they have implications for tobacco control, success will look like me getting abused on social media and I have to accept that.

Gretchen: Gosh, Emily, I hate to hear that, but your point really is that you can continue because you know how much public support there is for action?

Emily: That’s correct. I know that part of my job is to withstand that and not to be distracted by it because it is in the list of tactics that the tobacco industry uses. The other thing is, there are people out there who genuinely disagree as well and the other thing is, in public health, for some things, we do what we want to avoid, prohibition or banning things and this is really a situation where it isn’t a ban, it isn’t prohibition – it’s available on prescription. Like we don’t say antibiotics are banned. We don’t say the oral contraceptive pill is banned, it is available on prescription and part of the reason for that too is that when we reviewed the evidence on e-cigarettes and smoking cessation all of the trials that showed some benefits were in the clinical setting. So, it wasn’t just about here’s an e-cigarette, now go away. It was about supporting people to quit in terms of behavioural support, counselling, actually having a therapeutic relationship and access to e-cigarettes and the other thing is because they’re unapproved products there’s also wanting to make sure that use is under medical supervision.

Gretchen: And that public support is part of that data, isn’t it?

Emily: Well and then being able to say, and here’s the evidence about the public’s support of it because when policy makers are making decisions, and particularly when the politicians are making the decisions, they are there to represent their constituency and the Australian people. They are there to make decisions in the best interest of the Australian people. So it is helpful for them to know there is public support. They are getting very loud noises from industry about that but when it says, “80% of people out there in the general walk of life support this” they know that for every one of those voices, there’s a huge number, there are millions, who would actually support them and so it’s very helpful for them to actually get a clear sense of perspective.

The other thing is, if people already support something, it then helps with formulating the policy response because if you think about smoking, and at a time when more than half of adult men smoked, first of all, you had to actually bring in the legislation which upped the tobacco excise, ban tobacco advertising, ban smoking in public places but that had to be done gradually. But also, you had to be part of this campaign to really inform people: they weren’t on board. They were going: “There’s nothing wrong with it. I know someone who smoked until they were 92.” You know that kind of thing. It also tells you more about, what do I have to do as a public health professional and as a policy maker to make a difference.

Gretchen: So Emily, where to next for you in this fast-moving scenario?

Emily: Well, I think the first thing is to see how it plays out in terms of the details of the legislation and what is actually passed by parliament. It’s a really delicate time at the moment because there’s a huge range of tobacco control reforms that are going through, including refreshing the overarching legislation, making sure it’s brought up to date. Our current legislation actually gives us problems banning advertising on social media because back in the nineties when it was formulated, those things didn’t exist. So, we have to keep pace, and in fact get ahead, of industry on those things. There’s a huge range of things that have to go through and we also need to make sure that from my point of view, I’m constantly looking at the data about the health impacts of e-cigarettes and working with international colleagues.

The other thing is to make sure we are evaluating Australia’s policies because the world is looking to us at the moment and there are people saying: “Oh, well we are going to look at how that goes. And if it goes really well, we’ll think about the same thing.” So, it’s part of Australia being a world leader and not afraid to innovate and not afraid to be doing things which are a bit different, alongside the knowledge that more than 41% of the world’s population lives in countries where e-cigarettes are banned as consumer goods. I think the main thing to say is, where next, is to really monitor what is happening policy-wise, but to make sure that our understanding of the evidence and actually generating new evidence keeps pace with what the policy makers and the politicians and the community needs.

Gretchen: Professor Emily Banks with us here on Prevention Works. It’s been a great conversation and you can find out more about Emily’s work and the new legislation and other research on e-cigarettes, on The Australian Prevention Partnership Centre’s website.

Do share us with your friends and colleagues, even leave us a review. We really appreciate those. I’ll catch you next time. I’m Gretchen Miller.

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