Vaping: details from the Quit campaign

The information in this article was provided by the Quit campaign.

For updates, see Quit’s online hub for parents and carers, vapingfacts.org.au.

E-cigarettes: what parents are asking Quit

Nothing is more important than looking after the health and wellbeing of our community, particularly our children. Australia has made important progress when it comes to reducing the number of people smoking and, with fewer people smoking, more of us are enjoying healthier, longer lives.
Fewer people smoking is also why tobacco companies and others are now trying to make a profit by selling highly addictive e-cigarettes. We must prevent companies from using new products to get people addicted to nicotine, so we protect the health of our community; particularly the young people these companies target.

Vaping ‘epidemic’

We’re seeing an epidemic in the uptake of e-cigarette use (“vaping”) by children, which is deeply concerning. Vaping is not harmless; the aerosol from e-cigarettes contains toxic chemicals, heavy metals and fine particles that lodge in the lung – just like cigarette smoke. If the e-liquid contains nicotine, then the user risks becoming addicted to nicotine. Nicotine is thought to interfere with brain development in children, and nicotine poisoning (through ingestion) has, tragically, been lethal for several children. Vaping also increases the likelihood that children will start to smoke cigarettes.
In this article, we answer some of the most common questions parents have asked Quit and Quitline.
It’s not too late to reverse most, if not all, of the uptake of vaping by children and young adults. As a society, we have protected our children from Big Tobacco before. We can do it again.

What is vaping?

E-cigarettes (sometimes called ‘vapes’) are battery-powered devices that heat a liquid (also called ‘e-liquid’ or ‘juice’) and turn it into an aerosol. This aerosol is then inhaled, in a practice known as ‘vaping’.

A variety of e-cigarette devices

It’s helpful to know a little about what’s inside an e-cigarette to have informed conversations with others and to understand why health professionals are worried about the health effects of vaping.
Most of the e-liquid in an e-cigarette is ‘carrier solution’ (propylene glycol plus glycerol) that can, depending on its composition, make the aerosol either almost invisible (and thus hard to detect) or seem like a large cloud of smoke. For some children, “stealth vaping” is part of the attraction. For others, learning tricks with the aerosol cloud (“cloud chasing”) is part of the attraction (see ‘Why are children using e-cigarettes?’ below).

What’s in the vape liquids?

E-liquids contain flavouring chemicals that are safe to swallow but have not been demonstrated to be safe when inhaled. E-cigarettes that are ‘cool’ or ‘fresh’, like mint or menthol, are created by adding coolant flavourings (WS-3 and WS-23) to the e-liquid. These chemicals are used in toothpastes and shaving creams, but their effects when delivered to the lungs has never been tested. In the USA in 2020, more than 2800 people were hospitalised and nearly 70 died from a condition officially named ‘E-cigarette and Vaping-Associated Lung Injury’ (EVALI). It was later found that most but not all cases of EVALI resulted from manufacturers deliberately adding a chemical (to thicken the liquid) that they didn’t realise would cause extensive lung damage.
Some e-liquid ingredients decay over time, some degrade when heated, and some react with other chemicals when mixed. All these actions can create toxic by-products. E-liquids can also contain contaminants introduced because of the manufacturing process, including heavy metals (like cadmium, nickel and lead) that shed from the internal heating coil or, possibly, the soldering used to make the device. Toxic chemicals found in aerosols include: acetaldehyde (causes cellular and DNA damage, and is thus carcinogenic, i.e., causes cancer), acetone (key ingredient in nail polish remover), acrolein (that smell of burning fat? that’s acrolein being created; it’s commonly used in weedkillers) and formaldehyde (a strong-smelling carcinogenic chemical used in embalming and manufacturing processes).

Lack of standards for e-cigarettes

There are no requirements for e-cigarette manufacturers to list all the e-liquid ingredients on the label, and there are no quality standards for manufacturing the devices or creating and mixing the liquids. Most disposable e-cigarettes used by Australian children are mass-produced in large factories by people with no knowledge of what chemicals they’re mixing. Even if there were rigorous quality standards in place, however, this would not change the fact that the user is inhaling an aerosol of chemicals, heavy metals and fine particles deep into their lungs over and over again.
The power output of the device, the temperature of the heated coil, the dose (quantity of chemicals), duration of use and vaping style (shallow versus deep inhalations) all affect the user’s exposure to any one of the 200+ chemicals detected in e-cigarette aerosols.
Bottom line: no-one knows exactly what chemicals are being inhaled by an e-cigarette user nor their long-term harms. We do know, though, that our lungs are made to breathe in clean, fresh air to power our bodies and brains.

What about nicotine?

E-liquids might or might not contain nicotine. Labelling is not a reliable indicator of the nicotine content of any e-liquid, as studies have found mislabelling of e-cigarettes to be very common. Most e-cigarettes available for (illegal) retail sale in Australia do contain nicotine, irrespective of what’s on the label. The actual amount of nicotine in an e-cigarette (unless purchased from a pharmacy with a prescription) can be completely different to what is on the label.
Nicotine is a neurotoxin; a poison that affects the nervous system, including the brain. Nicotine is also highly addictive. Very simplistically, when nicotine reaches the brain, it attaches to a ‘receptor’ in the brain and causes a release of dopamine, the ‘feel good’ chemical. The brain also responds by producing more and more of those receptors in expectation of a regular dose of nicotine. When someone stops using nicotine, they no longer get the expected dopamine release and experience cravings to smoke or vape, and the receptors in their brain – expecting and not receiving nicotine – cause withdrawal symptoms to start. Nicotine withdrawal symptoms include: feeling anxious or depressed, having trouble sleeping or concentrating, feeling restless, and being irritable. They might also include headaches and constipation.

Harm from nicotine

Quitline is hearing from parents and teachers, and children themselves, who are reporting signs of nicotine addiction in children, including inability to concentrate in class, using an e-cigarette upon waking, and using e-cigarettes at night after waking with a craving.
Nicotine presents specific long-term risks for children. Exposure to nicotine during adolescence is thought to harm the parts of the brain that control attention, learning, mood, and impulse control. Using nicotine in adolescence might also make the brain more vulnerable to addiction to other drugs. Smoking and vaping have both been linked to poorer mental health and wellbeing for children.
Vaping nicotine gives children a momentary “head-rush”, which is part of the attraction for some. However, it can also make children physical ill if a high dose of nicotine is inhaled. ‘Nic sick’ (as it’s called) is caused by the immediate toxicity of nicotine, and can result in dizziness, nausea, vomiting and headaches. If the nicotine dose is very high, it can result in seizures. Asking a child who vapes about the “head-rush” they experience could be an opportunity to point out that they can actually feel the drug reaching their brain.
While nicotine affects the developing brain and keeps people smoking or vaping even when they want to stop, remember it’s inhaling the chemicals, heavy metals and fine particles present in all e-cigarettes that is of immediate concern with respect to harms.

What are the health risks of vaping?

The most comprehensive review yet of vaping harms, led by researchers at the Australian National University, found conclusive evidence that e-cigarettes cause immediate toxicity through inhalation, with seizures being the most serious symptom. E-cigarette use was also found to negatively impact the cardiac system, including blood pressure and heart rate.
Most oncology experts agree that long-term e-cigarette use is likely to cause cancers in the mouth and lungs.

Children’s lungs are still developing

The greatest risk of vaping for children and young adults is to the lung, because lung development continues into the early-20s. The American Heart Association has concluded that children who vape will likely have lower lung function as adults. This means they will be far more vulnerable to the development of pneumonia, and lung diseases, such as emphysema, chronic bronchitis and chronic asthma.
It took more than 30 years to learn the key health harms related to inhaling cigarette smoke deep into the lungs multiple times per week. It is inconceivable that inhaling e-cigarette aerosol deep into the lungs multiple times per week is not also going to cause long-term damage.

Are e-cigarettes less harmful than cigarettes?

This question is completely irrelevant for children, most of whom do not and will not smoke.
The last comprehensive study of children smoking and/or vaping—the 2017 Australian Secondary Students Alcohol & Drug (ASSAD) Survey—showed that 95% of secondary school students had not smoked in the previous week, and 98% had smoked fewer than 100 cigarettes in their lifetime. Only 1% of Australian secondary school students were smoking daily. (The 2020 ASSAD Survey was delayed due to COVID, and the next results will be available in 2023.)
The question to ask, with respect to children, is: “are e-cigarettes more harmful than breathing air?” And the answer to that is, “Yes.”
Cigarettes are uniquely harmful. Smoking cigarettes is the single leading cause of preventable death and disease in Australia, causing 19000 deaths each year. Unfortunately, the lack of knowledge about the full risks and dangers of e-cigarettes – remembering that it took three decades for the full risks of cigarettes to be understood – is being exploited by tobacco and e-cigarette companies and pro-vaping groups who are promoting e-cigarettes as “less harmful than cigarettes”, which is not the same as saying “e-cigarettes are harmless”.
Saying that e-cigarettes are less harmful than cigarettes is true, but it’s just as true as saying that it’s safer to juggle knives instead of chainsaws.

Any other risks of e-cigarettes to know about?

E-liquids containing nicotine present a significant poisoning risk if swallowed. Nicotine has, tragically, caused the deaths of several very small children around the world, including in Australia. E-cigarette related calls to Australian Poisons Information Centres doubled between 2020 and 2021.
If an e-liquid has come into contact with the skin, or has splashed into the eyes, mouth or nose, and especially if you suspect e-liquid has been swallowed, call the Poisons Information Centre immediately on 13 11 26.
If someone is very unwell after exposure to nicotine, have collapsed, stopped breathing, are fitting or having an anaphylactic reaction, ring triple zero (000) for an ambulance.
There is a small but real risk of e-cigarettes exploding and catching fire if they are defective, or modified or manufactured badly, or if they are stored under conditions that cause the battery to ignite. E-cigarettes are prohibited from checked luggage on aircraft and certain worksites because of this risk.
Quit strongly recommends that all e-liquids are treated as if they have nicotine in them, and that they are kept out of the reach of children to minimise any poisoning risk.
Quit strongly recommends e-cigarettes are not exposed to extreme temperatures and not kept in places where they can bang against other items, e.g. in a pocket with loose change.

Is there such a thing as ‘secondhand aerosol’?

Yes, secondhand aerosol is a thing. Like cigarette smoke, e-cigarette aerosol contains tiny droplets of chemicals and fine particles that are, unfortunately, just the right size to lodge in the lungs. There is conclusive evidence that vaping indoors or in enclosed spaces increases the amount of particulate matter in the air, and this can be inhaled by other people also in the room. Secondhand aerosol might trigger asthma attacks or cause respiratory irritation (e.g., coughing) or distress (difficulty breathing). The long-term effects of secondhand aerosol are not yet known.
Quit strongly recommends that people do not vape where others can inhale the secondhand aerosol.

Does vaping lead to smoking?

The best available evidence shows that vaping e-cigarettes increases the risk of starting to smoke cigarettes by at least three-fold (so three times as many children who vape go on to start smoking than those who had not vaped). This evidence suggests strongly that this is true even for children who are not usually at risk of smoking, e.g., those whose parents do not smoke or who are not ‘risk-takers’ or rebellious in nature.
Addiction to nicotine is likely to be the key reason. However, it is possible that social disapproval associated with smoking (the ‘denormalisation’ or smoking) are broken down by the similarities between smoking and vaping, such as the hand-to-mouth action, the inhalation of smoke/aerosol, the ‘throat hit’ sensation, and the exhalation of smoke/aerosol.
Seeing other children and adults vaping or smoking is likely to be ‘normalising’ vaping, and the hypothesis is that this could extend to renormalising smoking.
Quit recommends that adults do not vape in front of children, to minimise the risk they themselves will go on to vape or smoke.

Why are children using e-cigarettes?

There are two components to this answer. The first is that e-cigarettes are trendy with children and young adults just now, with most children reporting being (naturally) curious about trying something new and joining in the trend.

There are several reasons vaping is trendy (other than it being “new”), though, and it isn’t by accident:

Older children (mid-teens and up) are being targeted by tobacco and e-cigarette companies using predatory online marketing through (paid) social media influencers vaping and recommending products, “cloud chasing” competitions and how-to videos, and product placement in video games and music videos
Flavours are a key issue driving uptake of vaping by children and young (18-24 year old) adults, because different flavours are being handed around and tried, and – well – they taste good!
The packaging of the devices and the e-liquids are designed to be attractive to children, with some devices being sleek and shiny (for the older demographic) and some ripping off well-known confectionery or having “fun flavours” and cartoon imagery (for the younger demographic).

The second part of the answer is their accessibility. E-cigarettes are cheap (from $6), with some online sellers even offering free delivery. E-cigarettes are also widely available, even though there are laws that should be preventing children from accessing them.
E-cigarettes are being advertised and purchased through common social media platforms, including Facebook and TikTok, and there are multiple websites easily accessible to children. E-cigarettes are also being sold quite openly and illegally in convenience stores and tobacconists.
We need to keep a lid on individuals and companies seeking to profit from harmful and addictive products through strict regulation of e-cigarette marketing and availability that puts the health of our community first.

What’s the legal situation with e-cigarettes?

In short, e-cigarettes containing nicotine are illegal to buy or possess unless the purchaser/possessor has a valid prescription. Only pharmacies can legally sell e-cigarettes that contain nicotine. However, the laws that should work to protect our children from accessing e-cigarettes are not being enforced. Part of the problem is that e-cigarettes that do NOT contain nicotine can be sold legally…but the only way to tell whether an e-cigarette does or does not contain nicotine is to take them to a laboratory for testing.
The simplest explanation for the legality of e-cigarettes is that it is:

Illegal for any person to use a cigarette or any e-cigarette in a smoke free environment. This includes in cars when children are present.
Illegal for a retailer to sell a cigarette or any e-cigarette device or accessory (including an e-liquid capsule/container) to a person under 18 years old (regardless of whether the device or accessory contains nicotine).

If you suspect a retailer is selling cigarettes or e-cigarettes to children, contact your local Council to make a complaint. If you are not happy with your Council’s response, you can contact the State Government Tobacco Control Unit on 1300 136 775 or tobacco.policy@dhhs.vic.gov.au

Illegal for any person to buy or possess an e-cigarette or liquid containing nicotine unless you have a valid prescription
Legal for a retailer to sell an e-cigarette that does not contain nicotine to an adult
Illegal for a retailer, other than a pharmacy, to sell an e-cigarette or liquid containing nicotine (and only then to someone with a valid prescription)

If you suspect a retailer is selling e-cigarettes containing nicotine, contact your local police station or CrimeStoppers on 1800 333 000 or Crime Stoppers Victoria – Report Crime Information.

There are laws in place to protect children (and ensure adults who smoke have access to e-cigarettes with health professional support), but these laws are not being enforced. Protecting future generations from nicotine addiction and lung damage means acting against individuals and companies prepared to break the law and profit from children.

What can we do about children using e-cigarettes?

There’s no single solution; a comprehensive approach needs to be taken.
For families, it’s all about education and communication.
Quit strongly recommends talking about and treating ‘smoking and vaping’ and ‘cigarettes and e-cigarettes’ together. Most children already know smoking is dangerous and see it as “disgusting”; leveraging the ‘denormalisation’ of smoking when discussing vaping is very effective.
It’s important for parents to start talking with children now about both smoking and vaping. Having regular, non-confrontational conversations—about the risks of smoking and vaping (focusing on lung health and addiction), the companies’ and retailers’ motivations to hook new customers and make money, and predatory marketing designed to go undetected—all helps. Hopefully, you will find the information in this article and resources developed by Quit and the Royal Children’s Hospital helpful for these conversations.

More information

Treatment support

If your child is vaping and you’re worried about how to help them stop, you can visit your GP or call the Quitline on 13 78 48 (for the cost of the call). Quitline is a state government-funded clinical service that provides advice and information to family and friends, and confidential, child-friendly cessation counselling to develop and implement pragmatic, simple strategies to manage cravings and emotions and to help build a person’s motivation and confidence to quit.

Reduce accessibility

We urgently need the Victorian Government to introduce a licensing scheme for retailers who sell cigarettes and e-cigarettes. A licensing scheme will simplify enforcement, move enforcement to authorised officers (so Victoria Police can focus on other issues) and provide a strong deterrent for retailers who are thinking of doing the wrong thing (through on-the-spot fines and the risk of licence suspension or loss). A retail licensing scheme could also be used to introduce important public health measures, such as not permitting a cigarette or e-cigarette retailer to operate within 50 metres of a school.
If you’re talking to your State MP…this is the issue to raise.
We also urgently need the Federal Government to crack down on illegal imports. If this is too hard to do, then we need them to enact a ban on e-cigarettes that do not contain nicotine, so that only those being imported with a valid prescription or by a registered pharmacy wholesaler are coming into Australia.
If you’re talking to your Federal MP…this is the issue to raise.

Political will (and public pressure) is going to be needed to reverse the uptake of e-cigarettes by children and young adults. But it can be done.

Parents Voice in Government School Education