Support for e-cigarette regulations among Australian young adults

Recent years have seen an increase in the popularity of electronic nicotine delivery systems, especially electronic cigarettes (or e-cigarettes) [1, 2]. In Australia, the context of the present study, figures from the recent National Drug Strategy Household Survey (NDSHS) show an increase in lifetime use of e-cigarettes among adults from 4% in 2013 to 9% in 2016 [3]. This increase was observed in both smokers (18 to 31%) and non-smokers (2 to 5%). By contrast, tobacco cigarette smoking rates have decreased over time and this has been attributed to tobacco control policies such as taxation, clean air laws, advertising restrictions on tobacco products, product labelling, and the denormalisation of smoking behaviours [4, 5].

The substantial growth in the use of e-cigarettes has prompted calls for regulation of these devices to (i) minimise potential health risks to both users and non-users (via ‘passive vaping’) and (ii) prevent the renormalisation of smoking behaviours [6, 7]. Presently, the legal status of e-cigarettes varies widely across countries and jurisdictions [8, 9]. In Australia, the legal status of e-cigarettes is determined by existing and overlapping laws relating to poisons, therapeutic goods, consumer goods, and tobacco control. Generally, different laws apply depending on whether e-cigarettes contain liquid nicotine [10]. Nicotine is classified as a dangerous poison under Schedule 7 of the Australian Standard Uniform Scheduling of Medicines and Poisons and, as such, the manufacture, sale, or supply of e-cigarettes containing nicotine without lawful authority is prohibited in all Australian states and territories. However, individual users are able to lawfully purchase nicotine-containing e-cigarettes from overseas for personal use provided (i) they hold a valid prescription from a registered Australian medical practitioner and (ii) possession and use of an e-cigarette containing nicotine is legal within the user’s state or territory [11, 12]. Individual users are also able to unlawfully obtain nicotine-containing e-cigarettes and it has been suggested that a substantial black market for these types of e-liquids likely exists in Australia [10]. There is also evidence to suggest that a substantial majority of the e-liquids sold in Australia are incorrectly labelled, with scientific testing revealing the presence of high levels of nicotine in e-liquids that did not have nicotine listed as an ingredient [13]. This leads to the potential for consumers to be misinformed about the products they are consuming and may result in excessive nicotine intake and subsequent adverse health effects.

Nicotine is only one of the many toxic ingredients found in e-cigarettes, with tests of e-liquids demonstrating the cytotoxicity of non-nicotine ingredients such as additives and flavourings [14, 15]. These toxins impact the quality of indoor environments and expose users to additional risk factors for cardiovascular disease and cancer [16‐19]. Despite these risks, non-nicotine e-cigarettes are not uniformly regulated, which means the laws surrounding their sale and use in Australia are determined by individual states and territories. At the time this study was conducted (August – September 2016), only three of the eight Australian states and territories had specifically regulated the sale and use of e-cigarettes. Since this study was conducted, more jurisdictions have extended their tobacco control legislation to include specific provisions around the advertising, sale, and use of e-cigarettes. However, given legislation continues to vary between states and territories, one of the recommendations of a recent Parliamentary Inquiry into the use of e-cigarettes in Australia included the adoption of a national approach to the regulation of non-nicotine e-cigarettes to ensure regulations are applied consistently across all jurisdictions [20]. The Inquiry also recommended the establishment of a regulatory process to assess and restrict the non-nicotine constituents of e-cigarettes.

Support for policies is considered important to their successful implementation [21]. As such, the Inquiry’s recommendation for a clear regulatory framework with nationally-mandated rules for the sale, purchase, possession, and use of both nicotine and non-nicotine-containing e-cigarettes makes it important to gauge public opinion. However, data on support for potential e-cigarette policies in Australia are limited. The vast majority of research assessing public support for e-cigarette policies has been conducted in the US and the UK where there are less restrictive regulatory environments [10, 22]. Results from these studies suggest that most people are supportive of stricter regulation of e-cigarettes [23, 24]. Support for such policies tends to be stronger among non-smokers relative to smokers of traditional cigarettes [23, 24]. Research also suggests that tobacco smokers’ and ex-smokers’ perceptions of the harm associated with e-cigarettes relative to traditional cigarettes moderate support for various e-cigarette policies, with those who believe e-cigarettes to be as harmful or more harmful than tobacco cigarettes more likely to support restrictive policies [23, 25].

Whether policy support is moderated by perceptions of the absolute harm associated with e-cigarette use (rather than just the relative harm compared to traditional cigarettes) does not appear to have been assessed, nor have the views of non-smokers towards e-cigarette policy initiatives. In the one study conducted in Australia to date, the sample comprised e-cigarette users only [26]. Most of the study participants did not want restrictions placed on their ability to access and use e-cigarettes, which is consistent with other research indicating that differences in policy support are moderated by e-cigarette user status [23, 25].

Surveying opinions of various regulations relating to e-cigarettes can assist in the successful implementation of future policies and can help policymakers identify policies that (i) have broad support and are therefore likely to be easier to implement and (ii) are not generally supported and may benefit from efforts to build support to facilitate successful implementation [27]. To inform regulatory efforts in Australia, the aim of the present study was to assess young adults’ attitudes to various statements relating to the regulation of e-cigarettes. Differences in opinion by gender, age, smoking status, e-cigarette user status, and harm perceptions (both absolute and relative) were also assessed.

Young adults were of specific interest because e-cigarettes are considered especially appealing to this population segment, as evidenced by higher prevalence of use. For example, in Australia 49% of smokers and 14% of non-smokers aged 18 to 24 years had used an e-cigarette in their lifetime compared to 31 and 5% respectively among the general adult population [3]. The higher prevalence of use among youth, especially non-smoking youth, has prompted concerns about the potential for e-cigarettes to act as a gateway to traditional smoking [28] and calls have been made for greater regulation of e-cigarettes in Australia to account for the potential for unintended harm among youth [10, 29]. Previous research also suggests the majority of young adults use e-cigarettes for recreational reasons or out of curiosity rather than for therapeutic purposes [30]. By contrast, studies of the general population indicate that the majority of individuals cite quitting or reducing smoking as reasons for use [31, 32]. The views of young adults are therefore especially important to examine because (i) their status as the most prevalent users of e-cigarettes means they are more likely to be directly affected by e-cigarette regulations and (ii) their support for various policy options may differ to those of the general population as a result of their differing reasons for use.

Respondents’ support for various statements relating to the regulation of e-cigarettes is presented in Table 1. Across all statements, 10–22% of respondents answered “don’t know” and 23–35% neither agreed nor disagreed. Statements presenting restrictive regulations failed to achieve majority support in all instances. Of these, support was greatest (albeit moderate) for treating e-cigarettes like tobacco products, with around one in three respondents agreeing with this statement. The statements suggesting that e-cigarettes should be treated like prescription medicines and that the supply of non-nicotine e-cigarettes should be prohibited were least supported, with just one in ten agreeing with these statements. Of the two statements presenting non-restrictive regulations, allowing the use of e-cigarettes in smoke-free areas was the least supported (one in five respondents).

Given the importance of public support for successful policy implementation [21], the present study aimed to survey Australian young adults’ attitudes towards various options for the regulation of e-cigarettes. The young adults surveyed in the present study were generally ambivalent in their attitudes to the various options, with 32 to 58% of respondents selecting the “don’t know” or “neither agree nor disagree” response options for each of the statements. Such responses are reflective of the continued uncertainty and contradictory messages within the scientific community regarding the benefits and risks of e-cigarette use [34].

Moderate levels of support were observed for the treatment of e-cigarettes as a tobacco product, with significantly more young adults supporting than opposing this statement. By contrast, the use of e-cigarettes in places that do not allow smoking was the most strongly opposed, with nearly half of all respondents believing that use of e-cigarettes in such areas should be prohibited. This may at least partially reflect an increase in public concern over the risks associated with passive exposure to e-cigarette vapour [27]. The introduction of a policy prohibiting e-cigarette use in smoke-free areas is important for a number of reasons. First, e-cigarette initiation is facilitated by the ability to use e-cigarettes in places where smoking is prohibited [32, 35, 36]. The introduction of a policy prohibiting use in these areas therefore has the potential to result in a reduction in the uptake of e-cigarettes.

Second, the significant gains made with respect to tobacco control are due in part to the introduction of smoke-free policies that make it difficult for smokers to use cigarettes, and it has been suggested that smokers may use e-cigarettes to circumvent smoke-free laws rather than attempting cessation [37‐39]. Third, research indicates that seeing an individual use an e-cigarette increases smokers’ urge to smoke traditional cigarettes [40]. Finally, the significant gains made with respect to tobacco control are at least partly due to the denormalisation of smoking behaviours [5]. Concerns have been raised that the use of e-cigarettes in places that do not allow smoking will result in renormalisation of such behaviours [5, 41, 42]. The use of e-cigarettes in smoke-free areas therefore has the potential to hinder cessation attempts, increase smoking among current smokers, and lead to relapse among ex-smokers. The introduction of legislation prohibiting the use of e-cigarettes in places that do not allow traditional smoking may serve to mitigate these risks.

A substantial minority of respondents opposed the statements suggesting that e-cigarettes should be treated as prescription medicines and that non-nicotine e-cigarettes should be prohibited, suggesting that the introduction of these policies may be met with resistance from some members of this age group. The low levels of support for the treatment of e-cigarettes as prescription medicines is not surprising given previous research suggests the majority of young adults use e-cigarettes out of curiosity and for recreational rather than therapeutic purposes [30], and therefore may be unable to obtain a prescription. Among those using e-cigarettes for therapeutic purposes, the need to obtain a prescription and therefore visit a registered medical practitioner may be perceived as an overly burdensome, onerous, and financially costly process [43].

The particularly low levels of support for the statement that non-nicotine e-cigarettes should be prohibited indicates that efforts may be needed to increase support for the implementation of any regulations related to these devices, such as those recommended by the Parliamentary Inquiry into the use of e-cigarettes in Australia [20]. Given that greater belief in the harms associated with e-cigarette use was found to be associated with support for restrictive regulation of e-cigarettes, increasing awareness of the harms associated with the use of e-cigarettes and challenging beliefs of e-cigarette use as a risk-free habit represent potential strategies to gain regulatory support.

Consistent with the proposition that preferences for public policies are determined by people’s self-interest [44], current smokers and e-cigarette users were typically less likely than other respondents to support restrictive approaches. These groups therefore represent important target audiences for public health campaigns designed to build support for the introduction of regulation relating to e-cigarettes. Few differences were found by gender and age, suggesting that campaigns do not need to be tailored to specific sociodemographic groups.

Regulatory action is needed to protect the health of users and non-users and ensure e-cigarettes do not contribute to the renormalisation of smoking and potentially undermine decades of public health efforts [6, 51, 52]. The present study provides initial insight into Australian young adults’ support for potential regulatory approaches to e-cigarettes. These results have implications for Australian policymakers at all governmental levels in terms of prioritising policy actions and developing strategies to increase support for specific policies among the population segment that is most likely to be using these products [53].