This article starts on a hopeful note, however, even when we consider that only 75% of this subsample report that they are daily smokers, this still places people with HIV at a considerably higher rate than everyone else (an estimated 10.7% of the Australian population over 18 are daily smokers).
Living with HIV can lead to ways of managing stress and we all know that tobacco smoking is one of them. We also know how difficult it can be for some people to give up cigarettes and we have known for many years the links between cardiovascular disease, smoking and HIV (read more). Both Living Positive Victoria and Queensland Positive People have run support programs for just this reason.
An innovative study conducted in Queensland viewed success as not smoking tobacco but taking up vaping. The study was called (THRiVe) Tobacco Harm Reduction with Vaporised Nicotine: A Feasibility Trial of Nicotine Vaping Products for Smoking Cessation Among People Living with HIV.
I spoke to one trial participant who told me their story:
“I’ve been smoking since I was 15. I did it to socially integrate. When I moved to a capital city from a regional city you could smoke in clubs and cafes and a lot of my friends from the queer community were smokers. There was a social acceptance and I enjoyed doing it for stress relief and to concentrate and it was easy to have a social interaction when you did not know people.
By the time I hit 30, I had been smoking for half my life. I started getting bad asthma and chest infections in the winter. One year it was so bad I started looking into vaping. I investigated the evidence because I was interested in what was going on.
There was easy access through the black market, but I really got introduced into vaping through a cross-over trial called CARP
The two arms were a range of nicotine replacement therapies. Participants were randomised to either an intervention arm—vaping plus patches plus Quitline—or a non-intervention arm– patches, gum, mouth sprays and Quitline. After three months or six months, if people in the non-vaping arm were able to quit tobacco they were switched to the vaping arm.
What I liked about this trial was how transitioning to vaping was regarded as success. I did relapse once but resolved that by getting patches (on prescription at the time – three months for the costs of one month) and then using vapes from the local tobacco shop because it was convenient at that time.”
Earlier this year, I ran into Dr Alex Wodak at a social event. Many of you will know Alex as a long-term ally and progressive thinker in the AoD space. Alex told me how he has been advocating for vaping as a safer alternative to smoking. He explained that among advanced democracies, Australia is the most hostile to vaping.
Politics and the machinations of big business aside, he made the point that people taking medication for HIV are at greater risk of premature death from heart disease. And having compromised lungs does not help anyone.
I asked Alex if he would be prepared to answer questions from our community on vaping. He agreed and so I reached out to you.
Dr Alex Wodak, Dr Colin Mendelson and Dr David Bradford compiled the following answers to your questions.
What are the potential harms of vaping and how do they differ from the specific known harms of cigarette smoking?
Cigarette smoke contains about 7,000 chemicals in high concentrations including 70 carcinogens (cancer causing chemicals). It also contains tars and carbon monoxide.
Vaping aerosol contains 100 to 200 chemicals, and those present are mostly at less than 1% of the concentration in cigarette smoke. There are no tars and little if any carbon monoxide.
The blood or urine of smokers has higher levels of biomarkers (like the chemicals found in cigarette smoke) than the blood or urine of people who vape but no longer smoke.
21,000 Australians die prematurely from smoking every year, mainly from cancer or heart and lung disease. Up to two of every three long-term smokers will die from a smoking related condition, losing on average 10 years of life. Vaping took off in about 2010 and there are now about 82 million people vaping nicotine in dozens of countries.
So far there has not been one scientifically reported death from vaping nicotine.
Are the harms different if someone has reduced lung capacity or a pre-existing lung function issue?
The harms are no different if someone has reduced lung capacity or pre-existing lung function issues. In fact, they have more to gain. People with respiratory symptoms often report less severe symptoms or even disappearance of symptoms after switching from smoking to vaping. Measurements of lung function often improve. Studies have shown improvements in asthma and COPD (emphysema) after switching from smoking to vaping and fewer chest infections.
Why is it important for me to engage with my GP about vaping as an option when other attempts to quit have not been successful?
To start vaping legally in Australia you must ask your General Practitioner to write a prescription for nicotine. Only 8% of Australia’s 1.3 million vapers have a prescription and 92% purchase and use vaping products illegally without one, mostly online from overseas or from the black market.
Only 2% purchase nicotine liquid with a prescription from a pharmacy, the government’s preferred method.
Should I just buy any vape device and cartridges at the local tobacconist?
The best place to buy a vape device is from a vape shop. Vape shops have a wider range of products and can give expert advice on what to buy and how to use it safely. However, vape shops cannot sell nicotine, and most people purchase nicotine from overseas websites, mainly in New Zealand. The most popular starting devices are prefilled pod devices or disposables.
Experts agree vaping is substantially less harmful than smoking, but it is not risk-free. If vaping exposes users to fewer toxins and at lower levels than smoking cigarettes what are the risks, then?
In the short term, some people develop a cough, sore throat, nausea, or headache. These symptoms usually disappear in a week or so. It is most unlikely that serious risks will ultimately emerge because of the dramatic reduction of chemicals in vapour compared to smoke.
Vaping has now been around for over a decade and so many people are now vaping and serious harms from vaping are extremely rare. That’s not what you read in the newspapers or hear on radio or television, but Australia’s media is very partisan and hostile to vaping.
It is true that we cannot say what the precise long-term effects of vaping are. What is clear is the long-term harm from vaping is only going to be a tiny fraction of the harm from smoking.
What is safe to use? There are lots of black market vapes out there. Money will be a deciding factor for some when deciding to switch.
As you would expect, black market products are not tested for quality or safety and are not recommended. However, the ones tested so far are still far safer than smoking. Many people start with black market brands such as iGet, HQD and Gunpod and then switch to regulated brands once they have successfully quit or cut down.
I am someone who has never tried to give up smoking cigarettes. I have smoked for 30 years. The only times I stopped was when I was in hospital for lung cancer.
I have tried vaping. It is very strong stuff. To draw from a cigarette is easy and something I enjoy. But vapor is much stronger on my throat, and I do not like that feeling and in fact I cannot do it.
I am not convinced because I don’t think we know the actual content in the vape and so therefore I question the effectiveness on people and vulnerable communities of moving towards the use of vapes.
Black market vapes are very strong and often quite harsh. You should consider trying a regulated vaping product at a lower nicotine concentration, perhaps at 2-3% nicotine. Most vapers say they enjoy vaping as much or more than smoking once they find the right device, flavour and nicotine concentration for them.
Many regulated vaping products have had their emissions tested and we do know what they release. Toxic chemicals are mostly in extremely small doses. The evidence is now clear that vaping is an effective way to quit. It doesn’t work for everyone but is more effective than any other quitting aid. Smokers from vulnerable communities have more to gain from quitting and many have succeeded with vaping.
I am worried that the availability of vapes is too wide, particularly to children, teenagers, and young people. I feel they encourage young people to take up vaping. I’m a mother, that’s why I’m asking this question.
No one wants young people to vape, even if the risks are small. Breathing fresh mountain air is always going to be safer than vaping. Vaping should only be for adult smokers who want to continue enjoying nicotine or the smoking ritual but at a fraction of the risk, or smokers who want to quit smoking. Australia’s problem with so many young people vaping is a product of our large and rapidly growing vaping black market and the black market is a product of a ridiculously restrictive policy on nicotine vaping.
Most vaping by young non-smokers is experimental and short-term and causes little harm.
Regular vaping is largely confined to current or former smokers.
Very few doctors are prepared to prescribe nicotine, very few pharmacies are prepared to dispense nicotine for vaping and very few smokers want to go to doctors and chemists for nicotine for vaping. The idiocy of Australia’s policy is that the availability of vaping, at least 95% safer than smoking, is highly restricted while deadly smoking is readily available.
Does the cancer council support vaping?
Most health charities in Australia, including the Cancer Council, believe that smokers should just quit smoking and nicotine completely and vigorously oppose vaping. However, their counterparts in the UK and New Zealand strongly support vaping nicotine for smokers who can’t otherwise quit. This makes no sense as the cancer risk from vaping is less than 0.5% of the risk from smoking.
Vaping rates are lower in Australia than many other western countries. A decade ago, Australia’s smoking rate was lower than in the UK, US or NZ, but now it’s higher. It’s likely that the difference in vaping rates has played a substantial role in the greater decline in smoking rates in UK, US and NZ compared to Australia. Other countries use different forms of tobacco harm reduction, with Sweden and Norway using snus, and Japan using heated tobacco products.
I have heard that vaping will only be available by prescription soon does this mean that it will become cheaper if I have a concession card?
In Australia, a prescription is currently required to vape legally. It is very unlikely that vaping products will ever go on the Pharmaceutical Benefits Scheme and be subsidised by the government. However, vaping is around 10-15% of the cost of smoking and there is a huge financial benefit in switching for people on low incomes.
Could you explain what harm reduction means in this context?
Tobacco harm reduction means we concentrate on trying to reduce deaths and disease from tobacco by encouraging smokers to switch to less dangerous ways of using nicotine. Almost half a century ago, Professor Michael Russell in the UK said, ‘people smoke for the nicotine but die from the tar’. Vaping enables people to use nicotine without tar.
Harm reduction has been used extensively to slow the spread of HIV. Condoms enable people to continue enjoying sex but with a much lower risk of contracting HIV. Providing sterile needles and syringes while collecting used injection equipment enables people who want to continue injecting drugs to do so but with minimal risk of blood borne viral infections including HIV.
Does vaping have any other consequences in terms of oral health? Are there associated mouth or throat cancer risks that we need to be aware of?
Vaping has been associated with harmful effects on oral health, but much less than from smoking. Numerous studies have found that oral health improves when smokers switch to vaping. There are no reports of mouth or throat cancer risks caused by vaping nicotine. A real problem in this field is disentangling the possible complications of vaping from the common and severe complications of smoking, as most vapers have previously smoked.
This article also ends on a hopeful note. My personal observation, backed up by data from Futures is that fewer and fewer people with HIV are smoking tobacco. I have noticed, at our national forums for example, that fewer people are going out for cigarette breaks.
Clearly, from the responses above there is a pathway for us to reduce the harms from tobacco inhalation while still enjoying the benefits of nicotine and associated rituals. We can talk further with our doctors and health care providers and with the information provided from the experts above make our own decisions about the best ways forward.
Dr David Bradford has added his additional and very personal comments as an addendum to this article. We thank him for his personal honesty, and we thank Dr Alex Wodak and Dr Colin Mendelson for sharing their experience and perspectives.
Additional Comments on Vaping vs Smoking Cigarettes
– Dr David Bradford, retired Sexual Health Physician
I am no expert on vaping. However, I once was a smoker myself for about fifteen years throughout the HIV/AIDS years, It helped me cope with what was then a very difficult time for all health workers, and especially gay ones like myself. I know how extraordinarily difficult it is to give up smoking cigarettes, even when very strongly motivated as I was (because I was a doctor and knew how stupid it was and what damage it was doing me).
I eventually only stopped smoking around about 2000 by using alternative sources of nicotine: patches and gum.
I am strongly in favour of ANY harm reduction methods. I have seen them work not just in theory, but in everyday practice. I think of the effectiveness of condoms and safe sex; I think of the effectiveness of needle and syringe programs; I think now of the enormous effectiveness of PrEP and PEP. I am utterly convinced that harm reduction works.
We are not looking for PERFECTION; we are looking for what effectively reduces risk in the real world of real, live, everyday people.
From the current evidence, it seems crystal clear that vaping, while providing a comparable nicotine experience, is less harmful than smoking cigarettes by a great level of magnitude. In fact, as yet the evidence that vaping harms your health in any significant way, is not substantiated. Of course, doctors would rather people not smoke and not vape. But if stopping cigarette smoking is difficult (as it clearly is), and vaping is an effective and much less risky substitute (as all the evidence to date indicates that it is), then any sensible doctor would prefer that people vape instead of smoke.
That is my position, and I hope that this recommendation is endorsed and made clear to all smokers in the HIV positive community. Because cigarette smoking substantially ruins health and leads to an earlier death for everybody, but in HIV positive people that risk is greatly enhanced.
Thanks again for the information from:
Dr. Alex Wodak AM, Emeritus Consultant, Alcohol and Drug Service, St Vincent’s Hospital, Sydney, Darlinghurst, NSW, 2010, Australia. Chair, Australia 21. Director, Australian Tobacco Harm Reduction Association. Ambassador, Harm Reduction Australia.
Dr Colin Mendelsohn MB BS (Hons) who graduated as a doctor from the University of Sydney in 1976 with honours. He worked as a general practitioner for nearly 30 years, with a special interest in smoking cessation. Colin is a member of the Smoking Cessation Guideline Expert Advisory Group that develops the RACGP Australian national smoking cessation guidelines.
Dr David Bradford who graduated as a doctor in 1965, he has led a remarkable life. As a gay man and sexual health physician when HIV first arrived in Australia, he cared for hundreds of patients. In his biography’, Tell Me I’m OK, he recounts a poignant memoir of care during that crisis.