Dr Lindsay Robertson, Dr Jerram Bateman, Professor Janet Hoek
Members of the public health community hold divergent views on how access to vaping products or electronic nicotine delivery systems (ENDS) products should be arranged. Some believe ENDS should be as widely available as smoked tobacco and argue for liberal access. However, others suggest smoked tobacco should be much less available than is currently the case and propose that only retailers skilled in supporting smoking cessation should sell ENDS. In this blog, we probe concerns about allowing widespread availability of ENDS and related products. We first draw on related research into smoked tobacco products and then discuss findings from our recently published study that questions the wisdom of allowing ENDS to be sold by non-specialist retailers.
Proposed ENDS regulation
The Associate Minister of Health responsible for tobacco has announced that, in late 2019, she plans to introduce an amendment to the Smoke-free Environments Act 1990 that will regulate electronic nicotine delivery systems (ENDS) and other products, such as heated tobacco products (HTP).1 Among other topics, the Bill is expected to set product safety standards and regulate the type of marketing permitted.2
The proposed Bill enables retailers of specialist R18 vape stores to notify their business to the Ministry of Health (MOH), which would allow them to offer product samples and permit vaping onsite. However, aside from setting out the notification process and potential benefits, the Regulatory Impact Statement does not propose restricting the sale of ENDS, HTPs, or associated vaping items such as e-liquids, to specialist vape stores.2 This approach implies all retailers, including dairies, convenience stores, supermarkets, liquor stores and petrol stations, will continue to be able to sell these products (the current situation in NZ).
Balancing smoking initiation among youth with cessation among smokers
Several studies have concluded that greater access to outlets selling tobacco is associated with higher youth smoking.3 These findings suggest that any addictive product, including ENDS and associated products, should be carefully regulated to minimise adverse public health outcomes.
At the same time as considering the potential effect of widespread availability on youth uptake, we also need to consider smokers’ experiences using ENDS to quit smoking. As argued in previous blogs (here and here), switching from smoking to vaping may be more complex than people expect. Participants in our earlier studies reported missing physical sensations of smoking, such as the “mouth-feel”, “hand-feel” or “throat-hit”.4,5 Others found it difficult to know which e-liquid nicotine concentration would satisfy their nicotine cravings, while avoiding excessive intake that could induce unpleasant symptoms or increase their dependence.4
Realising ENDS’ potential to contribute to the 2025 goal
Making ENDS and other vaping products more available could encourage smokers to transition fully from smoking to vaping, which may improve public health and reduce health inequities. However, as the MoH acknowledges, ENDS’ capacity to achieve population health gains depends on “the extent to which they can act as a route out of smoking for New Zealand’s 550,000 daily smokers”.6 Retailers could play a helpful role in determining what population health gains are realised, but only if they have a sound knowledge of the products they sell and how successful switching occurs.
We recently used in-depth interviews to explore 18 non-specialist retailers’ knowledge of ENDS, attitudes towards selling ENDS and supporting customers’ cessation attempts, perceptions of ENDS’ risks and benefits, and views on the proposed legislation.7 Participants owned or managed dairies, superettes, service stations and supermarkets; 12 of the 18 retailers sold ENDS products.
Overall, participants had a weak understanding of ENDS products and smoking cessation; some confused nicotine with toxins caused by combustion, with only a minority regarding ENDS as a harm reduction tool. Most gave customers purchasing ENDS products no advice on how to use the device they had purchased, and, in a minority of cases, reported providing information that was incorrect. Many participants saw their role as strictly commercial, which reflected their perception that smoking and ENDS use were personal choices. Nonetheless, a small group noted they would direct people to services where they could obtain information, advice, and cessation support.
Our participants generally believed people who switched from smoking to ENDS use would gain financial benefits; relatively few saw ENDS as smoking cessation devices and some queried ENDS’ effectiveness, as they had observed customers relapsing from vaping to smoking. At the time of interviewing, retailers who stocked ENDS reported low customer demand and saw tobacco as more important to their business than ENDS. Unlike ENDS, retailers felt that tobacco resulted in greater repeat business and ancillary sales, and some reported receiving rebates from tobacco companies.
Participants typically supported liberalising ENDS availability, though several expressed concerns about potential youth uptake and supported R18 sales restrictions. A small number reported not using point-of-sale materials provided to them by ENDS manufacturers, due to concerns about exposing young people to vaping products.
How should the NZ Government proceed with regulating ENDS’ availability?
Given evidence that some people find moving from smoking to ENDS difficult because of the core behaviour changes required, retailers have a potential role to play in assisting smokers to manage this transition. It seems highly unlikely retailers will fulfil this role if they have weak knowledge of the products they sell and regard themselves simply commercial operators. Recent evidence that behavioural counselling increases successful transitions from smoking to ENDS8 implies supply arrangements should ideally incorporate cessation support. Failure to provide guidance at the point of sale risks leading to unsuccessful switching, reversion to smoking, and loss of confidence in ENDS.
Allowing only licensed specialist vape stores to sell ENDS would help ensure sales staff had relevant expertise, though it would create a conflict between promoting eventual vaping cessation and ensuring on-going revenue. Restricting ENDS sales to pharmacies could help ensure smokers access cessation support, would frame ENDS as cessation aids (rather than recreational products),9 and could support eventual vaping cessation. Nor would limiting access to these outlets appear likely to affect smokers. Recent data from the NZ ITC Project shows the proportion of ENDS users who reported making their last purchase of e-liquid, e-cigarette cartridges or disposable e-cigarettes from a vape shop grew from 35.2% in 2016 to 56.6% in 2018.10 Furthermore, more than three-quarters (76.5%) of the Wave 2 (2018) ITC participants disagreed or strongly disagreed that ECs or vaping devices are too hard to get.11
While we support allowing ENDS sales only in licensed specialist vape stores and pharmacies, this measure needs to be accompanied by restrictions on smoked tobacco’s availability.12 Licensing schemes for both ENDS and smoked tobacco could simultaneously reduce supply of smoked tobacco while requiring ENDS retailers to meet minimum knowledge standards. Until ENDS retailers fully understand the relative risks of smoking and ENDS, know the devices they sell, and understand the process of switching from smoking to vaping, there is a serious risk that non-specialist retailers may inadvertently undermine smokers’ transitions to ENDS use.
- Salesa J. Vaping and smokeless tobacco products to be regulated. 2018; https://www.beehive.govt.nz/release/vaping-and-smokeless-tobacco-products-be-regulated. Accessed 28 November, 2018.
- Ministry of Heath. Supporting smokers to switch to significantly less harmful alternatives. 2018; https://www.health.govt.nz/system/files/documents/pages/ris-support-smokers-to_switch-to-alternatives-jan-2019.pdf, 2018.
- Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS, Fortmann SP. Is adolescent smoking related to the density and proximity of tobacco outlets and retail cigarette advertising near schools? Preventive Medicine. 2008;47(2):210-214.
- Hoek J, Thrul J, Ling P. A qualitative analysis of young adult ENDS users’ expectations and experiences. BMJ Open. 2017;7(3):e014990.
- Robertson L, Hoek J, Blank M-L, Richards R, Ling P, Popova L. Dual use of electronic nicotine delivery systems (ENDS) and smoked tobacco: a qualitative analysis. Tobacco Control. 2018.
- Ministry of Health. Vaping and smokeless tobacco. 2018; https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/vaping-and-smokeless-tobacco. Accessed 06 January, 2019.
- Bateman J, Robertson L, Marsh L, Thornley L, Hoek J. New Zealand tobacco retailers’ understandings of and attitudes towards selling Electronic Nicotine Delivery Systems: a qualitative exploration. Tobacco Control. 2019:tobaccocontrol-2019-055173.
- Hajek P, Phillips-Waller A, Przulj D, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. New England Journal of Medicine. 2019;380(7):629-637.
- Wilson N, Edwards R, Hoek J, et al. Potential new regulatory options for e-cigarettes in New Zealand. New Zealand Medical Journal. 2015;128(142):88-96.
- Edwards R, Stanley J, White M, et al. Patterns of use of e-cigarettes among smokers and recent quitters: Findings from the 2016-18 ITC New Zealand Surveys. SRNT-O Conference; 24-25 October, 2019; Sydney, Australia.
- Edwards R, Stanley J, White M, et al. Perceptions and beliefs about e-cigarettes among smokers: findings from the 2016-18 ITC New Zealand surveys [Poster]. SRNT-O Conference; 24-25 October, 2019; Sydney, Australia.
- Robertson L, Marsh L, R E, Hoek J, Van der Deen F, R. M. Regulating tobacco retail in New Zealand: what can we learn from overseas? New Zealand Medical Journal. 2016;129(1432):74-79.