The first point to consider, when it comes to e-cigarettes is, are they safe? Professor Scott referred to a number of systematic reviews that considered over 100 studies and concluded that there was evidence of harm by e-cigarettes at several levels although a causal link is under debate. These include:

• Molecular (i.e., oxidative stress, cytotoxicity, cardiomyocyte dysfunction)
• Physiological (i.e. hypertension, tachycardia, worsening arterial stiffness)
• Clinical events, such as myocardial infarction

There is a concerning trend of increasing numbers of young people using e-cigarettes

Professor Scott spoke further regarding the potential harms of e-cigarettes and the concerning trend of increasing numbers of young people using e-cigarettes. He has personally “had very little success getting young people to quit” once they start. This is happening even in “never smokers”, with a large portion of teenagers who have never smoked using e-cigarettes. E-cigarettes may be a gateway to smoking and are associated with the initiation of smoking in young people. Some data suggests young people who use e-cigarettes are up to six times more likely to also smoke regular cigarettes than young people not exposed to e-cigarettes¹. Since the link between the risk of psychosis and smoking is about as robust as the link between cannabis and psychosis, there are strong reasons to reduce smoking and e-cigarette use, cautioned Professor Scott.

E-cigarettes are associated with initiation of smoking in young people, the data revealing they are up to 6 times more likely to commence cigarette smoking versus young people not exposed to e-cigarettes²

Another point of contention around e-cigarettes has been their potential as smoking cessation tools, and Professor Scott covered this also. He mentioned that in recent studies on the topic there were no significant differences in smoking cessation between e-cigarette and comparison groups.³ Further studies have found that in randomised controlled trials (RCTs), smokers assigned to nicotine replacement therapy (NRT) were more likely to be abstinent from cigarettes at follow-up versus those assigned to placebo or treatment as usual. Other research has shown that former smokers who use e-cigarettes relapsed to smoking more than those who used other strategies to stop smoking. It is important to note, Professor Scott cautioned, that the quality of the studies on smoking cessation and mental illness is quite weak (there are no RCTs), and they exclude the “real-world patients” such as those with recent mental illness exacerbation, substance use, and physical comorbidities.

A recent metanalysis of 18 randomised controlled trials showed robust evidence that some pharmacological interventions available on the PBS are helpful in smoking cessation.² Psychiatrists should therefore become better at prescribing smoking cessation therapies, Professor Scott suggested.

Finally, Professor Scott covered the RANZCP position statement on e-cigarettes; The RANZCP recognises the potential harm reduction benefits presented by e-cigarettes for people living with mental illness and the need for legislative reform for these to be realised. RANZCP therefore recommends:

1. exemption of nicotine-containing e-cigarettes and vaporisers from the restrictions imposed under the Poisons Standard
2. lower rates of taxation for e-cigarettes and vaporisers compared to smokable tobacco products to ensure affordability for low-income smokers

This statement is somewhat at odds with other colleges and with general advice, especially in light of the harms caused (including death), that they may not be the best option for smoking cessation either. They may be effective in people who are nicotine dependent, but no robust studies exist in mental illness.

Professor Scott concluded by advocating for the RANZCP to either withdraw or substantially revise their position statement on e-cigarettes, which are emerging as a serious risk to public health. A further recommendation is that the RANZCP develops a position statement on tobacco smoking in people with serious mental illness, where substantially higher quality evidence of effective interventions exists.