The ends do not justify the means when it comes to Australia's vaping policy

Smoking remains a leading cause of health inequalities and policy needs to reduce this gradient. Australia's current policy is not achieving its objective. Making e-cigarettes harder to access is keeping them from those who need them and feeds into a system which maintains inequalities. Smoking remains a leading cause of health inequalities and government policy needs to reduce this gradient. Many of the people who smoke are from underrepresented and disadvantaged groups [1-3], and therefore, hold little power when it comes to political decision making [4]. Hall [5] provides a range of evidence-based arguments that outline why Australia's e-cigarette policy is failing to deliver equitable and effective public health policy. Adding to Hall's own analysis of these issues, I have several further observations. First, smoking is so dangerous; there is an urgent need to provide evidence-based support to all people who smoke. We now have several systematic reviews that support the role of nicotine containing e-cigarettes for cessation and a growing number of studies showing the beneficial health effects when compared with smoking [6-8]. Even if some uncertainty remains on longer term health effects, to date, we know that e-cigarettes are a viable evidence-based option as a smoking cessation aid and should be available to people who need them. As Hall [5] highlights, although there have been changes in the prescription of e-cigarettes in Australia in recent years, the vast numbers of people who could benefit do not and most are accessing them illegally (without prescription). To protect young nicotine naive users, a system has been organised so that people can access e-cigarettes through prescription only, with the aim of preventing young people from using these products. What has unfolded is a system that makes products difficult to access and overly medicalised. Both consequences miss the real opportunities e-cigarettes can offer: e-cigarettes can be sold at retail outlets, albeit with sensible restrictions, and therefore, reach more people who smoke, and in the absence of an overly medicalised procedure they may be perceived as distinct from other forms of nicotine replacement therapies, which many people have tried and failed to stop smoking with. Second, the main objective of the policy is not being realised. Despite these restrictions, the number of young people using e-cigarettes has risen in Australia, seeing a steady rise since 2016 marked by a substantial increase from 2020 (4% 2020 to 19.8% 2023) [9], although, as Hall [5] notes, some data are overestimated by use of 'ever' e-cigarette use as opposed to the more accurate daily or frequent use estimate. Evidence-based practice should be informing governments how to minimise substance use among young people. We know what works because we have decades of evidence from tobacco and other substances like alcohol on how restrictions of sales and marketing, sale environments, age of sale and packaging can help minimise use (e.g. Fidler and West, Moodie et al., Nuyts et al., and Toomey and Wagenaar) [10-13]. Hall [5] gives some evidence-based examples of approaches that, even across territories, have been successful in driving down smoking rates among young people, which could be adopted. If these were to be adopted then they could be measured effectively through surveys; monitoring youth access through legal means is preferable to trying to estimate illegal use, which cannot be captured in some survey types and can lead to inaccuracies [14]. Third, good public health policy needs real-time monitoring surveillance from multiple sources that can provide observational trends across multiple time points. Doing so allows greater reaction to potentially flawed practices and policies. As things currently stand, these policies in Australia will be reviewed in 2026, but given the substantial harms caused by continued smoking, this is far too long. Fourth, a high percentage of adults who smoke are accessing e-cigarettes without prescription (estimated 90%) and, therefore, illegally, although Hall [5] notes most are unaware. Nonetheless, pushing people into a system of illegal acquisition and consumption, with no product control, will most likely disadvantage those who already are disadvantaged. Historically it is those who are poorer who feel the weight of the criminal justice system, because they lack access to adaptative social determinants to support them [15]. Put simply, by making access to e-cigarettes arduous and discouraging, it feeds into the system of determinants that maintain people in a position of inequality. Smoking kills. This is no longer a public health crisis where we do not know the outcome. Watching and waiting and holding back safer products while people keep accessing cigarettes are not a means that can be justified. Doing so contradicts the mission to improve the health of the public. Sharon Cox: Conceptualization (lead); writing—original draft (lead). None. None. Data sharing is not applicable to this article as no new data were created or analyzed in this study.