Is it better to vape than smoke? Definitely, but it’s still worse than quitting entirely

Before the pandemic and its many controversies, vaping – the use of electronic nicotine (or non-nicotine) delivery systems or e-cigarettes – was one of the most contentious topics online.

Talking about vaccines would start arguments, discussing raw milk might get some hate, but even the slightest hint of a position on vaping would get you immediately inundated with passionate replies from whichever side you had offended.

There are many reasons for all this passion, but the main thing has to do with uncertainty, and how we make public health decisions.

The new fantastically comprehensive report into vaping in Australia, which has resulted in calls to ban vaping entirely for younger Australians, is merely the latest in a long line of intense discussions. Depending on who you listen to, vaping is either a direct threat to human life, and children in particular, or the best public health intervention of the last 100 years, which has only fuelled the controversy on the practice.

The basic idea behind this discussion is simple: vaping is a way of ingesting nicotine (and other substances) that is far safer than smoking.

If we move people from cigarettes to e-cigarettes, as the World Health Organization review into the topic notes, it is almost certain that their health will improve, because e-cigarettes (and vape pens, cartridges etc) produce far lower levels of the most harmful chemicals that you inhale when you smoke.

But there are several obvious issues with this.

Firstly, vapes aren’t a homogenous intervention – there is enormous variability in vaping products and devices. The market is largely unregulated, which means the term “vape” covers everything from solid, reliable devices to something that will explode when you put it in your mouth.

These harms, while real, are thankfully pretty rare – even the biggest short-term issue, which is to do with serious lung disease caused largely by vapes containing a specific additive derived from cannabis, has only been seen a relatively small number of times. Yes, they’re important, but they aren’t really what we’re interested in when discussing vaping policy more broadly.

No, the real debate centres on a series of incredibly complex problems that continue to divide the topic of vaping today.

On the one hand, switching to vaping from smoking (ie giving up cigarettes entirely) is probably good for your health. That being said, the epidemiological evidence shows that this is relatively uncommon – while some people do use vaping to quit smoking entirely, most become what’s known as “dual users” who both vape and smoke in differing amounts.

The evidence on whether dual use is beneficial (as opposed to just smoking) is mixed, because the practice itself covers everything from people who rarely smoke and predominantly vape to those who basically add vaping to their current smoking regime.

Related: Call to ban vaping for young Australians after review concludes it causes ‘acute lung injury’

To add fuel to the fire there is experimental research, where people are randomised to either vape or quit smoking cold turkey, that seems to indicate some benefit for vaping. Unfortunately, these studies tend to be low-quality and it’s hard to know whether their results hold up outside of a clinical setting, although there is some evidence that they will.

Moreover, vaping is obviously worse for your health than quitting entirely.

While long-term problems have yet to be fully identified – vaping only became common in the last decade or so – there is certainly reason to believe that vaping is not entirely harmless, particularly given the massive spectrum of products you can use to vape.

On top of this, there’s pretty good evidence that vaping nicotine products is habit-forming and addictive, and there’s a great deal of concern among epidemiologists that specifically in young people vaping can lead to smoking, which is obviously a bad thing. Even this is hotly debated, because it’s hard to know whether vaping causes smoking or if it’s just that young people who start vaping are more likely to become smokers in the future anyway.

In addition, because somehow this topic gets even more complex, the recent evidence in Australia shows that people are vaping at ever-increasing rates.

A 2019 report from the Australian Institute for Health and Welfare found that about 3% of Australians are vaping regularly, which is low but also double the proportion from 2016.

In counterpoint to this, we’ve got data from the UK, where vaping has been deregulated for some time, showing that vaping rates have stabilised at about 6-7% of the population, even in younger people.

All of this complexity brings us back to the reason behind the vigorous debate – the simple truth is that this is all horribly complicated. On the one hand, from an individual perspective, switching entirely from smoking to vaping is almost certainly a good choice. That being said, picking up vaping is probably not a great idea if you don’t already smoke. From a public health perspective, the question of whether the harms of vaping, which are still a bit uncertain, outweigh the benefits of getting people to stop smoking is complex and almost certain to be an ongoing debate.

Usually I’d end here with some pithy sum-up that gives you basic advice on what to do, but the reality is that it’s a bit too complicated for even that. I’m certain to get hate mail from lots of people saying that I’ve oversimplified certain points – which is true, because you can only cover so many things in a single column – and from others saying I’ve not been harsh or lenient enough on vaping generally.

Is it likely that vaping will save a billion lives? Probably not. Is it better for you personally to vape than to smoke? Yes, definitely. Between those two ideas, there is an enormous grey area, and unfortunately what we’re left with is a great number of questions and not many satisfying answers.

• Gideon Meyerowitz-Katz is an epidemiologist working in chronic disease in Sydney’s west, with a particular focus on the social determinants that control our health