Register      Login
Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association

Healthcare costs attributable to e-cigarette use and subsequent uptake of cigarette smoking by Australians who have never smoked

Louisa G. Gordon A B C * and Paige Preston C D
+ Author Affiliations
- Author Affiliations

A QIMR Berghofer Medical Research Institute, Population Health Program, Brisbane, Qld, Australia.

B School of Nursing, Queensland University of Technology (QUT), Brisbane, Qld, Australia.

C School of Public Health, The University of Queensland, Brisbane, Qld, Australia.

D Lung Foundation Australia, Level 2/11 Finchley Street, Milton, Qld 4064, Australia.

Australian Health Review 48(1) 52-57
Submitted: 10 May 2023  Accepted: 1 December 2023  Published: 22 December 2023

© 2024 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA.



New legislation to curb the rapid increase in e-cigarette use among youth is underway. We estimated the future healthcare costs for chronic diseases from e-cigarette use among never smokers who transition to tobacco smoking.


Using population-attributable fractions, we estimated the health expenditure attributable to e-cigarettes based on the prevalence of e-cigarette use, uptake of tobacco smoking, and risk of smoking on developing chronic disease. Data for men and women were derived from published reports on e-cigarette use prevalence, risk of smoking-related disease and addiction, and health expenditure for 25 diseases. Sensitivity analyses were undertaken to address data input variation.


Future healthcare costs attributed to new e-cigarette-initiated smokers were conservatively estimated to be (in Australian dollars) $179.6 million annually. Collectively, the estimated costs were highest for respiratory diseases ($102.2 million; 57% of total costs), malignant cancers ($49.6 million; 28%), and cardiovascular disease ($27.7 million; 15%). The uptake rate of e-cigarettes was more important in driving healthcare costs than the proportion moving from e-cigarettes to cigarette smoking.


High avoidable health system costs are predicted for the treatment of chronic conditions created by e-cigarette-initiated smoking. These costs exclude the immediate and direct healthcare harms of e-cigarette-related poisoning, lung injury, and respiratory problems, and costs associated with the unknown health harms of e-cigarette use alone. The proposed regulations to curb recreational e-cigarette use in Australia are set to prevent expensive health care arising sometime in the future from new cigarette smokers.

Keywords: cost analysis, e-cigarette, electronic nicotine delivery system, healthcare costs, vaping.


Larcombe A, Allard S, Mullins B. Chemical analysis of fresh and aged Australian e-cigarette liquids. Med J Aust 2022; 216(8): 430 Epub 30 March 2022.
| Crossref | Google Scholar | PubMed |

Banks EBK, Joshy G. Summary report on use of e-cigarettes and impact on tobacco smoking uptake and cessation, relevant to the Australian context. Commissioned Report. Canberra: Australian Government; 2020.

Son Y, Weisel C, Wackowski O, Schwander S, Delnevo C, Meng Q. The Impact of Device Settings, Use Patterns, and Flavorings on Carbonyl Emissions from Electronic Cigarettes. Int J Environ Res Public Health 2020; 17(16): 5650.
| Crossref | Google Scholar | PubMed |

IARC Monographs Vol 128 group.. Carcinogenicity of acrolein, crotonaldehyde, and arecoline. Lancet Oncol 2021; 22(1): 19-20 Epub 26 November 2020.
| Crossref | Google Scholar | PubMed |

Tang MS, Tang YL. Can electronic-cigarette vaping cause cancer? J Cancer Biol 2021; 2(3): 68-70.
| Crossref | Google Scholar | PubMed |

Greenhalgh EM, Bain E, Jenkins S, Scollo MM. 18.3 Prevalence of e-cigarette use. In Greenhalgh EM, Scollo MM, Winstanley MH (eds). Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available at‐18‐e‐cigarettes/18‐3‐extent

Dautzenberg B, Bricard D. Real-time characterization of e-cigarettes use: the 1 Million Puffs Study. J Addict Res Ther 2015; 6(2): 229.
| Crossref | Google Scholar |

Centre for Epidemiology and Evidence. NSW Population Health Survey, HealthStats NSW. E-cigarette use. 2021. Available at [accessed 23 August 2022].

Australian Institute of Health and Welfare. Alcohol, tobacco and other drug use in Australia. Canberra: Commonwealth Government; 2022.

10  Soneji S, Barrington-Trimis JL, Wills TA, Leventhal AM, Unger JB, Gibson LA, et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA Pediatr 2017; 171(8): 788-97.
| Crossref | Google Scholar | PubMed |

11  Wakefield M, Tabbakh T, Scollo M, Durkin S. Current vaping and current smoking in the Australian population aged 14+ years: February 2018-March 2023. Melbourne: Centre for Behavioural Research in Cancer, Cancer Council Victoria; 2023.

12  Gardner LA, O’Dean S, Champion KE, Stockings E, Rowe AL, Teesson M, et al. Prevalence, patterns of use, and socio-demographic features of e-cigarette use by Australian adolescents: a survey. Med J Aust 2023; 219(7): 332-4.
| Crossref | Google Scholar | PubMed |

13  Hartmann-Boyce J, Lindson N, Butler AR, McRobbie H, Bullen C, Begh R, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2022; 11(11): CD010216.
| Crossref | Google Scholar | PubMed |

14  Butler AR, Lindson N, Fanshawe TR, Theodoulou A, Begh R, Hajek P, et al. Longer-term use of electronic cigarettes when provided as a stop smoking aid: Systematic review with meta-analyses. Prev Med 2022; 165(Pt B): 107182.
| Crossref | Google Scholar | PubMed |

15  Doan TTT, Tan KW, Dickens BSL, Lean YA, Yang Q, Cook AR. Evaluating smoking control policies in the e-cigarette era: a modelling study. Tob Control 2020; 29(5): 522-30.
| Crossref | Google Scholar | PubMed |

16  Kalkhoran S, Glantz SA. Modeling the Health Effects of Expanding e-Cigarette Sales in the United States and United Kingdom: A Monte Carlo Analysis. JAMA Intern Med 2015; 175(10): 1671-80.
| Crossref | Google Scholar | PubMed |

17  Levy DT, Gartner C, Liber AC, Sánchez-Romero LM, Yuan Z, Li Y, et al. The Australia Smoking and Vaping Model: The Potential Impact of Increasing Access to Nicotine Vaping Products. Nicotine Tob Res 2022; 25: 486-97.
| Crossref | Google Scholar | PubMed |

18  Petrović-van der Deen FS, Wilson N, Crothers A, Cleghorn CL, Gartner C, Blakely T. Potential Country-level Health and Cost Impacts of Legalizing Domestic Sale of Vaporized Nicotine Products. Epidemiology 2019; 30(3): 396-404.
| Crossref | Google Scholar | PubMed |

19  Pound C, Coyle D. A cost-utility analysis of the impact of electronic nicotine delivery systems on health care costs and outcomes in Canada. Health Promot Chronic Dis Prev Can 2022; 42(1): 29-36.
| Crossref | Google Scholar | PubMed |

20  Soneji SS, Sung HY, Primack BA, Pierce JP, Sargent JD. Quantifying population-level health benefits and harms of e-cigarette use in the United States. PLoS One 2018; 13(3): e0193328.
| Crossref | Google Scholar | PubMed |

21  Summers JA, Ait Ouakrim D, Wilson N, Blakely T. Updated Health and Cost Impacts of Electronic Nicotine Delivery Systems, Using Recent Estimates of Relative Harm for Vaping Compared to Smoking. Nicotine Tob Res 2022; 24(3): 408-12.
| Crossref | Google Scholar | PubMed |

22  National Drug Research Institute. Identifying the Social Costs of Tobacco Use to Australia in 2015/16. Perth: Curtain University; 2019.

23  Australian Institute of Health and Welfare. Health system spending per case of disease and for certain risk factors, Web report April 2022. Canberra: Australian Government; 2022.

24  US Department of Health and Human Services. The Health Consequences of Smoking – 50 Years of Progress. A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.

25  Australian Institute of Health and Welfare. Disease expenditure in Australia 2018-19, Web report Aug 2021. Canberra: Australian Government; 2021.

26  Melka A, Chojenta C, Holliday E, Loxton D. E-cigarette use and cigarette smoking initiation among Australian women who have never smoked. Drug Alcohol Rev 2021; 40(1): 68-77 Epub 4 August 2020.
| Crossref | Google Scholar | PubMed |

27  Australian Bureau of Statistics. National Health Survey, 2020-21 – Australia. Canberra: Australian Government; 2022.

28  Australian Institute of Health and Welfare. Alcohol, tobacco & other drugs in Australia, Web report April 2022. Canberra: Australian Government; 2022.

29  Wylie C, Heffernan A, Brown JA, Cairns R, Lynch AM, Robinson J. Exposures to e-cigarettes and their refills: calls to Australian Poisons Information Centres, 2009–2016. Med J Aust 2019; 210(3): 126.
| Crossref | Google Scholar | PubMed |

30  Wang Y, Sung HY, Lightwood J, Yao T, Max WB. Healthcare utilisation and expenditures attributable to current e-cigarette use among US adults. Tob Control 2022; 23(057058): 723-8.
| Crossref | Google Scholar |

31  Pettigrew S, Miller M, Kannan A, Raj TS, Jun M, Jones A. School staff perceptions of the nature and consequences of students’ use of e-cigarettes. Aust N Z J Public Health 2022; 46(10): 676-81.
| Crossref | Google Scholar | PubMed |

32  Jongenelis MI, Kameron C, Rudaizky D, Slevin T, Pettigrew S. Perceptions of the harm, addictiveness, and smoking cessation effectiveness of e-cigarettes among Australian young adults. Addict Behav 2019; 90: 217-21.
| Crossref | Google Scholar | PubMed |