Life expectancy in Aotearoa New Zealand has increased over recent decades, but these increases have not been distributed equally across population groups. Examining how changes in cause-specific mortality have contributed to changes in life expectancy can improve understanding of evolving mortality patterns and persistent inequities. This study quantified the contribution of major causes of death to changes in life expectancy over approximately two decades. Mortality data from the New Zealand Mortality Collection and population estimates from Statistics New Zealand were used to calculate life expectancy at birth for Māori, Pacific, Asian, and European and Other populations for the periods 2001-2003 and 2020-2022. Changes in life expectancy were decomposed by age and cause of death using the Arriaga method. Deaths were grouped into major disease categories and selected individual causes to estimate their contribution to the change in life expectancy. Life expectancy increased for all ethnic groups, with the largest absolute increases observed among Māori. Improvements were driven primarily by reductions in mortality at adult and older ages. Across all ethnic and sex groups, declines in cardiovascular disease and cancer mortality accounted for more than half of the total change in life expectancy. Reductions in mortality from diabetes and smoking-related conditions also contributed to increases among Māori and Pacific peoples. Despite these improvements, substantial ethnic inequities in life expectancy remain. Increases in life expectancy in Aotearoa New Zealand between 2001-2003 and 2020-2022 were driven largely by reductions in mortality from major non-communicable diseases, primarily cardiovascular disease and cancer. Māori experienced some narrowing of the life expectancy gap relative to European and Other populations, whereas the gap for Pacific peoples remained largely unchanged. Despite overall improvement, substantial inequities persist. Further increases are likely to depend on strengthening primary prevention, particularly reductions in smoking and cardiovascular risk factors, alongside improved participation in screening and early detection programmes, including the potential role of lung cancer screening, and ensuring equitable access across care pathways.
With the reduction in police involvement in front-line mental health responses in New Zealand (implemented November 2024), this study evaluates the primary legal justification supporting paramedics in using force to prevent suicide: Section 41 of the Crimes Act 1961. We conducted a qualitative analysis of 20 legal cases (1986-2023) identified through a systematic search. The analysis was structured thematically, focussing on the legal criteria for intervention, the role of de-escalation, the threshold for "reasonable force" and the unresolved conflict between intervention and patient autonomy. Cases were included if Section 41 was central to the legal reasoning or as a justification; cases where Section 41 was cited in passing without substantive discussion were excluded. Case review suggests that while Section 41 can provide a legal justification, its application is highly context dependent. Courts have held that force is justifiable only to prevent immediate and unlawful harm and that it should be proportionate to the threat. Failing to attempt viable, less-restrictive alternatives can render even minimal force unreasonable. Cases involving excessive force demonstrate judicial focus on proportionality and the availability of other options. The analysis highlights a legal and ethical "grey area" concerning patient capacity and the limits of intervention. There is limited case law interpreting Section 41 (20 substantive cases identified between 1986 and 2023). To improve safety for patients and practitioners, we suggest clearer operational guidance, multidisciplinary education and consideration of legislative options that would better support healthcare-led responses to mental health emergencies.
The prevalence of Māori experiencing ngā māuiui kai (eating disorders; NMK) is comparable to that of non-Māori. Despite this, little is known about Māori presentations within Kaupapa Māori health services. This paper uses Kaupapa Māori kaimahi expertise to describe these presentations and identify steps to strengthen access and support. Informed by Kaupapa Māori methodologies and participatory action research, this co-designed study involved Purapura Whetu, a Kaupapa Māori health service in Christchurch. A wānanga convened eight kaimahi to discuss challenges, service strengths and required supports for Māori experiencing NMK. Insights and themes were mapped to the New Zealand Eating Issues and Eating Disorders Strategy to show how Kaupapa Māori approaches can support its implementation. Six themes with 24 actionable points were identified. Themes were: 1) food insecurity, 2) the impact of comorbidities, 3) whānau ora model of practice, 4) access to secondary services, 5) workforce development, and 6) culturally informed screening and assessment tools. These were mapped to the strategy to highlight required actions and their operationalisation. While government acknowledgement of Kaupapa Māori services as a key investment area is important, these services and whānau expertise remain underused in policy and commissioning. Achieving health equity for Māori experiencing NMK depends on sustained resourcing and clear implementation priorities.
The aim of this article was to describe the use of venoarterial (VA) extracorporeal membrane oxygenation (ECMO) in adults in Aotearoa New Zealand. Survival at 1 year was the primary outcome. Equity of access was a secondary outcome. We carried out a retrospective cohort study of all patients undergoing VA ECMO between September 2017 and June 2024 in the Cardiothoracic and Vascular Intensive Care Unit (CVICU) at Auckland City Hospital. The CVICU is the national referral centre for adult VA ECMO in New Zealand. There were 151 patients who received VA ECMO, including 94 (62%) following cardiac surgery and 44 (29%) for cardiogenic shock. Survival to ECMO decannulation, hospital discharge and at 1 year was 114 (76%), 86 (57%) and 80 (53%), respectively. Increased age, non-transplant cardiac surgery and extracorporeal cardiopulmonary resuscitation were associated with decreased survival at 1 year. Major complications occurred in 33/151 (22%) patients and included bleeding in 15/33 (45%) and lower-limb ischaemia in 10/33 (30%). Māori received ECMO at a rate comparable to their population. Of the 144 New Zealand domiciled cases, 13 (9%) were from the South Island. These outcomes are comparable to international case series. Reduced access by geographic location underscores the need to further develop regional ECMO sub-centres.
This study aims to describe the urban-rural disparities in the incidence, demographic features and injury characteristics of trauma admissions in the Te Manawa Taki (TMT) Region of Aotearoa New Zealand. A retrospective observational study of the TMT trauma cohort was conducted using the data from the TMT trauma registry, which included all severities and all ages between 1 January 2013 and 31 December 2022. The Geographic Classification for Health used in Aotearoa New Zealand was adopted based on the patient's area of domicile into Urban 1, Urban 2, Rural 1, Rural 2 or Rural 3. Rurality was associated with a higher relative risk of trauma, with the incidence rate ratio (IRR) highest for Rural 3 at 2.0 (p<0.01) and 2.7 for major injuries (p<0.05) compared with Urban 1. Falls, road traffic crashes and motorcycle crashes disproportionately affected remote dwellers. Urban dwellers were more likely to sustain injuries from sharps/glass/knives/hand tools (p<0.01). Urban-rural variations in trauma admissions mainly relate to specific causes of injury, suggesting the need to customise injury prevention interventions for geographic areas. The underlying deprivation of rural areas and the socio-economic status of the demographic need further exploration for their possible modulating role in injury incidence and outcomes.
Femoral nerve palsy is a potential complication of brace treatment for children with developmental dysplasia of the hip (DDH). Little is known about its causes, and previous studies have been limited by their small sample size, retrospective design, and/or being single-centre series. The aim of this study was to examine the risk factors for femoral nerve palsy in the largest prospective cohort of children to date with DDH treated using an orthosis. A global multicentre prospective database of children with DDH was analyzed. Those treated primarily using an orthosis were included. Mixed-effects logistic regression was used to identify risk factors for the development of femoral nerve palsy, including sex, age at the time of diagnosis and application of an orthosis, the type of orthosis, the location of the femoral head, femoral head cover, and α angle. Both univariate and multivariate analyses were conducted. The study included 3,008 children (5,012 affected hips) who were enrolled from 21 centres in seven countries; 99 hips (2.0%) in 94 children (3.1%) developed a femoral nerve palsy, which occurred at a median of seven days (IQR 6 to 21) after the application of a brace. A significantly increased proportion of children who developed a femoral nerve palsy were treated in a Pavlik harness compared with those who did not develop a femoral nerve palsy (84.0% (n = 79) vs 61.9% (n = 1,804); p < 0.001). Univariate analyses identified a lower percent cover of the femoral head (odds ratio (OR) 0.87 (95% CI 0.84 to 0.91); p < 0.001) and lower α angle (OR 0.82 (95% CI 0.76 to 0.89); p < 0.001) to be significantly associated with the development of femoral nerve palsy. These risk factors remained significant in the multivariate model. This is the largest multinational study to date evaluating the incidence and risk factors for the development of a femoral nerve palsy in these children. The incidence of femoral nerve palsy was 3.1%. The severity of DDH was identified as a significant risk factor for its development. The use of a Pavlik harness was significantly associated with the development of a femoral nerve palsy. Understanding the factors which influence its development will be important to optimize outcomes of treatment in children with DDH.
This article extends on a previously published scoping review by describing the what and the how of a specialised, culturally responsive, joint early falls response service practice between occupational therapy and paramedics that could enhance falls management and prevention for older adults in Aotearoa New Zealand. The research replicated a previous literature search, with critical refinements in search terms and criteria, to identify new or previously overlooked research. Research included was pulled apart to describe an overall model that could be utilised for a local context. Fourteen studies focussing on how occupational therapists and paramedics work together were used. Articles discussed rapid response, early response and hybrid models of service to assess patients and effectively prevent recurrent falls. Articles also included studies on effective falls management and prevention involving occupational therapists following a fall. Grey literature sourced included government reports and healthcare evaluations. These sources informed key considerations for developing a falls response service in Aotearoa New Zealand. Investing in a rapid response, interprofessional service would enhance quality of life while easing pressure on emergency and long-term care. Cost-effective, community-based solutions present opportunities to support independence, dignity and wellbeing for an ageing population.
Lung cancer is the leading cause of cancer-related death in Aotearoa New Zealand and a major contributor to health inequities, particularly among Māori and Pacific peoples. Despite declines in smoking prevalence, lung cancer incidence remains high. Detailed projections are needed to inform future cancer service planning and support cancer control strategies. An age-period-cohort Poisson regression model was fitted to national cancer registry data (2001-2022), stratified by sex, prioritised ethnicity, age group and Health New Zealand - Te Whatu Ora region. Time-based weighting and non-parametric bootstrapping were used to derive projections and uncertainty intervals to 2045. Annual lung cancer cases are projected to increase by 38.3%, from 2,544 in 2020-2022 to 3,519 in 2045 (95% uncertainty interval [UI] 3,275-3,771), despite a decline in the age-standardised rate from 28.2 to 23.6 per 100,000 (95% UI 21.6-25.7). Substantial ethnic inequities persist. Māori cases are projected to rise from 570 to 1,063 (an 86.5% increase), and Pacific cases from 129 to 245 (an 89.9% increase). Although rates are projected to fall across all groups, Māori are expected to continue to experience the highest rates. Regional variation is also evident, with the Northern Region projected to experience the largest increase in case numbers, from 872 to 1,280 by 2045. Although age-standardised incidence rates are expected to decline, rising case numbers indicate growing demand for diagnostic and treatment services. These projections support the need for equitable implementation of lung cancer screening and sustained investment in culturally responsive prevention and cessation support.
We aimed to describe the occurrence and characteristics of vibriosis in Aotearoa New Zealand and the knowledge gaps caused by current disease reporting structures. Data on infections involving Vibrio spp. (vibriosis) were collated from New Zealand databases recording notifiable diseases, clinical diagnostic results, hospitalisations and deaths (1998-2024). These data were examined for trends and the effects of data collection protocols. V. parahaemolyticus, V. alginolyticus and non-O1/non-O139 V. cholerae were the most common Vibrio spp. reported from gastroenteritis cases and soft tissue infections. Some infections progressed to severe health conditions, including those due to V. vulnificus. The results indicated demographic and clinical trends, but further insights were limited by the lack of comprehensive case data (including exposure information), changes to data generation and collection over time and a decentralised reporting structure. Surveillance that captures all infections involving Vibrio spp. and associated metadata would make it possible to establish a baseline disease profile, prioritise health interventions and predict future epidemiological trends.
To provide a descriptive analysis of the overall health and well-being of older adults of Pacific Peoples ethnicity using the interRAI-Home Care assessments, compared with NZ Europeans. A cross-sectional retrospective analysis was conducted of interRAI-Home Care assessments assessed between 5 July 2016 and 31 December 2020. Basic descriptive information was gathered from Pacific Peoples and NZ Europeans separately. The frequency and percentage of the health conditions of interest were reported. Binary and multinomial logistic regression models adjusted for age and sex were used to investigate any differences between the prevalence of health conditions. A total of 123,023 interRAI-HC assessments were examined, of which 5390 (4%) were Pacific Peoples and 117,633 (96%) NZ Europeans. The mean age of Pacific Peoples was 75.8 years (SD 8.4) and NZ Europeans 82.6 years (SD 7.5). After adjusting for age and sex, Pacific Peoples were less likely to smoke, consume alcohol, have coronary heart disease, fall, report loneliness or have difficulty hearing than NZ Europeans. In contrast, Pacific Peoples were more likely to have diabetes, cognitive impairment, congestive heart failure, require a mobility aid or be bed bound, experience bladder incontinence, have difficulty understanding others or have poorer vision than NZ Europeans. Older Pacific Peoples who were assessed for home support and aged residential care have more complex needs and require services at an earlier age than NZ Europeans. There is a need for improvements in equity in the health system and underlying social determinants of health to raise the earlier age and lower the high burden of chronic diseases that Pacific Peoples face.
Helicobacter pylori (H. pylori) infection is the principle modifiable risk factor for gastric cancer and a key driver of ethnic disparities in gastric disease within Aotearoa New Zealand. Increasing antibiotic resistance threatens eradication success, yet secondary resistance patterns have not previously been described in New Zealand. This study aimed to describe, for the first time, secondary H. pylori antibiotic resistance rates in New Zealand and identify demographic predictors to inform eradication strategies. A retrospective review was conducted of H. pylori isolates referred for antibiotic susceptibility testing in Auckland between January 2018 and December 2023. Testing was performed at Middlemore Hospital Laboratory using gradient diffusion minimum inhibitory concentration (MIC) strips for amoxicillin, clarithromycin, metronidazole and tetracycline. Demographic data were obtained from the Auckland TestSafe database and analysed using univariate and multivariable logistic regression. Of 3,234 patients tested, 644 (20%) were culture positive. Resistance rates were clarithromycin 68%, metronidazole 68.5%, amoxicillin 2.5% and tetracycline 0%. Male sex was associated with lower odds of metronidazole resistance (p<0.001). Māori and Pacific peoples had lower odds of both metronidazole and clarithromycin resistance compared with Europeans (p<0.05), while Asian ethnicity was associated with higher clarithromycin resistance (p=0.02). This first-in-New Zealand description of secondary H. pylori resistance shows high rates of clarithromycin and metronidazole resistance. These findings lend support to use of non-clarithromycin-based salvage regimens. Future prospective studies of secondary and also, most importantly, primary resistance data are essential to inform testing and treatment guidelines and improve eradication outcomes.
Mental illness is the second-leading reason for tertiary students in Aotearoa New Zealand to consider dropping out of studies. Meta-analyses report moderate or greater symptoms of depression in 27% and anxiety in 34% of medical students. Rumination has been identified as a transdiagnostic risk factor for anxiety and depression symptoms in medical student populations, but no studies in New Zealand thus far have studied rumination alongside mental health symptoms in tertiary students. We conducted an online survey in 2023 to examine the rate of depression and anxiety symptoms, as well as rumination, in a Christchurch-based medical student sample. The survey included demographic questions (gender, ethnicity), the Depression Anxiety Stress Scale 21 (DASS-21) and the Ruminative Responses Scale (RRS), which includes questions on brooding, reflection and depression-related rumination symptoms. One hundred out of a possible 335 (29.9%) medical students completed the survey. Seventy-six were female. Thirty-six percent reported moderate or greater symptom levels of depression, 45% of anxiety and 42% of stress. All RRS subscales were significantly positively correlated with depression, anxiety and stress symptoms. Female students reported significantly more symptoms of anxiety than male students. Asian students reported significantly higher levels of brooding and total rumination than Pākehā students. This medical student cohort had concerningly high levels of depression, anxiety and stress symptoms. Rumination is likely an important contributor to negative mental health outcomes. Further research is required to tailor accessible interventions for students with high levels of rumination.
Breast cancer is the most diagnosed cancer among women in Aotearoa New Zealand, with incidence rates among the highest globally. Māori and Pacific women experience higher mortality and later-stage diagnosis, reflecting more aggressive cancers, symptomatic detection and systemic barriers to care. Previous projections have not reported results by both ethnicity and region, limiting their use for regional planning. Female breast cancer incidence to 2045 was modelled using age-period-cohort Poisson regression, stratified by age, prioritised ethnicity and Health New Zealand - Te Whatu Ora region. Time weights were used to adjust for recent trends, and uncertainty was quantified using 1,000 bootstrap iterations incorporating variation in case counts and population estimates. Age-standardised incidence rates (ASRs) were calculated for observed and projected data. By 2045, annual cases were projected to increase by 47% to 5,243, while the national ASR remained broadly stable at 98.6 per 100,000 (+3.4%). The Northern Region was projected to have the largest absolute increase (+55%), and Te Manawa Taki the largest rise in ASR (+8%). Māori and Pacific women were projected to continue having the highest incidence rates. Māori cases nearly doubled (+91%). Asian women experienced the largest proportional increase in case numbers (+215%), driven by population growth and ageing. Breast cancer cases will increase substantially by 2045 despite stable national rates. Ongoing inequities for Māori and Pacific women and rising numbers among Asian women underscore the need for ethnically responsive screening and equity-focussed cancer control strategies. Risk-based approaches may improve detection and manage future screening demand.
The aim of this article was to examine clinical and demographic factors associated with receipt of rhythm control procedures (electrical cardioversion [ECV] or ablation) in patients with atrial fibrillation or flutter (AF/AFL) in Auckland, Aotearoa New Zealand. We conducted a retrospective cross-sectional study of patients with AF/AFL, collecting data up to 31 August 2021. Descriptive statistics were used to characterise procedural use, and associations between patient factors and rhythm control procedures were assessed using multivariable logistic regression. We identified 1,908 patients with AF/AFL (46.8% female), of whom 292 (15.3%) underwent rhythm control procedures (ablation in 109, ECV only 183). In adjusted analysis, increasing age (adjusted odds ratio [aOR] per year 0.96 [95% confidence interval (CI) 0.95-0.97]) and female sex (aOR 0.46 [95% CI 0.34-0.63]) were associated with lower odds of receiving rhythm control procedures. Compared with European patients (New Zealand/other European), Māori (aOR 0.52 [95% CI 0.36-0.77]), Pacific peoples (aOR 0.41 [95% CI 0.28-0.60]) and other ethnicities (aOR 0.47 95% CI 0.28-0.79]) were less likely to undergo rhythm control procedures. The most common indication for rhythm control procedures was symptomatic relief (76.7%) followed by heart failure optimisation (13.7%). Rhythm control procedures are selectively applied and vary by demographic and clinical factors. Female sex and ethnicity-based differences highlight the need to understand decision-making and access to rhythm control pathways.
To evaluate the effectiveness of a twice-daily application of a wipe impregnated with emollient and barrier ingredients in reducing incidence of pressure injury (PI) in aged care consumers. A single-blinded, multicentre randomised controlled trial. Randomisation was stratified by facility, using simple 1:1 randomisation within each stratum. 20 residential aged care facilities in Rural and Metropolitan New South Wales and the Australian Capital Territory, Australia. 858 aged care consumers aged ≥65 years at risk of developing a PI. Participants were randomised 1:1 to receive either standard hygiene practices, repositioning and use of pressure redistribution surfaces (standard care) or twice-daily applications of a pre-packaged wipe impregnated with emollient and barrier ingredients (Contiplan) to the sacrum, buttocks and heels in addition to standard care for the study duration. The primary outcome was the incidence of PIs per 1000 consumer days. Treatment effects were estimated using an intention-to-treat approach, with the absolute difference and 95% CI estimated using the Wald method. The relative difference in the incidence of PIs was estimated using a negative binomial regression model (with log link). 858 participants were included in the study. There was a 50% relative reduction in the incidence of PI in the intervention compared with the control (95% CI 0.31 to 0.81, p=0.005), with an absolute rate difference of 0.31 fewer PIs per 1000 consumer days (95% CI 0.11 to 0.51). The use of wipes with emollient and barrier properties significantly reduced the incidence of PIs and prolonged the time to first PI, demonstrating efficacy as a PI preventive strategy in aged care. Australian and New Zealand Clinical Trials Registry, ACTRN12622001360707.
Our aim was to determine the 30- and 90-day all-cause mortality of healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB) and determine mortality risk factors. We collected HA-SAB events from 1 July 2022 to 30 June 2024. Patient age, sex, ethnicity and source of HA-SAB were submitted via a secure portal. Patients' National Health Index numbers were matched to the National Minimum Dataset, and 30- and 90-day all-cause mortality was determined. The mortality rate was calculated as a percentage of all HA-SAB events and by age, sex, ethnicity and source. There were 961 HA-SAB events: a rate of 0.15 cases per 1,000 inpatient bed days. Thirty- and 90-day all-cause mortality were 13.8% and 20.7%, respectively. There was no difference in mortality by sex or ethnicity. Mortality increased with age and increased significantly for ≥75 years of age. Invasive medical devices were the source of 70% of HA-SAB events, organs were the source of 12% of HA-SAB events, and surgical site infections were the source of 8% of HA-SAB events. There was no significant difference in mortality by attributable source. The 30- and 90-day all-cause mortality associated with HA-SAB is high. The most common sources are vascular access devices. The use of a "care bundle" incorporating proven interventions, applied using a quality improvement framework, should reduce patient harm from these events.
Primary healthcare data can be used to conduct cost-effective research that improves understanding of population health and disease, leading to more effective prevention, earlier diagnosis, better-informed health models and improved health equity. However, Aotearoa New Zealand lacks a national primary healthcare data collection and has no national infrastructure to integrate and interrogate routinely collected primary healthcare data. This paper describes new technical approaches used internationally to improve researcher access to healthcare data and considers how this may be applied in the New Zealand context using Māori data governance and ethical data stewardship principles. Data access may be improved through platform-level, algorithm-level and data-level approaches. Māori data governance and ethical data stewardship principles can be applied to these new technical approaches. A governance model requires strict management, administration and oversight. An open-access model could provide easier access for researchers to develop and test models on synthetic data within a trusted research environment. Improving primary healthcare data access for research in New Zealand requires partnership that upholds Māori data governance principles and ethical research standards. Debate of the advantages and disadvantages of these technical approaches and stewardship models including patients and the public is welcomed.
Gastric cancer (stomach cancer) is an important contributor to morbidity and mortality in Aotearoa New Zealand, with marked ethnic inequities. Although national incidence rates are declining, Māori and Pacific peoples continue to experience higher rates than other groups. Demographic change and regional population growth are expected to influence future burden, yet no published projections provide estimates disaggregated by ethnicity and region. Gastric cancer registrations from 2001 to 2022 from the New Zealand Cancer Registry were linked to population estimates and projections stratified by age, sex, prioritised ethnicity and Health New Zealand - Te Whatu Ora region. Incidence was modelled using an age-period-cohort approach with time-based weighting to emphasise recent trends. Projections to 2045 were generated, and uncertainty was quantified using 1,000 non-parametric bootstrap iterations incorporating perturbation of population denominators. Gastric cancer cases are projected to increase by 47.7% to approximately 725 per year by 2045, despite a decline in the age-standardised rate from 5.9 to 5.3 per 100,000. All regions show increasing absolute numbers, with the Northern Region experiencing the largest rise. Māori and Pacific peoples have the highest current incidence and a large proportional increase in projected cases, although incidence rates decline modestly for all ethnic groups. Future case growth is driven mainly by demographic expansion and an ageing population. Absolute gastric cancer cases are projected to increase, particularly among Māori and Pacific populations and in regions experiencing rapid population growth. This has implications for early diagnosis and specialist service delivery. These projections support equity-focussed prevention and service planning, including Helicobacter pylori control, timely diagnostic pathways, and regional planning for specialist cancer services.
Leptospirosis is a bacterial zoonosis often under-diagnosed due to its presentation as an undifferentiated febrile illness. This study aimed to explore the clinical complexities involved in diagnosing and managing leptospirosis cases in New Zealand. Qualitative content analysis of clinical notes from 42 leptospirosis cases used a dual deductive and inductive approach to identify key themes. Three key themes emerged, highlighting the critical role of clinician reasoning in early detection and appropriate clinical response: 1) multiple factors contribute to delayed diagnosis, including incomplete exposure histories and deviation of symptoms from textbook definitions, 2) there were challenges with diagnosis and the use of medication in post-acute care, and 3) interpretation and use of confirmatory tests was inconsistent and complex. Clinicians were confident in suspecting leptospirosis when clinical history taking also assessed relevant exposure. Based on these findings, we have made recommendations to prevent delayed diagnosis. We advocate updating clinical references to better reflect New Zealand-specific disease presentation and risk factors to support early diagnosis. National standardisation of diagnostic test timing, selection and interpretation is recommended, alongside clearer notification pathways. Further research could focus on early diagnostic markers to improve clinical decision making in practice.
Vaping was introduced as a means of quitting smoking by slowly reducing nicotine dose to wean smokers of their carcinogenic habit. In this setting the risks of vaping likely outweigh the benefits of eliminating the carcinogenic risk associated with smoking cigarettes. Soon after the introduction of vaping it caught on as a trendy alternative to smoking, particularly among young people. This means that the risk-benefit profile changed considerably because the benefit of smoking cessation was no longer part of the risk-benefit equation. Since vaping has now become a primary means of taking nicotine, a risk assessment of vaping per se is necessary to determine its potential effects on vapers' health. In this viewpoint, we use our knowledge of the chemistry of the production of "vape smoke" to identify its key toxic components. Then, using published animal toxicity data for these chemicals and estimates of vapers' exposure levels, we assess the magnitude of carcinogenic risk. We conclude that vaping is carcinogenic, but that the risk is likely lower than for smoking cigarettes. Therefore, someone taking up vaping not as a tool for smoking cessation is adding carcinogenic risk to their daily risk profile.