When vapes first came onto the UK market around 20 years ago, almost a quarter of adults were smokers. According to the latest ONS figures, that’s now fallen to less than 12 per cent (DDN, October, page 5).
A new briefing paper from the Global State of Tobacco Harm Reduction (GSTHR) points out that not only will the proportion of adults who smoke likely have fallen to just over ten per cent next year, but the proportion of vapers will have overtaken it. It will be a landmark moment, especially considering that when ONS first started compiling smoking statistics 50 years ago, more than half of men smoked, along with 41 per cent of women.
The document highlights that the large-scale shift to vaping, while clearly consumer-driven, has also been helped by successive UK governments making ‘pragmatic policy decisions based on the evidence’, publishing the science on the safety of vapes compared to smoking, and endorsing and promoting their use as a smoking cessation tool.
Controversy and confusion
But vaping remains controversial. While PHE stated in 2018 that it was 95 per cent less harmful than smoking tobacco, and anti-smoking charity ASH has long backed vapes as an effective quitting tool (while also expressing concerns about levels of youth vaping), the WHO’s position is that ‘strong decisive action is needed to prevent the uptake of e-cigarettes’.
Add in the extensive media coverage and it’s not surprising there’s a great deal of confusion around. Last year, a YouGov survey of more than 12,000 people found that just under 40 per cent of smokers thought vaping was ‘as or more risky’ than smoking, which prompted ASH to issue a ‘myth buster’ to challenge ‘common misrepresentations of the evidence’. The document summed up the argument by quoting chief medical officer Chris Whitty: ‘If you smoke, vaping is much safer; if you don’t smoke, don’t vape.’
‘A lot of the rhetoric around vaping, and the quite legitimate concerns about young people vaping, ends up creating a slightly toxic environment,’ David MacKintosh, a director at Knowledge Action Change (KAC) which runs the GSTHR project, tells DDN. ‘But one of the reasons the UK is in a better position than some other places is that we’ve had people in PHE who were prepared to say this is a good thing, and a cadre of academics who’ve done the research and have the evidence – the work coming out of UCL is always very balanced, for example.’
While some people argue that vapes haven’t been around long enough to fully understand the potential health effects, we’re now ‘starting to get to the point where we’ve actually got a pretty long exposure window’, says MacKintosh. ‘Inevitably there will be some issues – it’s not a healthy thing to do – but I’m sure we’ll be able to shoot some of the wilder foxes in terms of health effects.’
Negative coverage
In the meantime, however, the negative coverage does have an impact. One example is the ambitious ‘swap to stop’ campaign, which aims to provide nearly one in five smokers with a vape starter kit alongside other support to help them quit. ‘The smoking cessation people and people working with homeless populations and in drug services, I think they get it,’ MacKintosh states. ‘But when you’re trying to get local buy-in from the cabinet member for health, or whoever, that headline about “are they really safer, do we really know?” can have a chilling effect. I’ve seen it time and again with the drugs stuff, because those people aren’t necessarily experts and they are influenced by what’s in the paper or on the news. So the scheme has probably got a little bit lost, which is a shame because the potential was incredible. I can’t think of an equivalent public health campaign with that sort of ambition, that was realisable in a short, measurable timeframe.’
One problem is undoubtedly that people tend to see the hand of big tobacco in all this. But while the industry has certainly ‘played catch-up’, most of the safer nicotine products didn’t originate with them, he points out. ‘But it is a fundamental problem that none of these products have come from a public health laboratory – or even from a pharma company. That’s a genuine challenge, and it has fuelled a lot of the “it’s all a plot” thinking. Tobacco companies were – quite rightly – seen as big, bad, evil and wrong, and have been exposed in court and so on. But even though the companies in China that make the vast majority of the world’s vapes have no connection to them, ultimately it’s still industry. And there have been some huge missteps in the marketing, no doubt.’
One example is the marketing of fruit flavours, something the forthcoming tobacco and vapes bill intends to regulate. However, an evidence review commissioned by OHID found not only that vaping products were associated with the highest rates of success in helping people to quit smoking, but that fruit flavours were the favourite option for most current vapers. ‘There’s certainly scope for better regulation, but the risk is that you end up banning all flavours apart from tobacco, and then you’re really setting people up to fail,’ he says. ‘Fruit flavours start breaking the association with cigarettes. Why you would want to maintain that association, I have no idea.’
Having a wide range of products is important, he stresses. ‘Lots of people use different products at different times, and as long as it’s adults I really don’t think we should care. And we do need to be careful, because if we impose so many barriers that a legitimate, regulated market is undermined then a lot of this stuff isn’t that difficult to manufacture.’
Shifting attitudes
In terms of media reporting, however, things might finally be beginning to shift, he believes.
‘When the new government figures came out the BBC TV news report was actually quite a balanced piece, which is kind of not what I’m used to seeing. They had a pulmonary specialist consultant and he was very clear that vapes aren’t good for you – your lungs are designed for clean air – but compared to smoking they’re much better, and we mustn’t lose that message that smokers would be better off vaping. There are echoes of that across a lot of the other media at the moment, so I think we’re perhaps getting to a more mature media position.’
Ultimately, the prize is the smokefree 2030 target, which aims to get the smoking rate down to 5 per cent or less. Is it something we’re likely to achieve? ‘If we can show the same kind of ambition we put behind the swap to stop stuff, put in targeted supported for people, and don’t balls up access to products, I think we definitely can,’ he states. ‘Look at what we’ve already achieved, and the pace of change in other countries. But we need to get the messaging right and targeted at the smoking population.’
This means looking at groups where smoking rates remain extremely high. ‘We still have populations where smoking is the norm, so we need a good focus on that. If you can knock it down from say 60 per cent to 40 per cent in some of those populations, you’ll see quite rapid change.’
Some of this could be achieved through peer-to-peer engagement, but it also means getting professionals fully engaged. ‘Most health professionals have very limited understanding of the lives of a lot of the people where smoking is concentrated, so we need targeted support for those areas, making sure the GPs have all the information. And there’s still much more we can do in drug and alcohol services. Staff could – while emphasising the primary importance of giving up smoking – be encouraging service users to try vapes. It does wonders for people’s self-confidence, so these are quick wins.’
Crucially, it’s also something that costs almost nothing, he stresses. ‘Most smokers could easily experiment with vapes themselves at no cost to the public purse. We don’t have many public health outcomes with such a significant gain that require so little investment, so we really need to focus on the gains to individuals and communities. Fifty per cent of people who smoke regularly will die prematurely as a result, and we can significantly turn that around – even for people who won’t give up nicotine – by supporting them to get on a safer product.
‘So we’ve made a lot of progress and if we embrace the potential of tobacco harm reduction we can reach the 2030 target. It really is one of the great public health wins, and one that’s within our grasp.’
A smokefree UK? How research, policy and vapes have cut smoking rates available here
