Slow on the draw

Why are smokers reluctant to exchange the risks of cigarettes for the health benefits of e-cigs, asks Neil McKeganey.

E-cigarettes have been characterised by Public Health England as being as up to 95 per cent less harmful than combustible cigarettes. On the basis of that figure, and the fact that smoking kills around one in two of all smokers, you would have thought that smokers would be heading towards e-cigarettes in their droves – but that does not seem to be what is happening.

According to the UK charity Action on Smoking and Health (ASH), there are approximately 2.8m people in the UK who are using e-cigarettes, 51 per cent of whom are current smokers. ASH has also estimated that there are approximately 9.1m adult smokers in the UK. On the basis of those figures, only around 15.6 per cent of adult smokers in the UK are using e-cigarettes. Given the enormous individual and public health benefit that would flow from more smokers switching to the non-combustible product, it is important to identify what the barriers are to wider use of e-cigarettes by smokers.

As hard to believe as it might be, one of those barriers might be a misplaced assessment of how harmful e-cigarettes are compared to normal cigarettes. Both in the US and the UK there has been a worrying increase in the number of smokers who think that e-cigarettes are actually more harmful than normal cigarettes. The reason for such an erroneous view is likely to be news media headlines that repeatedly announce the harms of e-cigarette use, without comparing those harms to combustible cigarettes. It is entirely possible that some smokers are choosing not to switch to non-combustible nicotine products in the mistaken belief that to do so might actually increase their level of risk and harm.

In interviews with a sample of smokers, many of those who said that they had tried e-cigarettes but not continued with them commented that, in their view, these devices were a poor substitute for smoking. Some of the smokers said that they did not like the hard plastic feel of e-cigarettes or the feeling that vaping was ‘cold’ in a way in which smoking was ‘warm’.

Some of the smokers were clearly confused by the vast array of e-cigarette technology and put off by the bewildering details of nicotine strengths, flavours, coils, ohms, tanks, wicks and batteries. For these smokers, the cigarette had an appealing simplicity. If you have one, you light it, and you smoke it. The comments from these smokers suggest that the technology of e-cigarettes has some way to go before these devices become attractive to the majority of smokers.

Government can initiate measures that are likely to increase e-cigarette use among smokers. These measures include ensuring that e-cigarettes are taxed at a level that makes them cheaper than combustible products. Another thing that governments can do, is to discourage the various bans on e-cigarette use that have been instituted out of a misplaced belief secondhand vaping causes harm. Public health bodies, however, need to do much better in accurately conveying to smokers the relative harms of combustible and non-combustible cigarettes, tackling the large and growing proportion of smokers who don’t know, or who believe that smoking is actually safer than vaping.

There are other ways in which the use of e-cigarettes can be stimulated among smokers is for ‘stop smoking’ services to become e-cigarette friendly. While there are some services that positively encourage e-cigarette use by smokers as a way of bolstering individuals’ attempts at stopping smoking, there are other services that either frown on e-cigarettes and or ban the use of these products on their premises. Such bans contribute to stigmatising vapers and vaping, and ignore the fact that hundreds of thousands of smokers have used these devices as a way of stopping smoking.

Finally, manufacturers of e-cigarettes have an important role to play in increasing the appeal of these devices to smokers – which, ironically, may entail ensuring that the experience of vaping is closer to the experience of smoking.

Prof Neil McKeganey is at the Centre for Substance Use Research, Glasgow