Professor Sanjay Agrawal’s research shows that over the last four years there have been 84 reported cases of adverse events in the UK as a result of vaping. This may sound like a lot until you compare it to the 2 million people who presented at hospital with a tobacco-related disease in the same period. Adjusting for the prevalence of vapers in the UK population, vaping causes less than a tenth of a percent of the harm of tobacco.
So why do only 51% of the public believe the science? Professor Ann McNeil says the focus on combustibles is not translating into policy. This in turn leads the public somewhat down the garden path. Professor Martin Dockrell believes researchers have become preoccupied with reducing nicotine use, which isn’t the priority in the UK. He states, “We understand the enemy to be smoking.” Professor Schroeder agrees, “The controversy of anti-vape has taken the conversation away from [smoking] cessation.”
In this series of posts, we’ve broken down the science into the topics that dominate the vape debate.
It’s hard to take a debate seriously when one of the strongest advocates for a full flavour ban also believed injecting disinfectant might cure COVID-19, but nevertheless, there are convincing arguments on both sides of the flavour debate (from people who actually know what they are talking about). Experts generally fall into two groups: people who advocate for flavours as an important smoking cessation tool, and people who think too many flavours are unnecessary and serve to attract young people to take up vaping.
Professor Alan Boobis is of the former group, stating “If you eliminate the nicotine in e-cigarettes, you eliminate the route for smokers to switch from tobacco to e-cigarettes.” His research shows that many of the flavours in e-liquid are already used in food and so the threat from ingesting these is possibly not as high as previously thought, especially in heat-not-burn devices which all vapes are when used correctly. Martin Dockrell is of the same camp, stating that although there are hundreds of flavours available on the market, fears of a youth vaping ‘epidemic’ have so far proved unfounded.
Conversely, Dr Jasjit Ahluwalia argues that we don’t need hundreds of flavours like bubblegum and creme brûlée in order to retain the use of vapes as a cessation device, and that having so many flavours encourage young people to take up vaping. Professor Caitlin Notley’s recent systematic review on youth uptake showed no such trend. She stated that although young people do like e-liquid flavours that taste nice, this doesn’t necessarily lead to smoking tobacco (exclusively or at all). Coupled with the fact that tobacco flavoured e-liquid represents less than one percent of overall sales, it’s difficult to see a transition from vaping to smoking. Professor Notley argues that the paternalistic approach we have to protect young people is misguided regarding flavours, as we could be discouraging people from using a tobacco alternative. Dr Sharon Cox’s research shows that when switching from tobacco cigarettes, people often start on tobacco flavours and are disappointed. When they change to other flavours, they are much more likely to become long-term users of vapes instead. Professor Peter Hajek argues that the UK and EU regulations are “killing an excellent potential treatment for smoking.”
All nicotine products in the UK are governed by the Tobacco Products and Nicotine Inhaling Products (Amendment) (EU Exit) Regulations 2020 which builds on regulations last updated in 2016. This dictates everything from nicotine strength available in shops and tank size in devices to labels, packet warnings and MHRA approvals required. It is interesting to note that these regulations do not apply to nicotine products authorised as medicine, like nicotine gum and patches. This is why you may see a train station billboard for Nicorette products but not Marlboro, but Deborah Arnott’s work at ASH shows that vape companies are not abiding by the advertising rules set out in the regulations.
At the conference, Deborah Arnott called into question the disregard shown for industry regulations, highlighting that the ‘restraint’ that vape companies have been urged to exercise has not been seen. Arnott advocates for plain packaging so as not to encourage children to vape. Again, as this would bring vaping products in line with other nicotine products available, it’s hard to argue with the logic if you want people not to vape.
Whatever your take on flavours, Arnott argues that the “Government should fund social marketing campaigns to tackle misconceptions of harm.” This is a public health issue, after all.
After youth uptake, the next concern is usually second-hand effects. Does second-hand vaping actually happen? The answer is, not as we know it. Professor Boobis’ research shows that indoors, in a heavy and habitual use setting it is possible for bystanders to feel mild effects of the nicotine but there is no evidence for levels of anything else like you would expect to see from tobacco smoke.
In a panel discussion among Stop Smoking Service (SSS) leaders, Richard Holley, Tobacco Control Lead at Northamptonshire County Council, stated that in stop smoking services customisability of the experience (device type, flavour, nicotine content etc) kept people engaged in the service as they were able to tailor their experience to their preferences. There is no denying that this is a powerful draw. Some argue that such a range of choice is what makes vaping attractive to young people, though you could say that choice is generally attractive to everyone.
Professor Sanjay Agrawal argues something that shouldn’t be as controversial as it sounds, “You want to make e-cigarettes attractive to smokers who want to quit.” Is it possible to make it look good to quitters without making it look good to young people? Well, considering that young people are people, if there is a way to do it, it will be complex.
Deborah Arnott and Clive Bates have differing views on how to regulate this. Arnott wants stricter regulations to protect children. Bates argues that there are stronger rules on advertising vaping products than on alcohol. Though they are opposing statements, the researchers’ opinions overlap more than it seems at first glance. Regulations targeted at adolescents and underage people seem to be the common ground, though Bates maintains that “adolescents are far more at risk from alcohol-related accidents, violence, sexual vulnerability.”
Could the ends justify the means? Could we make vaping accessible and attractive at the risk of encouraging young people, in order to tackle the huge health crisis caused by tobacco? In the UK smoking is the number one preventable cause of cancer. The cost in human life, as well as so the health services, are so huge it is hard to conceptualise.
A panel of SSS front-line workers all agreed that vape devices have been an astonishing tool to get long-term (60+ years) users off tobacco and made it possible for young smokers to access support.
Louise Ross, VP for the New Nicotine Alliance says, “I took a leap of faith.” When there was a serious lack of scientific research evidence, she listened to people who actually used the devices and it was enough to convince her it was worth trying in her service. With the results they have seen with their service users, they say they have never looked back.
Research by Professor Peter Hajek and the Cancer Prevention Group at King’s shows that vapes are better than any other kind of nicotine replacement therapy (NRT), like patches or gum, for helping people to quit smoking, and are much more cost-effective for SSS which are run by local authorities.
The Cochrane Tobacco Addiction Group found that when considering cessation, nicotine-containing vaping performed better than NRT, non-nicotine-vaping and behavioural support only. In terms of safety, there was no significant difference between cohorts, but more data and more studies are needed.
TL: DR Too much focus on flavours, not enough focus on health benefits.
The views expressed are those of the author. Posting of the blog does not signify that the Cancer Prevention Group endorse those views or opinions.
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