The developed world’s relationship to nicotine is changing. Between 2000 and 2015, the number of smokers plummeted by 29 million. That drop hasn’t been spread equally around the world — China now accounts for 44% of all cigarettes smoked each year, for example — but in many Western countries, the world’s favourite addiction is fast going out of fashion.
Some fear it’s just being replaced by new harms: the use of e-cigarettes — otherwise known as vaping — is skyrocketing in the US. Today, around 10.8 million American adults vape. The Federal Drug Administration is looking to crack down on e-cigarette use. Officials in San Francisco are even considering banning the sale of e-cigarettes outright,i pending a review of their impact.
Why has the public health response to smoking been so successful in some Western countries? And should those same tools now be turned against vaping?
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The World Health Organisation (WHO) is aiming for a 30% drop in smoking prevalence among over-15s by the year 2020. Only a handful of countries are set to meet those targets. The UK is one of them.
“The UK’s [has] been one of the most comprehensive approaches in the world, but there hasn’t been anything particularly unique about what we’ve done,” said Marcus Munafo, Professor of Biological Psychology at the University of Bristol, who specialises in addiction.
“All of the UK’s tobacco control policies — which were world-leading at the time — have been implemented elsewhere, but we’re one of the few countries to implement all of them,” Munafo said.
The UK first started getting to grips with smoking as a public health epidemic in 1962, when a report by the Royal College of Physicians first laid out the manifold harms of the habit.
The paper recommended restricting tobacco advertising, increasing taxes, cracking down on the sale of cigarettes to children, and spreading more information on the tar and nicotine content of cigarettes. Three years later, tobacco ads were banned on television.
“The civil society response in the early days was usually limited to education,” said Deborah Arnott, Chief Executive of Action on Smoking and Health (ASH), one of the UK’s foremost campaigning charities who have led the charge against big tobacco. “There were advertising campaigns, and public awareness efforts, but there weren’t many policy measures that could impact population level health.”
Over the subsequent decades, ASH and other campaigners coaxed government into pulling a range of policy levers: upping the number of smoke-free zones on the tube, increasing taxation, and restricting advertising across multiple forms of media.
The crucial battle, according to Arnott, came at the close of the 20th century. The government at the time expressed interest in tobacco control, but offered little in the way of comprehensive policy measures.
ASH and others started lobbying for a comprehensive ban on smoking in public places, hinging around a central idea: that legislation isn’t about interfering with smokers’ rights, but instead, the rights of other workers to live in a smoke-free environment. Focusing on the harms to others opened the door to substantive change.
After years of resistance, a multi-pronged campaign forced the government to act: in 2007, smoking was banned in all workplaces and enclosed public places.
“There’s no better way to get young people to start something than saying they shouldn’t.”
“It was a real turning point,” said Arnott. “The difference with the smoking ban was that it was an engagement of competing rights of smokers and non-smokers: prior to that, interfering with smokers rights was taboo.”
Following the ban, other innovative solutions have cemented the successes: in 2015, smoking in cars with children under the age of 18 was prohibited. And in 2016, a high court battle concluded that big tobacco had conspired to appeal to teenagers, and all colourful packaging was banned, replaced by a simple green-brown packet that carried gruesome pictures of tobacco’s potential effects.
Today, around 16% of the British population smokes, compared to 46% in 1974.
“The thing about tobacco control is that there’s no silver bullet, you need to a range of policies, each of which may have aoutrig small effect, but whose compound effect is significant,” said Munafo.
“The impact is in part on the level of individual policy, but there’s a tipping point at which tobacco use becomes much less visible. Even compared to 20 years ago, it’s much less visible in the UK: there’s no ads, no displays of tobacco products, no vending machines — and fewer people are smoking.”
But the UK’s success in recent years hasn’t been in spite of an uptick in vaping, but partly because of it.
In the US, media outlets and government bodies have reacted strongly against figures showing a 78% increase in teen vaping between 2017 and 2018, with Scott Gottlieb, director of the FDA until last month, calling the phenomenon an “epidemic.”
The UK instead has encouraged vaping as a tool to quit, including on NHS websites. One large clinical trial, published this year, found that combining vaping with face-to-face support helped people quit smoking at twice the rate of people who used nicotine patches or gum.
“The UK’s approach to vaping has been unique: we’ve taken the view that vaping is a good tool for people to stop, and should encourage it in that context,” said Munafo.
As a consequence, Munafo added, vaping in the UK is often seen to be the preserve of the middle-aged, trying to kick their smoking habit once and for all, not a rebellious act by a new generation of teenagers.
“The US approach seems to be glamorising [vaping] to young people,” said Arnott.
Munafo echoed the point: “There’s no better way to get people — particularly young people — to start than saying you shouldn’t.”
Arnott expressed particular concern at the way that US statistics conflate smoking and vaping under tobacco use, equating the dangers of the two, when the science suggests they’re incomparable. One study, conducted by Public Health England, demonstrated that vaping is approximately 95% less harmful than smoking.
“Nobody is saying we should have a free-for-all unregulated free market model approach to vaping,” said Munafo. In the UK, there are age restrictions, health warnings on bottles of vaping liquid, restrictions on formulations of the liquids, and advertisements are banned on television before 9pm.
“There’s a middle ground where you can encourage vaping as a way to stop, while still seeking to minimise the number of people taking it up,” he added.
The long-term effects of vaping aren’t yet known, and research into potential outcomes remains vital.
But in the absence of that evidence, it seems that the discussion of vaping’s place in public health debates is rather more about political beliefs than evidence-based policy.
“People do things that are harmful all the time without moral panic, like climbing or skiing: there’s a level of risk and harm we accept as society. Where vaping sits in relation to the implicit level of risk that we accept is a philosophical question. It’s not for science to solve.” — Edward Siddons
(Picture credit: Pixabay)