31 October 2021

Source: The Sunday Times

England is an outlier in promoting vaping as a safe alternative to smoking. Other countries are far from convinced

Less than a fortnight ago the World Heart Federation, a respected medical body based in Geneva, warned of a growing epidemic sweeping the globe. Victims’ lungs, heart and brain were put at risk, and the young were particularly susceptible. The source of this health threat? Electronic cigarettes.

The report, written by a panel of cardiologists and academics from the United States, South America, Europe, Africa and Asia, called for governments around the world to mount a “determined effort to stop the e-cigarette epidemic in its tracks”.

On Friday, just ten days after the publication of this alarming report, Sajid Javid, the health secretary, made an announcement that made clear the growing divide between Britain and the rest of the world in its approach to e-cigarettes. Regulations were to be streamlined to pave the way for e-cigarettes to be prescribed on the NHS for the first time, Javid said.

While other nations warn of the dangers of the devices, England will become the first country in the world to treat e-cigarettes as a medicine.

A high street takeover

E-cigarettes were invented in 2003 by Hon Lik, a pharmacist from Shenyang in northeast China. His device contained a liquid form of nicotine that was heated into vapour to be inhaled. Hon developed the gadget to help him kick his heavy smoking habit but failed to quit, continuing to smoke cigarettes as well as vaping.

But the company he started, which was later bought by a subsidiary of Imperial Tobacco, kickstarted a revolution on the other side of the world.

Some 3.6 million people in Britain — 7.1 per cent of adults — now use e-cigarettes. Their impact can be seen in the very fabric of our cities and towns. Vape shops are now more common on British high streets than Italian restaurants, shoe shops, dry cleaners, travel agents or book shops. They outnumber hotels, recruitment agencies and Indian takeaways. In 2011 there were 185 vape shops. Now, according to figures produced by the Local Data Company, there are 3,444.

There is a strong correlation between vape shops and deprivation. Hyndburn, in Lancashire, has 13 e- cigarette shops — about one for every 6,241 residents, the highest rate in Britain. The local authority, which includes Accrington, is the 18th most deprived in England. In Wokingham, the least deprived area in England, there is just one vaping shop for its 174,000 residents.

The global outlier

The UK — and England in particular — has put e-cigarettes at the heart of its public health strategy since a landmark report in 2015 concluded vaping was 95 per cent safer than smoking. Public Health England (which was abolished last month) championed the devices as a key part of its annual “Stoptober” quit smoking campaign, with TV adverts endorsing vaping and promoting positive research.

Simon Capewell, professor of public health at Liverpool University, said: “This laissez-faire English approach contrasts with almost every other health authority around the world. Many countries have now banned or severely restricted their sale. England is an outlier.”

The US Food and Drug Administration (FDA) tightened restrictions two years ago after record numbers of American youngsters turned to vaping, with some so addicted to nicotine that they had to be treated with drug therapy.

India, Japan, Singapore, Argentina and Uruguay are among nations which have banned their sale and the World Health Organisation (WHO) has raised concerns about cancer-causing chemicals in vaping liquids and highlighted evidence that vaping may act as a “gateway” to tobacco, particularly among teenagers.

British exceptionalism

So why does the UK take such a different approach from that of other countries?

Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, believes this is a question of “groupthink” and “British exceptionalism”.

“Nobody would really seriously say the UK is right and the WHO and the rest of the world is wrong,” he said. “The issue is you’ve got people who are coming from a particular perspective and there is no discussion outside that group view. There is also an exclusiveness that you get in the UK science policy area, which does not look for experience elsewhere.”

Scientists generally agree e-cigarettes are safer than tobacco and also acknowledge they are not completely safe. But there is disagreement over what that means.

In this country, other than a few outspoken critics such as Capewell and McKee, a consensus has gradually been reached among health officials and public health academics that the benefits of promoting e-cigarettes to quit smoking outweigh the risks.

In other countries — particularly America — researchers are concerned about the threats to the lungs and heart and believe a precautionary principle should be followed until more is known.

There are also worries that many people adopt e-cigarettes as a “lifestyle tool” rather than to help them stop smoking. They fear many users have never smoked tobacco, or are “dual users” who smoke cigarettes outdoors and vape indoors.

Capewell said: “With more and more evidence of the harms they cause, I have become increasingly worried and frankly bewildered by the unquestioning enthusiasm for supporting e-cigarettes among the English public health bodies who should be protecting us.”

A moral crusade

Many say these fears are overblown. Robert West, professor of health psychology at University College London, said last week: “Since the advent of e-cigarettes the UK has taken a balanced approach, recognising their potential use in helping smokers to stop while ensuring that they are not marketed to young people who are not already smokers. There is strong evidence that this approach has been successful, increasing the numbers of smokers quitting with negligible take-up of e-cigarettes by non- smokers.”

An NHS-funded study West published in 2019 found e-cigarettes were nearly twice as effective as nicotine gum or patches at helping people quit smoking and six times more effective than trying to kick the habit alone. More than 50,000 people in the UK are estimated to have stopped smoking by using the devices. But while smoking rates have fallen from 20 per cent in 2011 to 14 per cent in 2019, they remain highest in deprived areas.

Speaking at the launch of his study in 2019, West said opposition to e-cigarettes had been driven by a “moral crusade” by campaigners who once fought tobacco giants. “The side effect of that fight has spilled over into a more general ethical view about anything which isn’t the pure way of stopping smoking, which is just do it yourself and pull your socks up and be a hero,” he said. “There is a general sense that addiction is a bad thing, that nicotine addiction is a bad thing, that anything remotely connected with the tobacco industry is horrendous.”

Healthwashing

The five most popular UK brands — Vype, Blu, Juul, IQOS and Logic — are all owned by tobacco companies, including British American Tobacco, Imperial Brands and Japan Tobacco International.

Jonathan Grigg, professor of paediatric respiratory and environmental medicine at Queen Mary University of London, believes the role of the tobacco industry is crucial in understanding e-cigarettes. “This is healthwashing,” he said. “This is the way the tobacco industry can present themselves as being interested in health. The day they stop selling cigarettes, you can take that seriously, but we’re not there yet. They’re pushing cigarettes around the world globally, killing eight million people every year, and you have to judge them by that.”

Dead in the water?

This is not the first time health bosses have floated the idea of prescribing e-cigarettes on the NHS. However, doctors recognise that the marketing, variety of flavours and wide availability of e-cigarettes does not sit well with positioning them as a quit-smoking tool, so have long been drawn to the idea of pharmacists issuing them without glitz and glamour.

After receiving positive noises from health officials British American Tobacco had its Voke nicotine inhaler licensed for medical use by the Medicines and Healthcare products Regulatory Agency (MHRA) in 2015 but never brought the device to market.

John Dunne, director-general of the UK Vaping Industry Association, said the regulatory hurdles had taken too long. By the time the device had a licence the technology was out of date. “The government has been calling for brands to do this for several years,” Dunne said. “They’re desperate to get a company to do it — and they want one that is not a tobacco company. But nobody’s really stepped up to the plate because I don’t think it’s going to be viable.”

Javid’s new rules will provide a simpler route to apply for a licence through the MHRA. Dunne said companies were unlikely to find that the returns justified the investment. However, there are tax benefits: e-cigarettes are subject to VAT at 20 per cent, contributing £4 to the cost of a £20 vaping kit. Medical products are subject to VAT at just 5 per cent. By comparison, last week’s budget raised the cost of a premium pack of cigarettes from £12.73 to £13.60, of which £7.50 – 55 per cent – is tax.

Peter Hajek, a professor of clinical psychology at Queen Mary University of London who is a long-term champion of e-cigarettes, is sceptical about vaping on prescription. “Smokers are more likely to benefit from e-cigarettes if they can select flavours, strengths and products that they like, rather than being limited to whatever becomes licensed,” he said.

As Dunne puts it: “Who is going to go to the trouble of going to a doctor to get a prescription when they can go to Tesco to get the same thing? They are trying to solve a problem that doesn’t exist.”