I am rather happy that my country is widely regarded as a global leader in tobacco harm reduction. Enthusiastic take-up of vaping products has led to the UK boasting the second lowest smoking prevalence rate in Europe, behind only Sweden. Sadly, it hasn’t always been this way.
Our government used to prefer the stick to the carrot. In 2007, after years of hiking taxes on tobacco, it implemented a nationwide smoking ban in indoor public spaces. Post-implementation reviews by tobacco control activists spoke of the potential for making life so inconvenient for smokers that they would surely quit. Instead, the next three years saw a stall in the previous long-term steady decline in smoking prevalence, with 21 percent of the public stubbornly continuing to smoke.
It was in this environment that e-cigarettes first appeared in the UK, a few years after their invention by Chinese scientist Hon Lik.
Regulators quickly noticed cigarette-like devices being sold by small-scale entrepreneurs in pubs and clubs. Early adopters pulled them apart, worked out the tech and built their own “mods” in their workshops and garden sheds.
“We looked hard at the evidence and made a call: We minuted the PM and urged that the UK should move against banning e-cigs.”
In May 2010, as popularity grew, the UK’s Medicines & Healthcare products Regulatory Agency (MHRA) ran a consultation on how to regulate the new kid on the nicotine delivery block. Its first (and preferred) of three proposed options was to ban the products entirely within 21 days. The second was that they should be prohibited until manufacturers had achieved medicinal products licensing. The third, carefully worded to deter its being chosen, was: “Do nothing and allow these unregulated products containing nicotine that have not been assessed for safety, quality and efficacy to remain on the market.”
The consultation was swarmed by ordinary vapers detailing positive experiences with their devices. Over 1,000 submitted testimonies succeeded in forcing the MHRA to, well, do nothing. Any decision to ban e-cigarettes—given how many people testified that they helped smokers do exactly what the state wanted them to do—would have exhibited high hypocrisy from a government which continually talked of smoking’s harms.
At around the same time, David Halpern, head of then-Prime Minister David Cameron’s new “nudge unit,” formally known as the Behavioural Insights Team, learned of the existence of e-cigarettes. His team—which sought to make changes in public behaviour based on principles put forward in the book Nudge by Richard Thaler and Cass Sunstein—was tasked with coming up with proposals to prove the theory could work. Noticing that British vapers were almost exclusively smokers or former smokers, he sensed an opportunity.
In his book Inside the Nudge Unit, Halpern wrote: “We looked hard at the evidence and made a call: We minuted the PM and urged that the UK should move against banning e-cigs. Indeed, we went further. We argued we should deliberately seek to make e-cigs widely available, and to use regulation not to ban them but to improve their quality and reliability.”
By 2012, vaping had gone mainstream. An unprecedented and dramatic decline in smoking rates followed.
Under this hands-off approach, businesses sprung up and innovation prospered to attract the country’s 12 million or so smokers to this new safer alternative. By 2012, vaping had gone mainstream. An unprecedented and dramatic decline in smoking rates followed, from just under 21 percent in 2011 to less than 15 percent in 2020.
The idea of medical licensing hadn’t gone away though, and the MHRA was still promoting this concept in 2013. But it was resisted by Cameron’s coalition government in favour of deferring to the decisions taken by the EU’s Tobacco Products Directive (TPD). Once again, consumers spoke up and campaigned heavily to stop medicinal licensing—and all the barriers that entailed—as the entry route for vaping products. As a result, this approach was voted down by the European Parliament in October 2013.
The vaping category was still in relative infancy. Following the EU TPD—and with the UK government’s preference for “light touch” regulation to encourage smokers to switch—UK public health groups and regulators were faced with the task of consulting businesses and consumers to learn exactly what they were supposed to be regulating. With a burgeoning industry rapidly innovating and introducing new products to bring smokers into the vaping fold, it was no simple task.
A report from Public Health England in 2015, entitled E-cigarettes: an emerging public health consensus, changed things dramatically. It famously concluded that vaping was at least 95 per cent less harmful than smoking. The report was endorsed by groups including Action on Smoking and Health (ASH); the Association of Directors of Public Health; the British Lung Foundation; Cancer Research UK; the Faculty of Public Health; the Royal College of Physicians; the Royal Society for Public Health; the UK Centre for Tobacco and Alcohol Studies; and the UK Health Forum. And representatives of consumer groups were invited to attend the report’s media launch.
This sent many traditional tobacco control groups into a tail-spin, creating a furious backlash. But Public Health England’s conclusions were backed up the following year by the Royal College of Physicians, which declared in its own report, Nicotine Without Smoke, that “the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5 percent of the harm from smoking tobacco.”
Today, vaping is endorsed by the National Health Service, and promoted in “Stoptober,” the nation’s annual quit-smoking drive.
The rest, as they say, is history. Disgruntled voices sounded for a while, but one by one they changed tack or fell silent as they recognized their outlier status. Today, vaping is endorsed by the National Health Service, and promoted as a smoking cessation option—advertised on TV—in “Stoptober,” the nation’s annual quit-smoking drive.
The latest report by ASH (published last month) assessed that there are 3.6 million vapers in the UK, two-thirds of whom are ex-smokers. Of the remainder, 30 percent are “dual” smokers and vapers—often a stage on the journey towards quitting smoking or smoking a lot less. Under 5 percent of vapers have never smoked.
University College London estimates that every year, 50,000-70,000 people quit smoking using e-cigarettes who would not have done so by other means. A collaborative US/UK study published in 2020 concludes that this will prevent up to 200,000 avoidable deaths in England alone by 2052.
And, yes, the rumors you heard were correct: We do have vape shops in NHS hospitals here.
There is now a cross-party political consensus in the UK, with little denial from any politician of the benefits of tobacco harm reduction, at least regarding e-cigarettes. Tobacco harm reduction is also being more widely considered: Reduced-risk options such as nicotine pouches and heated tobacco products are being debated for England’s upcoming Tobacco Control Plan. Previous incarnations spoke of “maximizing the availability of safer alternatives to smoking.”
With this progress, the question is where to go from here.
Now that the UK has left the EU, there has even been an announcement of a review into the ban on snus. Snus is the product responsible for Sweden claiming the lowest smoking rate in Europe and, by consequence, the lowest rate of smoking-related illness too. But it has been prohibited for sale in all EU member states (except Sweden) since the 1990s.
With this progress, the question is where to go from here. Well, with some talking of an “end-game” for tobacco use and the UK government committing to achieving a Smokefree 2030 (that is, less than 5 per cent smoking prevalence), our recent history would suggest an accelerated decline in cigarette sales driven by the wide availability of smoke-free alternatives as the best way to go about it.
The UK just needs to follow past success, pursuing a light-but-sensible regulatory regime and a positive-information environment for all reduced-risk nicotine products, in order to drive down cigarette sales further. We’ve done it before, and it worked.
Photograph of a vape advertisement in Newport, UK by Jaggery via Geograph/Creative Commons 2.0