Vaping?

The science is clear. So why can’t governments agree on vaping?

The great divide on what to do about e-cigarettes is only growing wider.

BY ASHLEIGH FURLONG

There’s one thing scientists, doctors and health officials debating vaping can agree on: They want people smoking tobacco cigarettes to quit.

That’s where consensus ends. 

Since e-cigarettes burst onto the scene in the 2000s, they have divided scientists, perplexed regulators and resulted in a dramatic reversal of fortunes for an industry whose products were in decline. 

The debate is at times toxic, pitting former colleagues and collaborators against one another.

And it has led to wildly different policies among governments that are all considered "tobacco control champions."

Brazil and Panama, for example, have banned e-cigarettes, whereas in places like the U.K. and Canada vapes are freely available to those who want them. Other countries sit somewhere in the middle. 

Yet these countries are all basing their policies on the same evidence; much of which Vinayak Prasad from the World Health Organization (WHO)’s No Tobacco Unit says is undisputed.

“Nobody is disputing that this is addictive. Nobody is disputing that there is an appeal to it, because of the way it is being promoted … Nobody in the world is disputing that non-smokers should not use it. Nobody in the world is disputing that minors should not use it,” he said.

But what is being disputed — and what’s driven a seemingly insurmountable divide between countries and scientists — is how the scientific evidence should be translated into policy.

Follow the science 

Jamie Hartmann-Boyce says the evidence shows that how harmful or beneficial vaping is depends on who you are.

“It's really a product that's good for some people and bad for other people, which doesn't feel like too complex of a statement, but actually feels like something that is difficult for many to grapple with,” said Hartmann-Boyce, who is an associate professor of evidence-based policy and practice at the University of Oxford. 

She led a 2022 Cochrane review — considered the best type of analysis of the available evidence — which looked at studies of e-cigarettes for smoking cessation. It found the strongest evidence yet that vaping works better than traditional nicotine replacement tools such as patches or gum to help people stop smoking. For those advocating that vaping is an effective harm-reduction mechanism, it was a significant win.

But it’s also more complicated than that. 

Hartmann-Boyce said that since Cochrane first started looking at the evidence nearly 10 years ago, things have changed dramatically. The devices themselves are different now and are much better at delivering nicotine. That’s good for people trying to give up smoking but creates a problem with non-smokers like kids who are trying these for the first time.

But not everyone is even convinced it's good for most smokers in the long term.

Jørgen Vestbo, a clinician and emeritus professor of respiratory medicine at the University Hospital of South Manchester, who recently returned to his native Denmark, agrees that the randomized controlled trials show e-cigarettes can help people quit. 

But he also points to data from clinical trials that show people given e-cigarettes were more likely to use them for longer than those using aids such as nicotine gum. Vestbo said population-level evidence shows that as long as you are addicted to nicotine you are more likely to start smoking again.

“There's no doubt that vaping can — better than any other nicotine substitution — make people stop smoking. It's just that we don't apply it the same way [as a medicine]. The vaping is not on prescription, anybody can buy it. So you cannot easily apply the findings from the randomized control trials to the real world. And I think that's where we disagree,” he explained.

There's also no data yet on the long-term effects of e-cigarettes, leading some policymakers, such as the WHO, to embrace the precautionary principle when it comes to vaping.

“Until independent research shows the real risk profile of these products, governments should be cautious,” said Adriana Blanco Marquizo, head of the WHO Framework Convention on Tobacco Control Secretariat, in the WHO’s 2021 report on new tobacco products.  

Prasad said the WHO’s principles that were in place six years ago on e-cigarettes haven’t actually changed much. In fact, if public comments are anything to go by, the WHO has dug in even more firmly. In June, WHO Director General Tedros Adhanom Ghebreyesus said that the narrative that e-cigarettes are a part of harm reduction is “not true” and “a trap.” 

Digging in 

Comments like these illustrate John Britton’s point about the vape debate. Before he retired, Britton was director of the U.K. Centre for Tobacco & Alcohol Studies at the University of Nottingham and has been highly influential in helping shape the U.K.’s approach to vaping. The U.K. has embraced e-cigarettes as a way to help smokers quit and this year announced a "world first" scheme to give smokers a vape starter kit along with behavioral support.

As he sees it, many organizations and individuals are not following the most up-to-date evidence and find themselves trapped in entrenched, outdated positions. 

“You sort of paint yourself into a corner where if you say, at the outset, ‘I don't like the look of this, let's ban it,’ and then gradually evidence comes along, say, that banning it might not be quite a good idea, you've either got to have the courage to say, actually, ‘I've got the call wrong’ and change your position. Or you just hunker down. And the WHO has taken that approach.”  

However, the WHO and people like Vestbo argue they are following the science — they’re just looking beyond the individual smoker and considering it from a whole of society approach. 

Hartmann-Boyce, who authored the Cochrane review, agrees that different perspectives can help explain the divide between the science that she produces and the policies on the ground. 

"For the most part, the decision [governments] are making is not 'should this person who smokes be given an e-cigarette to help them quit smoking?' They're thinking: ‘Should we allow these to be sold in grocery stores?’" she said. 

And, of course, looming large over every discussion on vaping policy is Big Tobacco. It’s “almost the No. 1 biggest issue in some ways,” said Hartmann-Boyce.

To many on both sides of the argument, the tobacco industry’s embrace of e-cigarettes has clouded the policy debate. It’s not just the fact that the industry is producing vapes — although that's enough to put many off the idea of promoting them. It’s that the industry’s involvement has made the products as appealing as possible, encouraging take-up by non-smokers, including kids — precisely the populations that everyone agrees should not use them.

Britton said Big Tobacco is “an immortal, reprehensible industry that makes a fortune by addicting children and killing them” but he said they won’t just hold up their hands and admit that. ”They're going to carry on making their money out of it, however they can, for as long as they can."

And while Vestbo comes down on a different side of the policy argument, he agrees that Big Tobacco's involvement is unhelpful.

The tobacco industry is “so powerful, so dominant, they are using all the old tricks,” he said. “So, of course, if you are not against e-cigarettes, perhaps then you've been either bought or cheated by the tobacco industry ... There's this big monster in the background."