In deciding how to regulate vaping and its advertising, policymakers face a conundrum due to the competing priorities of attracting long-term smokers to less harmful products and of preventing children and young people from taking up vaping. George Gaskell and Francisco Lupianez-Villanueva look at research findings that seek to determine the broader impact of vaping in the future.

As conventional smoking declines in many advanced countries, vaping has created a new market segment for the tobacco industry. The marketing of vaping was greatly assisted by Health Authorities claiming that vaping is much safer than conventional cigarettes. The agenda for a forthcoming meeting of the WHO Framework Convention on Tobacco Control has been described by Philip Morris International as a “prohibitionist attack on smoke-free products” that, they claim, are an historic opportunity for public health.

In 2019, we conducted a study to inform the European Commission’s review of the Tobacco Products Directive 2014. The study looked at five categories of tobacco and related products: waterpipe tobacco, slim cigarettes, small cigarillos, novel tobacco products (NTP) and electronic cigarettes. In light of the Government’s recently announced plans aiming to create a “smoke-free generation”, it seems an apposite moment to examine what these findings tell us about the impact vaping is likely to have on the rates of tobacco product use.

Harm reduction

At that time, a particular controversy surrounded the public health response to e-cigarettes. The issue was whether e-cigarettes could be an aid for quitting conventional cigarettes or at minimum a means to reduce health risks (the cessation scenario) or whether young people who take up the use of e-cigarettes might progress to conventional cigarettes (the gateway scenario).

Public Health England (PHE) held that “the current best estimate is that e-cigarettes are around 95 per cent less harmful than smoking and that “Nearly half the population don’t realise e-cigarettes are much less harmful than smoking”. On the gateway scenario, PHE stated that “despite some experimentation with these devices among those who have never smoked”, e-cigarettes are attracting very few young people who have never smoked into regular use.

In the US, the National Academies of Science, Engineering and Medicine reported that e-cigarettes are “not safe but safer” and acknowledged that e-cigarettes “might be useful as a cessation aid to smokers who use e-cigarettes exclusively”. The report highlighted the risks to young people and to bystanders. On the gateway scenario “youth who begin with e-cigarettes are more likely to transition to combustible tobacco cigarette use and become smokers who may be at risk of suffering the known health burdens of combustible tobacco cigarettes”.

For the US Authorities, the protection of children was the paramount goal, while for PHE the goal was to wean smokers away from traditional tobacco products to the safer substitute of e-cigarettes.

Fairchild et al, (2019) pointed to the crux of the controversy “whose risk should be given priority”. For the US Authorities, the protection of children was the paramount goal, while for PHE the goal was to wean smokers away from traditional tobacco products to the safer substitute of e-cigarettes.

Looking at the evidence

Our study involved an online survey in 10 countries: Bulgaria, France, Germany, Greece, Italy, Latvia, Poland, Slovakia, Spain, and the UK. In each country, at least 600 people between 18 and 25 years were recruited, along with a further sample of 600 users and past users of tobacco products aged 26 or over. The questionnaire included questions on the perceived risks of conventional cigarettes and e-cigarettes and current and past tobacco use. It is important to note that the samples in each country were not representative of the population. That acknowledged, we can map the “careers” of users and past users of conventional cigarettes and e-cigarettes.

Evidence for the cessation scenario

Just below one in five (18 per cent) in both age groups said they had previously used other products but were now only using e-cigarettes. One in 12 of the younger age group and one in 25 of the older age group were exclusive e-cigarette users and had not used other products. Of past e-cigarette users, one in four in both age groups had been dual users and now were not using any tobacco or related products. Given that “cutting down or quitting other tobacco products” was cited as a reason for taking up e-cigarettes, these findings are suggestive of the cessation scenario.

Evidence for the gateway scenario

Over seven in 10 of the 18-25 age group and eight in 10 of 26+ age group were dual users of e-cigarettes and other products, mainly conventional cigarettes. One in four of the 18-25 age group and three in 10 of the 26+ age group had been exclusive e-cigarette users and now reported using other tobacco and related products, with some 90 per cent reporting the use of conventional cigarettes. Marginally more than four in 10 of both age groups were past e-cigarette users and reported current dual use of other tobacco and related products. The use of e-cigarettes had not made an impact on their use of tobacco.

The survey findings that emerged in 2019 are suggestive of both the cessation and gateway scenarios. This takes us back to Fairchild et al’s question. Whose risk should public health authorities consider most pressing – the current smokers of conventional cigarettes or young people who experiment with e-cigarettes and then gravitate to conventional cigarettes? We argued that the challenge for public health was to ride the two horses simultaneously and tailor communications appropriately.

A rapidly changing picture

In recent years, accumulated medical evidence is beginning to undermine the assumption that vaping is more or less risk-free. The “gateway scenario” of vaping leading to smoking conventional cigarettes has been replaced by vaping addiction. The claim that young people only experiment with vaping is challenged by the emergence of a “teen vaping” epidemic in the US and among school aged children in many European countries. The UK Office of National Statistics reported that 6.7 per cent of women aged 16-24 vaped daily in 2022, up from 1.9 per cent in 2021, with occasional vaping at 12.2 per cent.

Is the existing public health advice to substitute vaping for conventional cigarettes sustainable?

What are the implication for the “cessation scenario”? Is the existing public health advice to substitute vaping for conventional cigarettes sustainable? Will there be calls for new products to wean a generation of young people away from the addiction of vaping?

Addressing this challenge is complicated by the fact that young people are intensive users of the social media in which health misinformation is rampant. Tobacco companies have become the vaping industry producing a range of innovative products. While there are restrictions on advertising cigarettes in the traditional media, the promotion of tobacco products and vaping is largely unrestricted on social media. Memes and images are designed to normalise vaping in contemporary society. The effect of banning shop sales of vapes to children is diluted as with a credit card and a willingness to register as “over 18”, vaping products are readily available online. While there has been a noticeable silence from the public health authorities and governments, what will it take for them to tackle the ubiquitous marketing practices in the new media landscape?

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.

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