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There’s one thing that scientists, doctors, and health officials who discuss vaping can all agree on: They want people who smoke tobacco cigarettes to quit.
That’s where the consensus ends.
Since e-cigarettes hit the scene in the 2000s, they’ve divided scientists, puzzled regulators, and led to a dramatic reversal of fortune for an industry whose products had been in decline.
The debate is sometimes toxic, pitting former colleagues and associates against each other.
And it has led to very different policies between governments that are all considered « tobacco control champions ».
Brazil and Panama, for example, have banned e-cigarettes, while in places like the UK and Canada, vaporizers are freely available to those who want them. Other countries sit somewhere in between.
Yet these countries are all basing their policies on the same evidence; much of what Vinayak Prasad of the World Health Organization’s (WHO) No Tobacco Unit says is undisputed.
“No one questions that this is addictive. No one disputes that there is an appeal to it, due to the way it is promoted… No one in the world disputes that non-smokers shouldn’t use it. No one in the world disputes that minors shouldn’t use it,” she said.
But what is at issue – and what has led to a seemingly insurmountable gap between countries and scientists – is how scientific evidence should be translated into policy.
Follow the science
Jamie Hartmann-Boyce says evidence shows that how harmful or beneficial vaping is depends on who you are.
« It’s really a product that is good for some people and bad for other people, which doesn’t seem like too complex a claim, but it actually seems like something many are hard to grapple with, » said Hartmann-Boyce, an associate professor of evidence-based policy and practice at the University of Oxford.
He drove a 2022 Cochrane revision – considered the best kind of analysis of the available evidence – which looked at studies of e-cigarettes for smoking cessation. He found the strongest evidence that vaping works better than traditional nicotine replacement tools like patches or gum in helping people quit smoking. For those who argue that vaping is an effective harm reduction mechanism, it was a significant victory.
But it’s even more complicated than that.
Hartmann-Boyce said that since Cochrane began examining the evidence nearly 10 years ago, things have changed dramatically. The devices themselves are different now and are much more effective at delivering nicotine. It’s fine for people trying to quit smoking, but creates a problem with non-smokers like kids trying them for the first time.
But not everyone is convinced that it’s good for most smokers in the long run, either.
Jørgen Vestbo, a clinician and emeritus professor of respiratory medicine at South Manchester University Hospital who recently returned to his native Denmark, agrees that randomized controlled trials show that e-cigarettes can help people quit.
But it also indicates data from clinical trials that show people given e-cigarettes were more likely to use them longer than those who used aids such as nicotine gum. Vestbo said population-level evidence shows that the longer you are addicted to nicotine, the more likely you are to start smoking again.
“There is no doubt that vaping can, better than any other nicotine replacement, lead to smoking cessation. We just don’t apply it the same way [as a medicine]. Vaping is non-prescription, anyone can buy it. So it is not possible to easily apply the results of randomized control trials to the real world. And I think that’s where we disagree,” she explained.
Furthermore, there is still no data on the long-term effects of e-cigarettes, leading some policy makers, such as the WHO, to embrace the precautionary principle when it comes to vaping.
« Until independent research shows the true risk profile of these products, governments should be cautious, » said Adriana Blanco Marquizo, head of the WHO Framework Convention’s Tobacco Control Secretariat, in the WHO 2021 report. relationship on new tobacco products.
Prasad said WHO principles that were in effect six years ago on e-cigarettes haven’t changed much. Indeed, if public comments are anything to go by, WHO has dug in even more firmly. In June, WHO Director-General Tedros Adhanom Ghebreyesus said the narrative that e-cigarettes are part of harm reduction is « not true » and « a trap ».
Comments like these illustrate John Britton’s take on the vaping debate. Before retiring, Britton was Director of the UK Center for Tobacco and Alcohol Studies at the University of Nottingham and was highly influential in helping shape the UK’s approach to vaping. The UK has embraced e-cigarettes as a way to help smokers quit and this year announced a « world-first » scheme to offer smokers a basic vaping kit along with behavioral support.
According to him, many organizations and individuals do not follow the latest evidence and find themselves trapped in ingrained and outdated positions.
“You kind of find yourself in a corner where if you say, at the beginning, ‘I don’t like the look of this, let’s ban it,’ and then gradually comes evidence, let’s say, that banning it might not be a good idea, you have to have the courage to actually say, ‘I screwed up the call’ and switch sides. Or you just squat. And WHO has taken this approach. »
However, WHO and people like Vestbo say yes I am following the science – they are just looking beyond the individual smoker and considering it from a whole society approach.
Hartmann-Boyce, author of the Cochrane review, agrees that different perspectives can help explain the gap between the science it produces and the policies on the ground.
« In large part, the decision [governments] are not doing is ‘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, Big Tobacco looms large over every discussion of vaping politics. It’s « almost the No. 1 biggest issue in some ways, » Hartmann-Boyce said.
For many on both sides of the argument, the tobacco industry’s adoption of e-cigarettes has clouded the political debate. It’s not just that the industry is producing vaporizers, though that’s enough to put many off the idea of promoting them. It’s that industry involvement has made the products as attractive as possible, encouraging adoption by non-smokers, including children, the very populations they all agree shouldn’t use them.
Britton said Big Tobacco is « an immortal and reprehensible industry that makes its fortune by addicting children and killing them, » but said they won’t throw up their hands and admit it. « They’ll keep making their money, as best they can, for as long as possible. »
And while Vestbo descends on a different side of the political argument, he agrees that Big Tobacco’s involvement isn’t helping.
The tobacco industry is « so powerful, so dominant, they’re using all the old tricks, » he said. « So obviously, if you’re not against e-cigarettes, maybe you’ve been bought or tricked by the tobacco industry… There’s this big monster in the background. »