Can vapes save the world from smoking?

This story first appeared on Mosaic Science on July 2. It is republished here under Creative Commons license BY-NC-ND 2.0.

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Karl Erik Lund first puffed on a cigarette at a party not long after smoking rates peaked in Norway. In the mid 1970s, almost half of adults in the country smoked. Lund, who is now 60, was young and would never take to smoking in a big way. But in 1986, as a graduate in Oslo, he spotted an advert for a research role at the government agency that collated tobacco statistics. He needed the money, but he soon became addicted to the data. “I wanted to ask the question: why do people keep going with a behaviour that breaks society’s rules?” he says.

Smokers in Norway, and in neighbouring Sweden, were being targeted by one of the most advanced anti-smoking pushes in the world. In 1975, Norway banned all tobacco advertising and added health warnings to cigarette packs. In the 1980s, ratcheting taxes made it one of the most expensive countries in which to buy cigarettes. Schoolchildren were encouraged to beg their parents to quit. Bans came into force on public transport and in offices. In one anti-smoking TV advert, Dracula sank his teeth into the throat of a young smoker only to cough and stagger back in a black cloud.

“The aim of Norwegian tobacco policy was to become a nicotine-free society,” Lund tells me from his country house outside Oslo, where he is recovering from a dog-walking injury. Norway set out to educate, tax and scare people into quitting. But there was a problem: it wasn’t working. Smoking rates had dropped only to about 38 per cent by 1990.

Restrictions on indoor smoking culminated in a ban on smoking in any public space, including bars and restaurants, in 2004. The country was the second after Ireland to introduce such a ban. “Welcome to Norway. The only thing we smoke here is salmon,” a health ministry poster said at the time.

But Norway is a cold country in which to smoke outside. By the time of the ban, smokers had already begun to find another way to get their nicotine hit: snus. Snus (it rhymes with “moose”) is a type of oral snuff that has a long tradition in Scandinavia. Users place moist tobacco under the top lip, absorbing nicotine through the lining of the mouth rather than the lungs. In the 19th century, when smoking boomed elsewhere in the world, Norway and Sweden had favoured snus. But from around the 1920s, cigarettes soared in popularity there too, and by the late 1960s, when snus use reached its lowest point, it had come to be seen as a relic – something your grandfather did.

From the 1970s, though, manufacturers had fuelled a snus renaissance, designing new packaging and adding new flavours. The loose tobacco the older generation had used had by then been packed into neat teabag-like pouches sold in colourful little tins.

Snus was becoming cleaner, more convenient – and cooler. In 1994, when Sweden held a referendum on joining the European Union, it demanded that Brussels exclude the country from an EU snus ban. As the 2004 smoking ban approached in Norway (which is not an EU member), Lund recalls, bar owners, worried about business, worked with snus manufacturers to install vending machines.

For a country that had set out to rid society of nicotine, the rise of snus was alarming. There were fears that the power of marketing and a new cachet would draw young non-smokers into addiction, undoing decades of steady if slow progress. Snus users were warned that their habit could give them mouth and pancreatic cancer.

But Lund saw something different. As snus use tripled in the decade after the indoor smoking ban, smoking rates entered a steeper decline. In 2017, snus use overtook smoking in Norway. Norway and Sweden now have among the lowest smoking rates in Europe – just 12 per cent among adults in Norway and only 10 per cent in Sweden, compared to an EU average of 28 per cent. Rates of lung cancer in Sweden are among the lowest anywhere.

An often fierce debate about snus in Norway would foreshadow a wider argument after the emergence of another alternative for smokers: the e-cigarette. It would pit many scientists, including Lund, against public health orthodoxy. At the heart of it were seemingly simple questions. Could an alternative nicotine product, sold on the free market, save millions of lives and stub out cigarettes for good? Were smokers finding their own solution to a deadly problem in the very drug the world had come to fear?

Lund is in no doubt about the potential of non-combustible tobacco. Last November, he travelled from Oslo to the Royal Society in London for the sixth annual UK E-Cigarette Summit. At the end of a presentation about Sweden’s and Norway’s relationships with nicotine, he told delegates: “It is difficult for us in tobacco control to realise and accept that snus and e-cigarettes may have greater potential to make smoking obsolete than the regulations we have spent a lifetime fighting for.”

Deborah Arnott remembers going to a casino near Leicester Square in London for the launch of an unusual new device. It was February 2008, less than a year after England had introduced its indoor smoking ban. Arnott has been chief executive of the Action on Smoking and Health charity (ASH) since 2003 and is a leading figure in the UK’s tobacco control movement. “Conference Presents Scientific Breakthrough for Much Safer Smoking”, the invitation read. The event was run by a company called SuperSmoker, whose director, the Belgium-based entrepreneur Dimitri Kyriakopoulos, sat alongside doctors and what Arnott remembers as a minor celebrity (it was the chef Antony Worrall Thompson, who was then a heavy smoker).

Very quickly, manufacturers moved away from what are known as “cigalike” devices to create a dizzying range of choices. The slimmest e-cigarettes now resemble pens or sleek memory sticks, while chunkier units, known as “mods”, have interchangeable parts and create billowing clouds. There are more choices of flavour than there are colours on the Pantone chart.

The SuperSmoker device looked like a long cigarette with an orange mouthpiece, a white shaft, and even a “burning” tip. But the tip was an LED light that glowed with each puff, or blinked when the battery ran low. Inside, cartridges contained nicotine in a liquid that turned to vapour when the user activated an element while inhaling. Food additives mimicked the taste of tobacco. The device cost £79 and cartridges were £7.95 for six. Arnott was underwhelmed.

The SuperSmoker was one of the first e-cigarettes to hit the UK market. But, like Arnott, smokers were initially sceptical. When journalist Terri Judd puffed on a SuperSmoker in a London pub soon after the launch event in 2008, drinkers were “stunned at what in one short year has become a shocking sight,” she wrote in the Independent. “One man grabs his mobile phone to take a picture.”

Judd, who remembered smoking in a bar with a friend on the eve of the UK ban, like “mourners at a wake, savouring our memories of better days”, concluded that it would be a while before e-cigarettes brought “sceptical, rebellious smokers” in from the cold.

A decade after the SuperSmoker launch, in April last year, a giant cloud was building over an exhibition space at the ExCel centre in east London. Below it, more than 100 businesses were showing their wares in an explosion of music and strobe lighting. Charlie Rabone, a 20-year-old from Stockport, was blowing vapour rings at the stand belonging to an American producer of vape liquids. (“Juice”, as enthusiasts call the liquid, is a blend of the additives vegetable glycerin and propylene glycol, as well as nicotine and flavourings.) An Italian company was selling £300 cases for e-cigarettes, hand-carved in spalted beech wood.

This was Vape Jam UK, now in its fourth year. After a lukewarm reception, the e-cigarette had evolved dramatically and spread fast. What had been conceived as a utilitarian device, which looked and behaved like a cigarette, had become something very different. A cottage industry of small businesses had fuelled a global market now worth an estimated $12 billion. Vape Jam felt like equal parts tech convention, food fair and rock festival.

Very quickly, manufacturers moved away from what are known as “cigalike” devices to create a dizzying range of choices. The slimmest e-cigarettes now resemble pens or sleek memory sticks, while chunkier units, known as “mods”, have interchangeable parts and create billowing clouds. There are more choices of flavour than there are colours on the Pantone chart. For a lot of the enthusiasts at Vape Jam, vaping had become a lifestyle and culture. But the products on show there filter down to the petrol-station counters and vape shops mushrooming on high streets across Britain.

ASH did not start monitoring e-cigarette use until 2012, by which time 700,000 people in the UK already reported vaping. That number had almost doubled by 2013 and last year reached 3.2 million. Unlike snus in Scandinavia, the e-cigarette was a new product. But, Lund says, “They are both grassroots and consumer-driven, and have occurred without the support of the authorities.” And vaping worried some guardians of public health in the same way that snus did. Here, they thought, was a rogue product of the free market that would enable addiction and appeal to young people, potentially acting as a new gateway to cigarettes.

In contrast, the giant tobacco companies soon began investing in this rising threat to their business models, marching into a market that had been conceived to undo a health catastrophe of their making. Until then, Lund says, the tobacco industry had been seen as “the good enemy we can all agree to hate”. There were traditionally three aims in tobacco control, Arnott explains. “And they all used to align quite nicely. One was to get rid of harm caused by smoking. Two was stopping addiction. Three was destroying the tobacco industry.”

The EU did not move against e-cigarettes in the way it had against snus, which it banned in 1992. But the EU Tobacco Products Directive, implemented in 2016, outlawed broadcast advertising and brought in new standards for liquids and devices. It required new health warnings about nicotine addiction on labelling and called for more to be done to deter teenage vapers. Britain had already banned sales to under-18s in 2015. Other countries, including Australia and Canada, have taken a much harder line. E-cigarettes are banned entirely in several, including Argentina, Brazil, Singapore and the United Arab Emirates.

There were warnings again about the unknown long-term health risks of inhaling vapour, and a growing public perception that vaping wasn’t much safer than smoking. In the US, between 2012 and 2017, two regular surveys found big increases in the proportion of people thinking that e-cigarettes were as harmful as cigarettes or even worse. In Britain, vaping indoors is legal but businesses have broadly forbidden it, forcing vapers to share pavements with smokers.

But senior public health officials take a different view. In 2015, a report from Public Health England estimated that vaping was 95 per cent less harmful than smoking. In 2014, David Nutt, a professor of neuropsychopharmacology at Imperial College London, and a former drugs adviser to the UK government, described e-cigarettes as “the greatest health advance since vaccines”. A year earlier, Professor John Britton, chair of the Tobacco Advisory Group at the Royal College of Physicians, said that millions of premature deaths in Britain would be prevented if smokers switched to e-cigarettes, describing this prospect as “a massive potential public health prize”.

Ian Blandamer started smoking when he was about 14. “All my mates were doing it and I didn’t want to be left out,” he says. Blandamer, who is now 54, grew up in Leicester and remembers his father smoking up to 80 cigarettes a day. Aged 16, Blandamer would spend his pound a day of lunch money on fags and chips, eventually working his way up to a 40-a-day smoking habit that lasted for 37 years.

When Blandamer hit 50, he started to exercise more. His GP told him he also ought to quit smoking. “The kicker was asking my mother what she wanted for her 80th birthday and her telling me she wanted me to quit the fags,” he recalls. “When I told her recently about the dinner money she nearly killed me.”

Blandamer had a coworker who knew about quitting, so they met for a drink. Mark Dickinson had worked for GlaxoSmithKline, the pharmaceutical giant. In 1998, he had led the European launch of NiQuitin, a range of nicotine patches and gums. It was November 2016 and Dickinson had just launched his own health consultancy. He was beginning to work with companies in the vaping industry. After a drink near Dickinson’s home in south-west London, he took Blandamer to a vape shop. Blandamer tried a Chinese-made Innokin T18 device and added some fruit-juice-flavoured liquid.

“I thought, ‘This is bloody brilliant,’” Blandamer says. He and Dickinson, who is not a smoker, went on to a coffee shop and sat outside, vaping some more. Blandamer quit that day and hasn’t lit up since. “I had about 15 cigarettes left in a packet and put them in my shed,” he says.

Until the e-cigarette arrived, smokers had less choice. Soon after landmark studies and reports in the 1950s and 1960s confirmed the link to cancer and compelled governments to act, tobacco companies tried and failed to create less deadly cigarettes, an attempt that would further erode trust in them.

Sweden provided an alternative. In 1967, Claes Lundgren, a military doctor, had noticed that submariners, who were banned from smoking because of fire risks, were using traditional alternatives such as snus. Wondering if there might be a better solution, he wrote to his friend Ove Fernö at AB Leo, a Swedish pharmaceutical company. Fernö began experimenting with nicotine in chewing gum. By 1978, he was ready to launch his gum. Lundgren had already suggested a name, based on the words “nicotine” and the Norwegian word for “right” – “rette”.

Nicorette triggered a new phase in tobacco control. Pharmaceutical companies developed medicinal remedies that would be prescribed or sold over the counter as part of what became known as nicotine replacement therapy. Nicotine patches were patented in the US in 1986 and arrived in the UK in 1992, adding to a medicine cabinet that has also included lozenges, inhalers and nasal sprays. Prescription drugs designed to reduce nicotine cravings came later.

Medical solutions rely on smokers to recognise their addiction as a medical issue. Blandamer never did. He also enjoyed smoking as a relaxing and often social activity. Patches offered him nothing beyond nicotine. As well as a chemical addiction, the hand-to-mouth habit itself can be powerful. “That’s one of the clever ways nicotine works,” says Robert West, professor of health psychology and director of tobacco studies at University College London. “It pharmacologically binds your actions to situations and generates the impulse to do what you’re doing.”

West says this may partly explain why vaping appears to work for many smokers. But it’s not that simple. Studies that pre-date e-cigarettes, in which smokers were given either patches or a pharmaceutical nicotine inhaler, showed no increased effect in the inhaler group, despite its mimicry of smoking motions.

Yet contemporary research shows vaping is more effective as a quitting aid. One study, carried out by Peter Hajek, director of the Wolfson Institute of Preventive Medicine’s Tobacco Dependence Research Unit at Queen Mary University of London, found that e-cigarettes were almost twice as effective as nicotine replacement products such as patches. A year after the start of the study, which was published earlier this year in the New England Journal of Medicine, 18 per cent of the e-cigarette group had quit smoking, compared to 10 per cent of the nicotine replacement group.

Another study compared the quitting power of various aids. Smokers who were prescribed patches, lozenges or gum, alongside motivational support, were 34 per cent more likely to quit successfully than those who tried with no aids. Those who bought patches or gums off the shelf were no more likely to quit. Those who were prescribed an anti-craving drug were 82 per cent more likely to stop. Smokers in the e-cigarette group were about 95 per cent more likely to quit. Jamie Brown, who led the research team, said: “It is important that e-cigarettes appeared to be equally effective for smokers of all ages and social backgrounds.”

More than satisfying any impulses or habits, West puts the e-cigarette’s relative success down to a simple factor: the efficiency with which it gets nicotine into the body. “I think there is probably a tipping point in the speed of nicotine delivery which takes a product from something that only prevents withdrawal symptoms to something that gives you positive reinforcement and keeps you doing it,” he says. This effect plays out in Hajek’s recent study. Among the smokers who had quit, 80 per cent of the e-cigarette group were still vaping after a year, while only 9 per cent of the nicotine replacement group’s quitters were still using their products.

The efficiency of vaping also leads many ex-smokers to reduce the levels of nicotine in their liquids. ASH’s latest surveys, carried out by YouGov, show that 43 per cent of vapers have lowered the strength of nicotine they use over time. At Vape Jam I met a handful of vapers who had dropped all the way to zero nicotine. They had started in order to quit smoking and then cut back on nicotine as their cravings dulled. But they still liked to vape.

In 2015, a Californian startup called Juul Labs launched a new e-cigarette. Small and sleek, it looked like a USB flash drive, and soon developed a following among teenagers despite age limits on sales. Reports spread last year of an epidemic of “Juuling” in high schools. The company, which promoted its brand on social media, was accused of targeting a new generation of non-smokers for whom vaping might act as a gateway to cigarettes.

Parents also feared Juul’s high nicotine content, which was approximately three times the EU limit, as permitted in the US, and the potential long-term health risks of the chemicals that make up e-liquids. Vaping may be better for their children than smoking, parents argued, but there was still uncertainty about its health effects – and what’s more, Juuling was harder to detect. The Food and Drug Administration (FDA) launched a series of investigations. Two surveys, published by the Centers for Disease Control and Prevention in 2019 and by researchers at University of Michigan’s Institute for Social Research in 2018, showed a spike in high-school students who reported having vaped in the previous 30 days. The Michigan survey suggested more than a quarter of high-schoolers were vaping.

The response was swift. US states have lined up this year to raise the minimum age for buying e-cigarettes and tobacco products from 18 to 21, and there are calls for a federal limit. The FDA ordered manufacturers to limit the range of flavours they sold and do more to prevent underage sales.

The city of San Francisco, home to Juul Labs, has announced a ban on the sale of e-cigarettes from next year “until due diligence is carried out by the FDA concerning Big Tobacco companies like Juul marketing to our youth”. Juul says it fears the move will drive smokers who have successfully switched to vaping back to cigarettes. “We have already taken the most aggressive actions in the industry to keep our products out of the hands of those underage and are taking steps to do more,” says the company’s spokesman, Ted Kwong.

More widely, reports in the press have warned that e-cigarettes can cause “popcorn lung”, a condition that can require a transplant. (It was first observed among workers in a popcorn factory who had been exposed to very high levels of a flavouring called diacetyl, also used, in small doses, in some flavours of e-liquids.) There have been no recorded cases of popcorn lung in e-cigarette users, and diacetyl is no longer permitted in e-juice sold in the EU (and is not an ingredient in Juul). Studies have also warned against the presence in vapour clouds of formaldehyde, a potential carcinogen, which has fuelled fears of passive vaping.

But compared with smoking tobacco, UK health bodies say, there’s no contest. Still, they have faced heavy criticism of their support for e-cigarettes as effective quitting aids. When Public Health England estimated in 2015 that vaping was 95 per cent less harmful than smoking, it triggered an eruption. Editorials in the Lancet and BMJ said the evidence of the long-term effects of vaping did not go back far enough and was not concrete enough to support such a bold statement. In 2016, the World Health Organization called for tighter regulation of e-cigarettes in the absence of stronger evidence of their safety and potential as quitting aids. An editorial this year in the journal Nature pointed to an “evidence gap” regarding the safety of e-cigarettes and their effectiveness as a smoking cessation aid. Until more is known, it said, “it seems premature to advocate strongly for e-cigarette use, and imperative that regulators develop guidelines to limit vaping by adolescents”.

“England is a complete outlier when you look at the international scene,” says Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine. McKee is the most prominent vape-sceptic among UK academics (more than one of whom has described McKee to me as “isolated”, an idea he forcefully rejects). McKee, too, points at the lack of long-term safety studies. Vaping is safer than smoking, he accepts, but this does not justify its promotion until we know more. He calls the 95 per cent figure “untenable” and says his own position has earned him abuse and even death threats.

Martin Dockrell, the Tobacco Control Programme lead at Public Health England (formerly director of research and policy at ASH), stands by the “95 per cent” report and was surprised by the reaction to it. He agrees that more research is needed to determine the long-term effects of vaping. His bigger concern was the effects that media stories about possible dangers of vaping have on smokers who might like to quit. “Year on year we saw the number of people who believed vaping was at least as harmful as smoking was increasing,” he says. “Why would they switch? We wanted to redress the balance.”

ASH’s latest survey, in 2018, found that only 17 per cent of the British public said vaping was a lot less harmful than smoking. Around a third of smokers (37 per cent) had never tried vaping. The most common reason they gave was a reluctance to substitute one addiction for another (18 per cent). The next biggest reasons (each reported by 11 per cent of smokers) included a lack of information and concerns about safety.

Dockrell says reporting of some academic studies into “passive vaping” was misleading, and that levels of potentially harmful chemicals in e-cigarette vapour were too low to cause anything like the horrors of tar and carbon monoxide, the most harmful ingredients of tobacco smoke. Nicotine itself, while highly addictive, is not classified as a carcinogen (see What do we really know about vaping?). Peter Hajek and others have even contended it is roughly as risky as caffeine.

Hajek is critical of the US response to vaping. He says the surveys that measure vaping during the preceding 30 days risk categorising casual experimentation among teens as longer-term use. He questions the idea that young vapers become young smokers. “If anything it’s the opposite,” he says. “The decline in young people smoking has accelerated when alternative products come out. In Norway there are virtually no smokers among young people.” In Britain last year, 1.7 per cent of people aged 11 to 18 reported vaping every week. Just 0.2 per cent of the same age group reported vaping weekly while never having smoked. Among longer-term vapers of any age who have never smoked, meanwhile, it is hard to say how many would have become smokers instead.

Ian Blandamer was so struck by his own switch to vaping that in January last year, 20 years after Dickinson had helped launch NiQuitin, the pair opened a vape shop together in south London. Blandamer can’t understand the hostile response to the e-cigarette, and resents the way that tightening rules on vaping make him feel like his former smoking self.