The United States surgeon general said last week that vaping – the use of e-cigarettes – is a threat to the health of young people and needs to be combatted. But there is very little evidence of vaping among people of any age who have never smoked, so what counts is the risk relative to smoking. When you last saw somebody vaping in the street, did you think “there goes somebody who has been a smoker”? If so, you’d be right 99% of the time.
The nicotine industry is being turned upside down. Until recently, all public health experts agreed that the only good tobacco policy was abstinence, if necessary assisted by nicotine patches, gums or acupuncture. Then a few years ago, along came vaping, which enabled smokers to get a nicotine hit from electronic devices without any smoke. Now there’re more products: heat-not-burn devices, big in Japan, and things called “snus”, big in Sweden. Public health experts are in a quandary.
On the one hand, vaping seems like a new lease of life for something that looks awfully like smoking; it might even tempt new users, re-glamorise tobacco and lure in children. One the other hand, it quickly has become clear that vaping is dramatically safer and gets smokers off cigarettes much more effectively than patches and gums. Some countries have banned it. Others impose strict regulation. The European Union, egged on by Britain and the pharma industry, tried to insist it be licensed as a medicine, and did ban advertising.
Vaping means people go on being addicted to nicotine, but is that any worse than begin addicted to caffeine? There’s no evidence that it is. The tobacco industry has reacted by buying vaping firms and making its own smokeless nicotine products. Philip Morris has said it wants to get out of smoking products altogether. This is surely good news, not bad.
Yet there are still die-hards determined to hate vaping despite the evidence. Shamefully, the World Health Organisation is a hotbed of such anti-scientific prejudice as it proved in a recent summit in Delhi by supporting bans on this life-saving innovation. The purists demanding abstinence, rather than harm reduction, are like the religious puritans who objected to encouraging condom use by gays in the early years of the AIDS epidemic.
Meanwhile, we have a neat, long running experiment to show that harm reduction works in tobacco control. It’s called “snus”. You hadn’t heard of it? Well that is because this smoking alternative – a small teabag of tobacco placed inside the lip – has been illegal in the EU since the last lurch in policy in 1992.
There is one exception. Sweden forced the EU to allow it to continue to use snus as a condition of it joining in 1995. This niche product is used by a remarkable 25% of Swedish men. Quite a niche. So what has been the result of this Swedish experiment with tobacco harm reduction? Has this product been a gateway for their young people to move into smoking? Has it hindered the progress of young smokers to quit? Not at all. Rather it has secured Sweden’s place at the bottom of the league table of European smoking.
In the critical group of young men aged 16 to 29, only 6% smoke daily. Some 17% use snus instead – seeming to inoculate themselves from the desire to smoke.
Through a Parliamentary Question I have asked the UK Health Secretary what the comparative figures are here. I suspect that we will find that as in Sweden the best part of a quarter of young British men use tobacco. But whereas British tobacco users are exposing themselves to the appalling risks of smoking, the large majority of Swedish men are using a vastly safer form of snus.
Vastly safer? The World Health Organisation has said it is “considerably less hazardous than cigarettes”. America’s Food and Drug Administration has decided to authorise snus for the “protection of public health”. If you prefer your evidence to be British, then our Royal College of Physicians has described snus as “proof of concept for harm reduction” that has led to Sweden having “the lowest smoking prevalence, and lowest male lung cancer incidence in Europe”. Younger Swedish men, who have the highest use of snus also have the lowest levels of oral, esophageal and pancreatic cancer.
Smokers know the terrifying health consequences of their habit. They daily experience all the stigmas and barriers society puts in their way. It is no surprise then that most not only want to stop but have tried on multiple occasions to quit. Our remaining smokers have done gum and patches. Most of them have had a go with vaping. Yet many would-be quitters are still struggling to find products which are pleasurable or cheap enough to help them prevail. Snus – which you can use on aircraft, in the office and in front of the kids – is attractive to some smokers. It might catch on here, given that no-one predicted the spectacular success of vaping.
What is clear is that as Brexit speeds towards us, our Department of Health can no longer hide behind the European legislation blocking snus. It needs to build an intellectually coherent framework for regulating nicotine products. This includes the products currently permitted, new technologies like the heat-not-burn devices now reaching our shores and old-tech snus which after 200 years of use in Sweden hardly merits the precautionary excuse of waiting for more evidence.