Electronic cigarettes and harm reduction - Matt Ridley

Lots of doctors are now recommending vaping as a way of quitting smoking. It is because of vaping that Britain now has the second lowest percentage of people who smoke in the European Union. The youth smoking rate in the UK has fallen from 26% to 19% in only six years.

How did this happen here? It’s partly the fault of the advertising executive Rory Sutherland; he is the Walter Raleigh of this revolution. In 2010, he walked into an office in Admiralty Arch to see an old friend, David Halpern, head of David Cameron’s new “nudge unit”, formally known as the Behavioural Insights Team. Sutherland pulled out an electronic cigarette he had bought online, and inhaled. By then, several countries including Australia, Brazil and Saudi Arabia had already banned the sale of electronic cigarettes — usually at the behest of tobacco interests or public-health pressure groups. California had passed a bill banning them, though Arnold Schwarzenegger, then the governor, had vetoed it. It looked inevitable that Britain would follow suit.

“I was a very early convert,” Sutherland tells me now. “Partly because I was a longtime ex-smoker myself who found them much better than constant relapses; I was also interested in the placebo effect they offered by mimicking the act of smoking. But I was almost equally fascinated by the psychology of the people who instinctively wanted to ban them.”

In his book Inside the Nudge Unit, Halpern wrote: “We looked hard at the evidence and made a call: we minuted the PM and urged that the UK should move against banning e-cigs. Indeed, we went further. We argued we should deliberately seek to make e-cigs widely available, and to use regulation not to ban them but to improve their quality and reliability.”

REX / IMAGE MANIPULATION BY JUSTIN METZ

The market did the rest. Entrepreneurs ranging from nightclub owners to former RAF pilots were already sniffing the opportunity to make and sell the devices. Experimental designs proliferated in Britain as nowhere else. As so often with innovators, all they needed was nobody getting in their way. They knew from the start that their target market was smokers desperate to quit, but who found gums, patches, acupuncture and hectoring did not work very well.

Professor Gerry Stimson of Imperial College, an expert on harm reduction, points out that it’s much easier to persuade people to do something if it is enjoyable rather than a painful chore: “For those trying to stop smoking, ecigarettes have profoundly changed the experience. For the first time, quitting cigarettes is no longer associated with being a ‘patient’ and with personal struggle.”

Sutherland recalls the early days: “I very quickly noticed that vaping could work as a substitute in a way patches didn’t — the throat hit, the trigeminal nerve effect, and so on. Besides, I often hung around in vape shops and could see lines of manual workers — the toughest groups to get to quit — queuing up to ‘try something cherry flavoured with a sub-ohm coil’ or whatever.” That vaping was far cheaper than smoking was a key incentive. Today, Britain has more than twice as high a vaping rate as the rest of the European Union: 5% versus 2%.

The person who deserves the credit for inventing the modern ecigarette, a Chinese scientist named Hon Lik, had come up with the idea specifically to help himself quit smoking after watching his father die of lung cancer. While working as a chemist at the Liaoning University of Traditional Chinese Medicine, he was smoking two packs a day. He tried and failed to quit by himself, then tried nicotine patches in 2001, but hated them.

The idea of electrical or electronic cigarettes had been around for decades: there was a patent in the 1930s, a prototype in the 1960s and a commercial product in the 1980s. But all came to nothing before the miniaturisation of batteries and electronics.

It so happened that Hon was working in a lab with access to liquid nicotine, used to calibrate other products. He had the idea of turning the liquid to vapour using ultrasound, but it did not work well, so he switched to a heating element. By 2003 he had filed a patent on his first practical prototype. “I already knew it would be a revolutionary product,” he laughs when I ask him about it, adding immodestly: “Some in China have called it the fifth invention — after navigation, gunpowder, printing and paper.”

The product went on sale after several months of toxicology testing and soon spread to Europe and America.

Nicotine is a chemical produced by tobacco plants and others in the nightshade family as a defence against pests: it is toxic to insects and other arthropods, and was once used as a pesticide; modern “neonicotinoid” insecticides are close cousins of the chemical. (Sparrows that build their nests out of cigarette butts in Mexico are less troubled by blood-sucking mites, a study has found.) In people, nicotine acts as a stimulant, but also a relaxant, by promoting the release of chemical messengers between brain cells.

True, nicotine is addictive, but so is caffeine, another anti-pest chemical produced by plants that has psychoactive effects, but is ingested by people in a less risky form than smoke. Smoking’s health risk comes not from nicotine, but from the chemicals created in the flame.

So giving smokers nicotine without giving them any smoke just has to be safer. In 2016, a series of key scientific papers from the lab of Dr Grant O’Connell, a scientist working for the ecigarette manufacturer Fontem Ventures, reported that smokers confined in a clinic for five days who switched to ecigarettes got the same amount of nicotine but much less exposure to the harmful toxicants known to cause smoking-associated disease risks, such as nitrosamine and carbon monoxide. After five days, the levels of harmful toxicants measured in their blood and urine was like that of smokers who went cold turkey over the same time. The subjects also had improvements to lung and heart function.

This year the team published one of the first long-term clinical studies, which monitored 209 smokers who used ecigarettes for two years. It found no evidence of any safety concerns or serious health complications in smokers after two years of continual ecigarette use. The studies that tabloid newspapers like to trumpet, about potential risks from vapour, by contrast, are all speculative extrapolations based on unrealistic levels of vapour in unnatural conditions. Even then, the effects are small.

For vaping to be beneficial, it does not have to be harmless. Surveys suggest 98% of vapers are smokers, so even if vaping carries a moderate risk, so long as it is less than the risk of smoking, there will be harm reduction.

In the 1980s, Britain pioneered “harm reduction”. Faced with a growing Aids epidemic among heroin addicts, the health secretary, Norman Fowler, chose a pragmatic rather than moralistic response: setting up needle exchanges and ignoring those who protested that this condoned drug use, undermined calls for abstinence and sent the wrong message to young people. It worked — Aids among injecting drug users slowed down. By 2010, only 1% of British drug injectors had HIV, compared with about 18% in America and 48% in Brazil — countries that were slow to adopt harm reduction.

Fortunately for vaping, some of the people involved in the needles episode found themselves in a key position when ecigarettes came along. Kevin Fenton, Rosanna O’Connor and Martin Dockrell had all worked on Aids or drugs and knew the benefits of harm reduction. They fought within Public Health England, against strong opposition from the chief medical officer and others, to get vaping seen in the same terms. In 2015, they succeeded and PHE came out with its bold statement that “ecigarette use is around 95% less harmful to health than smoking”.

Yet, despite official endorsement and the growing strength of the evidence for vaping’s harm reduction, public opinion has been moving against ecigarettes. More than 25% of people now erroneously believe vaping to be at least as harmful as smoking, up from 7% in 2013, thanks to tabloid headlines claiming as much.

Much of this misinformation came from vested interests. The pharmaceutical industry lobbied hard behind the scenes to defend its lucrative line in medicinal nicotine patches and gums against a new competitor. Both patches and smoking cessation services have lost about half their business since 2011.

As ever with prohibition campaigns, this was a coalition of what the economist Bruce Yandle once called “bootleggers and Baptists”: profiteers and preachers. Much opposition to vaping came, and comes, from puritans horrified at the thought that somebody, somewhere, might be enjoying themselves. If quitting smoking is pleasurable then it must be sinful.

In 2014, at the height of the ebola epidemic, the director-general of the World Health Organisation, Margaret Chan, made it clear that she considered opposing vaping a high priority. The European Commission, egged on by the British government, which had temporarily given in to the nannies, also tried to kill the industry by demanding they be regulated as medicinal products. The European parliament killed the proposal, but agreed to include in the Tobacco Products Directive (TPD) a ban on high-strength eliquids and the advertising of ecigarettes.

This directive, which came into force in 2017, has slowed the growth of vaping in the UK. Strong liquids are the ones heavy smokers need if they are to switch. Not being able to advertise hamstrings the vaping industry’s attempts to reach smokers who have been misled into thinking it’s more harmful than smoking. The tobacco industry is, of course, the devil incarnate for many people working in public health. The industry has joined the harm-reduction bandwagon because it is spooked by the rise of vaping, fearing it might end up being killed by innovation in the same way Kodak was. But this volte-face hardened many in the medical profession against vaping: if big tobacco is into this, it must be bad.

Opponents of vaping still worry it is a gateway into smoking, fearing the young are being lured into nicotine addiction by vaping before moving on to smoking. Clive Bates, a former civil servant and campaigner for progressive causes, lambasts the gateway argument as patronising: “Kids have been weaponised in an activist battle to bend the adult world out of shape where it serves an abstinence-only agenda.”

Bates points out that smoking rates among young people are falling faster since 2010 than they were before, that surveys show the majority of underage vapers are former smokers or would-be smokers, and that young people give harm reduction as their main reason for vaping when asked. As with adults, ecigarettes look as though they are protecting children against smoking much more than luring them into it. In short, the gateway argument just does not hold up.

The argument that vaping cannot yet be proven safe, so must be assumed to be unsafe, is an example of what can go wrong with the “precautionary principle”. If an existing technology is killing people, and a safer alternative comes along to save their lives, then waiting for watertight evidence about the risks of the new technology is effectively culpable homicide. The precautionary principle thus applied holds new technologies to a higher standard than existing ones, stifling beneficial innovation.

There’s also the social-justice impact of vaping. Smoking is now more common among poor people than rich people. Current tobacco-control policies make this regressive impact worse by taxing and stigmatising the poor more than the rich. Vaping offers to reduce the cost of nicotine addiction greatly, helping the poor.

Most premises insist on sending vapers out in the cold to stand shivering among smokers in winter, treating the two groups the same. This, say vaping’s proponents, is madness. It reinforces the false message that vaping is just as harmful as smoking. Further, it actually makes it harder to quit by exposing them to temptation.

One of the advantages of ecigarettes is that you don’t have to finish them. Take one quick puff and put it back in your pocket. With a cigarette, you feel obliged to smoke the whole thing. If a worker has to trek out into the street to vape, he will take more puffs than if he can do it at his desk. And he will waste more of his employer’s time.

It’s actually easy to vape discreetly, with no visible vapour and no smell, so lots of vapers are probably already doing it surreptitiously at work. I neither smoke nor vape, but I have sometimes challenged vaping friends to take a secret puff in the Houses of Parliament; so far they have always got away with it. The “cloud-chaser” vapers who produce huge fogs of vapour are the exceptions, not the rule, though they dominate the pictures in the media. Imagine a firm that said vapers can do it at their desk as long as their neighbours don’t object, or adopted a policy similar to that of using a mobile phone. A smoker working at such a firm would have a big incentive to switch.

The New Nicotine Alliance, which campaigns for nicotine harm-reduction, recently launched a campaign to challenge property owners to drop their policies of treating vapers like smokers. PHE states “that ecigarette use is not covered by smoke-free legislation and should not routinely be included in the requirements of an organisation’s smoke-free policy”, a recommendation routinely ignored by local councils and most businesses.

Britain stumbled into world leadership of the vaping industry. It’s a textbook example of disruptive innovation: a new technology, a decision not to block it, a history of harm reduction, a flowering of experiments, lots of research into the impacts, a lot of lives saved and financial benefits shared between consumers and producers. Plus a sudden acceleration of the race to extinguish for ever a nasty habit. And all at zero cost to the taxpayer. What’s not to like?