The writer is associate professor in cardiometabolic health at the University of Exeter and chairs the BMA Board of Science
Smoking kills. In a world where physicians cannot achieve consensus on other major health threats, this unambiguous fact is something that we can all agree on.
Tobacco use is the biggest cause of preventable disease in the UK and exacerbates the health gap between rich and poor. It damages the blood vessels to increase the risk of coronary heart disease, stroke and dementia, while being responsible for about 70 per cent of lung cancers — as well as cancers of the mouth, throat, oesophagus, bladder, bowel, kidney, liver, stomach and pancreas. Second-hand smoke increases the risk of lung cancer by about 25 per cent, with devastating effects on the health and development of children and a disproportionate impact on the already-deprived.
Helping people stop smoking is one of the most beneficial things we can do and we use any tools that are available. Sitting in my acute stroke clinic, I discuss why people smoke. If it’s the taste, we try gum; for cravings, nicotine patches; and if it is the whole ritual, including the “hit” received from drawing on the cigarette, then vapes (e-cigarettes) are recommended. Vapes are one of the best modern treatments for addiction to cigarettes but in the back of my mind, I do worry that we have no long-term data on e-cigarettes, which were only introduced to the UK market in 2007. Have we transitioned patients from a lifetime exposure to tobacco to a lifetime exposure to a nicotine-delivery method with unknown long-term consequences? Compared with the 5,000 or so chemicals and 70 proven carcinogens in tobacco, however, I am confident that the switch is a positive health move.
But at no point in my stroke clinic have I felt the need to discuss bubblegum-flavoured vapes. No patient recovering from a heart attack has rejected the need to quit smoking until they were offered a cherry-scented quit aid. The colour of the packaging is never the deciding factor in making someone focus on the impact of their habit on their children. Quite the contrary, actually.
An individual who is looking to conquer their smoking addiction for the benefit of their family is unlikely to want their chosen weaning technology to be more attractive to the children than to them. Yet the commercial rather than medical exploitation of vaping has taken us down a peculiar path: these products are now a ubiquitous, damaging mass phenomenon.
There is no reason to produce flavoured vapes with bright packaging designs, unless it is to appeal to children. Highly addictive, nicotine-based products should not be marketed to anyone, let alone the young. In 2020, menthol cigarettes were banned in legislation focused on discouraging young people from smoking. But at that time, it was perfectly legal for companies to offer children free samples of flavoured, single-use vapes to entice them. That these “starter packs” are nicotine-free is little consolation — they can act as a gateway to long-term nicotine use. This week Prime Minister Rishi Sunak announced that loophole would be closed.
My colleagues in public health tell me that young people vaping is one of the biggest threats to future generations. Given the level of marketing and promotion of vapes, it is also one of the most easily addressed. They talk of a rise in 11- to 15-year-olds using e-cigarettes from 6 to 9 per cent over four years, and a doubling in use in those aged 11 to 17 since 2014. The availability of illegal products in the UK is also concerning. Children are being found in possession of illegal vapes, with potentially carcinogenic levels of lead and similar volatile organic compounds.
The £3mn illicit vape enforcement squad is a welcome start to bringing this under control. In-school health programs and stopping free samples for children are welcome but this does not go far enough. The BMA is calling for the same restrictions on packaging as on tobacco products, mandating one colour and font and making it illegal to display products at the point of sale. Flavourings should also be limited, in line with regulations on tobacco products.
E-cigarettes must have proper health warnings. Vaping is not risk free. At the very least, we know nicotine is highly addictive. It has been shown to impair attention, learning, mood and impulse control in children and young adults. Many of the flavourings, while safe for oral consumption, have an unknown impact when inhaled deep into the lungs. Some legal products contain nickel, tin and lead at very small doses: long term, when inhaled, this may be associated with lung disease.
The effects are unknown at this stage. For smokers, encouraging the swap to vaping undoubtedly lowers health risks. But here’s another unambiguous fact: we need to discourage people taking up vapes and completely prevent them being marketed and sold to children.