Vaping, smoking, and children

Tobacco smoking causes cancers and a whole range of life-limiting diseases. The active ingredient of tobacco, nicotine [1], is one of the most addictive substances known.

As well as denying or suppressing the evidence of smoking harm, tobacco companies have also researched safer ways to deliver nicotine. The problems with smoking are mainly tar, nicotine and carbon monoxide (CO). The invention 20 years ago of the e-cigarette enabled nicotine to be delivered without the tar and CO.

In order to deliver nicotine efficiently into the user’s bloodstream (and thence to the brain), e-cigarettes vaporise a solution of nicotine with a battery-powered heater; the vapour is then inhaled (hence “vaping”). Nothing is burnt, so there is no tar or CO. Solutions may be pleasantly flavoured, appealing to children. It is beyond doubt that vaping is far less harmful than smoking. But...

How does nicotine hook people?

Nicotine is quickly absorbed into the bloodstream, rapidly reaching the brain. Here it mimics a natural neurotransmitter, triggering nerve impulses which release dopamine, associated with feelings of pleasure and reward (and loss of appetite). This reinforces the behaviour supplying the nicotine but people don’t keep using nicotine merely because it makes them feel good. With continued use, tolerance develops (where more and more is needed to produce the same effect) and addiction.

Withdrawal symptoms include intense cravings, irritability, negative mood changes, restlessness, difficulty concentrating or sleeping, and weight gain; some may also experience headaches, coughing, constipation, mood swings, or flu symptoms.

These make it extremely difficult to give up smoking, with fewer than 10% succeeding each year. One study estimates a typical 30 attempts to quit before success. There is some evidence that counselling or giving people money increases rates of cessation.

Some people use nicotine replacement therapy (NRT), patches or gums, but success rates are still low. These are less addictive, however, perhaps because the nicotine reaches the brain more gradually (i.e. there is no nicotine “hit”). Of course, they do not deliver the carcinogens found in cigarette smoke.

Vaping reduces the intake of carcinogens while delivering the nicotine hit as fast as cigarettes. Their use in attempts to stop smoking seem more successful than NRT or simply trying to stop completely. A recent Cochrane review (the gold standard for evidence-based medicine) found that e-cigarettes helped about 10% of people stop smoking for at least 6 months, compared with 6% using NRT or 4% with no support.

Safety of vaping

Vaping is substantially safer than smoking, even if only to satisfy nicotine addiction. About 7% of the UK adult population use e-cigarettes. Of these, the vast majority are ex-smokers, though some continue to smoke (presumably to a lesser extent). A tiny proportion of adult vapers have never smoked. Given that well over half of smokers die of smoking-related conditions, a substantial reduction in harm comes with substituting vaping for smoking, estimated by Public Health England at 95%.

However, nicotine itself contributes to heart disease and raising blood pressure, a contributory factor to stroke. Furthermore, the solution contains propylene glycol, glycerine and additives. While much less harmful than cigarette smoke (and used in foodstuffs), the long-term effects of inhaling these are unknown. Heat is needed to vaporise these chemicals and can cause breakdown products to form, again with uncertain effects. Many other additives may be used in vaping solutions, some of which have been linked to lung disease and deaths.

More worrying is the uptake of vaping among young people. It seems that, while 6% of 11-18 year olds were smokers in 2022, some 9% were vaping, with estimates as high as 18% for 15 year-olds. These are similar to the percentage of UK adults currently smoking and/or vaping (13%), suggesting that new nicotine addicts will be recruited to the adult population, even if some are using less harmful e-cigarettes.

Young people below 18 have been legally unable to purchase or consume tobacco products since 2007, including e-cigarettes, but this has never stopped youngsters obtaining them. The difference is that vapes are often marketed to be attractive to youngsters and do not produce the tell-tale reek of smoke in the air or on clothing or skin. Advertising emphasises bright colours with fruit flavours.

Disposable vapes are available for as little as £2 each, comparable to the price of three cigarettes, while supplying up to 600 puffs. Inevitably, some young vapers will become addicted to nicotine, an addiction which is very difficult to break.

Some vapes are nicotine-free, with no risk of addiction, but some vapes marketed as “nicotine-free” actually do contain nicotine, so the product analysis company Inter Scientific reported recently, the highest concentration being 50% higher than the legal limit for nicotine vapes! Trading standards experts report up to a third of vapes sold on high streets being illegal in size or nicotine content.

Age should be verified by retailers if purchasers look younger than 25, but test purchases by the compliance auditing service ServeLegal have shown that this is not done in a quarter of cases.

The government proposes to encourage adult smokers to quit by providing free vape starter kits to about one in five, together with behavioural support. In addition, they will encourage pregnant smokers to quit using financial incentives. Given that up to two in three lifelong smokers die prematurely from smoking and a quarter of cancer deaths are due to smoking, these are worthwhile interventions. They are also proposing a crack-down on vape sales to children through a “vape squad”, though it is not clear how far the promised budget will go.

Studies from two years ago showed that vapes with plain packaging are less attractive to youngsters than branded ones, but the government is merely proposing to consult on whether it should go further to reduce youth vaping. Tobacco companies have never voluntarily taken action to prevent harm from their products and there is no reason to expect vape companies to act differently.

[1] Nicotine is an insecticide produced by the nightshade family, including tobacco, so its effect on humans is purely accidental.