PHE: Vaping in England, An Evidence Update (2020)

Summary

“The conclusions of our previous reports are still important messages for preventing harm. These can be broadly summarised as:

1. Vaping regulated nicotine products has a small fraction of the risks of smoking, but this does not mean it is safe.
2. Smokers should be encouraged to try regulated nicotine vaping products along with smoking cessation medications and behavioural support. This will greatly increase their chances of successfully stopping smoking.
3. People who have never smoked should be encouraged not to smoke and not to vape.
4. Vapers should be encouraged to use regulated nicotine products only and stop smoking completely”.

Useful quotations and evidence

PHE restates the clear harm reduction rationale for vaping
“Despite reductions in smoking prevalence, smoking remains the largest single cause of preventable death and disease and a leading cause of health inequalities. Hence, alternative less harmful nicotine delivery devices could play a crucial role in reducing this health burden.”

Vaping does not increase smoking
“The data presented here suggest that vaping has not undermined the declines in adult smoking”.

“Vaping remains most common among smokers and former smokers, with less than 1% of people who have never smoked currently vaping”.

Youth vaping is low and steady in the UK
“No surveys reported much increase in vaping prevalence.”
“Current vaping is mainly concentrated in young people who have experience of smoking. Less than 1% of 11- to 18-year-olds who have never smoked are current vapers”.
“Current vaping prevalence (weekly or less than weekly) among young people in England has remained reasonably steady.”

Youth vaping is not a problem in the UK as in Canada or the US (i.e., vindication of the UK model combining support for THR with appropriate regulation):
Comparisons across countries are hampered by inconsistent questions and survey methods
but one study comparing vaping among 16-19 year olds from 2017-18 using consistent methods found lower levels of vaping in England compared to Canada and the US.

“The Hammond et al study used cross-sectional data from England, Canada and the US between 2017 and 2018 [64]. There were significant increases in vaping (past 30 days, past week and 15+ days in the past month) in Canada and the US between 2017 and 2018, while there were no significant increases in England (in line with evidence presented in this chapter). Of concern, in Canada there was an increase in past week vapers among never smokers. The use of JUUL increased in all 3 countries, particularly the US and Canada”.

Misinformation about vaping undermines public health goals
“Increasingly incorrect perceptions among the public about the harms of vaping could prevent some smokers using vaping products to quit smoking”.

NB: An estimated 34.4% of current smokers in 2019 thought that vaping was less harmful than cigarettes, a figure that has declined since 2014 when 45.2% held this view. The proportion of smokers who thought that smoking and vaping were equally harmful has increased from 26.1% in 2014 to 41.8% in 2019. See also the chart below.

Flavours are important to get smokers to quit, and not the primary driver of youth vaping
“A ban on flavoured liquids could have adverse effects and unintended consequences for smokers using vaping products to quit. It should only be considered with caution”.

“Vapers said that banning flavoured liquids would deter them from using vaping products to help them quit or reduce their smoking. It could also push current vapers towards illicit products.”

Flavours does not appear to be the main driver of youth experimentation in the UK. While cited by 10.4% of never smokers, more important factors were “just to give it a try” (cited by 70.6%) and
“other people use them, so I join in” (by 10.9%).

EVALI
“The spate of lung injuries and deaths in the US is not attributable to the regulated nicotine vaping products currently sold in England”.

“It should be noted that in England THC is prohibited and vitamin E (like other vitamins) is prohibited in regulated nicotine vaping products.”

Vaping is the most effective cessation aid
“As in previous years, data from stop smoking services in England suggest that when a vaping product is used in a quit attempt, either alone or with licensed medication, success rates are comparable to, if not higher than, licensed medication alone.”

NB This quote is quite conservative. The chart below (from page 101 of the PHE report) shows how vaping is more effective than licensed medication, although licensed medication continues to be used in supported quit attempts at publicly funded cessation clinics.

Potential concerns

Increasing use of vaping by never smokers
An increasing proportion of vapers are never-smokers. PHE does not appear unduly concerned about this as the proportion is still relatively small (7.1% in 2019 compared with 5.7% in 2018 based off a small sample size in one data set). PHE notes that an increase in the proportion of vapers who are never smokers also reflects an increasing proportion of never smokers in the general population. PHE adds that more research is needed to understand whether vaping by never smokers is likely to increase population use of nicotine or prevent people from initiating smoking.

Gateway and increased youth experimentation among never smokers
An increasing percentage of young UK vapers are trying vaping without having been smokers first. An increasing percentage are also smoking, having first vaped, which may be used by proponents of the ‘gateway theory’.

Smoked then vaped Vaped then smoked Vaped but never smoked
2014 70 7.5 18.8
2016 44.7 30
2019 47.6 17.8 28.9
See page 48 of the PHE report.

There was also a brief reference to youth smoking increasing in Canada (significantly) and the UK (marginally) whereas the US saw no change:
“There was a significant increase in smoking in Canada, a marginal increase in England in regular smokers (not seen in data reported in this chapter), with no change in the US”.

One comment implies that the UK has made little or no progress in reducing youth smoking since 2014 (despite significant success in reducing adult smoking). Since vaping grew rapidly in the UK since 2012, overseas advocates of gateway theory may argue that youth vaping is undermining UK tobacco control success, particularly with respect to youth smoking rates.

“Current smoking prevalence (weekly or less than weekly) among 11- to 15-year-olds halved between 2009 (11%) and 2018 (5%) but has remained relatively steady since 2014.”

PHE did not have much data to analyse on youth vaping outside the UK and North America:
“For all other countries [except UK and US], there were only 7 studies found that reported vaping prevalence among youth (Table 7). Hammond et al. presented data from Canada and England (as well as the US) [64], 2 studies presented prevalence data for Germany [65, 66], 2 for Mexico [67, 68] and one each for China [69] and South Korea [70]. Current or past 30-day use was highest in 16- to 19-year-olds in Canada at 14.6% in 2018 [64], and lowest in 12- to 17-year-olds in Mexico, at 1.1% in a study using data from 2016”.

Marginalisation of Heated Tobacco
Although PHE is a cheerleader for tobacco harm reduction, it remains firmly sceptical of the tobacco industry’s role in THR. The report is careful to note that two thirds of vape products in the UK are manufactured by independent companies. Also that UK public health policy was “rated as the best at resisting interference from the tobacco industry.”

Ideological opposition to the industry, and sensitivity to criticism of PHE’s position on THR and e-cigarettes is likely to have made it cautious around HTPs. Low uptake of HTPs in the UK allows PHE to ignore the category and focus instead on ecigs (at least for now). In its 2018 review, PHE warned: “with a diverse and mature e-cigarette market in the UK, it is currently not clear whether heated tobacco products provide any advantage as an additional potential harm reduction product”.

Similar reasons probably explain why it also referenced JUUL. As PHE tries to allay fears around vaping and distinguish the US experience, the low uptake of JUUL in the UK reinforces that narrative and the message that youth vaping in the UK is not a major problem.

In its 2020 report, PHE explained:
“use of JUUL and heated tobacco products remains below 1.5% for smokers and recent former smokers; although it is important to note that JUUL has only been available in the UK since July 2018. In the past 12 months of the STS survey just 24 participants out of over 20,000 said they used heated tobacco products which have been available in the UK since late 2016. Similarly, in the ASH-A survey just 0.6% said they used heated tobacco products; and of those who had used heated tobacco products, just 6% used them daily”.

PHE may not be able to ignore the heated tobacco category so easily in its next report in 2021. IQOS has been growing much faster since a price re-positioning in Q3 2019 (just before the report started to be written). Particularly if this leads competitors to enter the market, PHE will need to comment further on the category (just as they began to product annual evidence reviews on ecigs only after the category gained traction in the UK).