Has the UK's anti-smoking efforts reached its peak?

When is a cigarette company not a cigarette company? When it stops selling cigarettes, and starts selling nicotine. Many people mistakenly view the two as the same thing, they are not. The overwhelming harm from smoking comes from the cocktail of more than 4,000 chemicals released from the combustion of tobacco, many of which are poisonous, and more than 70 of which may cause cancer. While nicotine is an addictive drug, a 2016 Royal College of Physicians (RCP) report found “nicotine alone in the doses used by smokers represents little if any hazard to the user”. It is the tobacco smoke not the nicotine that does the damage.

The UK has some of the world’s most stringent anti-smoking policies, and the results in getting smokers to stub out the cigarette is something to be proud of – going from 45 per cent of the population who smoked in the 1970s to 15.5 per cent by 2015. However, smoking is still the primary cause of preventable illness and death. The NHS points to 474,000 hospital admissions and 79,000 deaths per year attributable to smoking.

Smokers under the age of 40 have a five times greater risk of a heart attack than non-smokers. Smoking causes about 80 per cent of deaths from lung cancer, around 80 per cent of deaths from bronchitis and emphysema, and about 14 per cent of deaths from heart disease. More than one quarter of all cancer deaths can be attributed to smoking. Smoking causes stroke, diabetes and chronic obstructive pulmonary disease. About half of all life-long smokers will die prematurely. On average, cigarette smokers die 10 years younger than non-smokers.

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Have government policies, taxation and health campaigns, designed to encourage smokers to give up reached their peak? Despite tremendous gains the rate of smokers quitting has slowed in recent years. The vast majority of smokers know that smoking is bad for health but the UK still has 9.1 million adult smokers.

Giving people more health information to encourage them to make better health choices has limits in effectiveness. Taxation and banning from the public sphere also has its limits. There is still a sizeable portion of the population who continue to smoke, regardless of regulation or public education campaigns – it is unreasonable and naive to assume that policy can make everyone quit smoking. Many don’t want to stop; some do, but can’t.

Worldwide there are one billion smokers. Tobacco use causes nearly seven million deaths per year. This is a global challenge, so it’s necessary to be pragmatic and come up with fresh ideas. “Reduction of harm” is the second wave of combatting the scourge of tobacco. This may mean having to have uncomfortable “alliances” as a means to an end, with improved health outcomes for hundreds of millions as the prize.

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In recent years there has been a breakthrough in technology where nicotine, which doesn’t kill, can be delivered separately from the tar and chemicals, which do. Electronic cigarettes (e-cigarettes) or “vapourisers” were first released to the market in about 2007, they are handheld battery-operated devices that deliver nicotine-containing vapour. They generally consist of a cartridge containing liquid nicotine (eliquid) of varying concentrations, an atomiser and heating device, and a mouthpiece. E-cigarettes contain no tobacco. The year 2012 saw the first involvement of the tobacco industry in the sales of vapour products. Since then, all the Big Tobacco companies have introduced e-cigarettes of their own, now accounting for about half of the global vapour products market.

The charity, Action on Smoking and Health (ASH) estimate that 2.9 million adults in the UK use e-cigarettes, up from 700,000 in 2012. More than half (52 per cent) e-cigarette users are ex-smokers and 45 per cent are still smokers. The main reason given by ex-smokers who are currently vaping is to help them stop smoking, while for current smokers the main reason is to reduce the amount they smoke. ASH advise, “that potential health benefits of e-cigarettes as a means of helping smokers to cut down and quit smoking are significant. Therefore, it is not only appropriate, but indeed essential for health campaigns and local stop-smoking services to develop messaging helping people make the switch from tobacco to e-cigarette use, including by making reference to the devices themselves and providing factual information about them.”

Public Health England (PHE) confirm that e-cigarettes are 95 per cent less harmful to health than normal cigarettes, and when supported by a smoking cessation service, help most smokers to quit tobacco altogether. This is endorsed by Cancer Research UK and the British Medical Association. In reference to a 2016 report by the RCP, Professor John Britton, chair of the RCP’s Tobacco Advisory Group, stated: “This report lays to rest almost all of the concerns over these products, and concludes that, with sensible regulation, electronic cigarettes have the potential to make a major contribution towards preventing the premature death, disease and social inequalities in health that smoking currently causes in the UK. Smokers should be reassured that these products can help them quit all tobacco use forever.”

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The harm reduction approach works, but it needs to go further. ASH believes the numbers of smokers who are swapping to e-cigarettes is slowing, and that not enough smokers are aware that vaping is less harmful than smoking. There is a need for clear and balanced information on the relative harm of e-cigarettes and cigarettes. Is it time to allow limited advertising or information awareness to help smokers make the switch?

Many organisations and individuals who have over the years campaigned fiercely against Big Tobacco are against the idea of “promoting” e-cigarettes for it seems, two reasons: firstly, they conflate vaping with smoking. Secondly, they don’t trust Big Tobacco and regard their conversion to e-cigarettes as a cynical attempt at PR.

The first reason is incorrect – vaping is not smoking tobacco. The second reason is not unjustified considering the deceitful history of the cigarette industry.

In a seemingly remarkable shift, Philip Morris International (PMI) the cigarette and tobacco manufacturing company, and owners of the Marlboro brand, has announced its intention to transition its resources from cigarettes to smoke-free alternatives, and to switch its adult smokers to these alternatives as quickly as possible around the world. Is it possible that a cigarette company intends to stop selling cigarettes? Sceptics argue that this is a ploy by PMI to expand its vaping market while still retaining its global cigarette market. Is it? Has PMI developed a conscience? Or does it realise that it’s no longer sustainable to base its profits on such a vilified product? The future for tobacco is not going to get any easier. Countries and markets that have less regulation than the UK will likely get tougher. Perhaps PMI is being pragmatic in its drive to deliver nicotine without the harm of tobacco combustion? If it really is transitioning away from cigarettes this is a major positive development regardless of the reasons.

In order to help people understand the benefits of harm reduction, further evidence-based research is needed, but there is a void in the research due to a lack of funding. This is where the “Foundation for a Smoke Free World” may have a significant role to play. Set up in September last year, the foundation’s goals are to accelerate global efforts to reduce health impacts and deaths from smoking, with the ultimate goal of eliminating smoking worldwide. It argues that knowledge gaps are impeding progress in research – more needs to be done to assess the effectiveness of the approaches to smoking harm reduction. The foundation has the money to make a huge impact in this area, but this is where it comes under criticism – it is receiving funding of $80m (£56) a year for the next twelve years, from PMI.

Smoke-Free World is headed by Dr Derek Yach, formerly a director of the World Health Organisation (WHO). According to the foundation, “the grant terms, bylaws, and non-profit status of the Foundation preclude PMI or other tobacco industry representatives from involvement in Foundation governance, or from having any influence over the Foundation’s funding decisions, strategy, or activities.”

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The cynics and sceptics are obviously having a field day, but are they letting their dogma get in the way of progress? During his tenure at WHO, Yach served as cabinet director under director-deneral Gro Harlem Brundtland, where he led the development of WHO’s Framework Convention on Tobacco Control and the Global Strategy on Diet and Physical Activity. Yach has been a passionate health advocate and campaigner for many years, he argues that to progress it is necessary to consider all approaches. Over 12 years the foundation will have almost $1bn to contribute to the advancement of smoking cessation and reduction of harm. If Smoke-Free World proves to be independent and transparent in its activities and research recommendations, it sounds like an opportunity too important to be missed because of entrenched dogma.

Smokers need help and information to encourage them to transition to a product that does 95 per cent less harm. More research needs to be done to assess the long-term safety of e-cigarettes and related products, to ensure that one type of harm isn’t simply being replaced by another type of harm. However, research so far is encouraging. Some smokers want to give up; the UK’s major health bodies agree that e-cigarettes are proven to be more effective at helping smokers quit tobacco than other smoking cessation aids. We should acknowledge that many smokers don’t want to give up. As part of a proactive campaign encouraging this cohort to transition to vaping products, we should make a regulatory distinction between e-cigarettes and cigarettes, so that further strides can be made in reducing those 79,000 deaths every year in the UK. Globally, the health of one billion lives is at stake.