As conversations around Tobacco Harm Reduction (THR) ensue, there seems to be little or no consensus between public health and THR advocates on the adoption of nicotine products as alternatives to smoking combustible cigarettes. A few days ago, the World Health Organisation (WHO) launched the "Stop the lies" campaign, an initiative WHO believes will protect young people from the tobacco industry's interference in health policy as well as protect them from what they termed “Deadly Products,” in the form of novel nicotine products.

Data shows that young people who vape are more likely to smoke largely due to low and incorrect risk perception, whereby young people perceive smoking to be equivalent to vaping. In the United Kingdom (UK), scientific evidence shows that the number of youths who Vape or use e-cigarettes has been increasing over the years while that of smoking combustible cigarettes has been fluctuating as youths switch between vaping and smoking cigarettes.

Current data on youth vaping and smoking from the Action Smoking and Health GB adult and youth surveys 2013-2023 show that the use of e-cigarettes has been steadily increasing between 2013 (0.8 percent) and 2019 (4.4 percent) before taking a dip in 2020 (4.1 per cent) and 2021 (3.0 percent). However, there was a sharp increase in the uptake of e-cigarettes in 2022 (6.9 percent) and 2023 (7.9 percent). On the other hand, cigarette smoking has been fluctuating albeit exhibiting a declining trend. In 2013, the use of cigarettes was 6.0 percent and dropped to 4.7 percent in 2014 only to rise again in 2015 to 5.5 percent. In 2014, it dropped to 3.8 percent and rose to 5.6 percent in 2015. Currently, cigarette smoking among youths stands at 3.6 percent at the back of an increase in vaping among youths in the UK.

The debate around youth vaping dominated the just-ended E-Cigarette Summit in England recently. Giving her Opening Keynote at the E-Cigarette Summit, Professor Caitlin Notley, Professor of Addiction Sciences, at Norwich Medical School, University of East Anglia (UEA) said youths have a low-risk perception of smoking.

“So what’s the real problem that we are facing in the United Kingdom at the moment? I would suggest that it is less about the quantity or what young people do in their vaping and it is more about the issue that young people seem to be smoking and vaping interchangeably which of course is concerning for health outcomes. Young people have incorrect risk perceptions, they are seeing tobacco smoking as equivalent to vaping and that is consequential for their behaviour,” said Professor Notley.

She added that the media focus on vaping at the expense of the harm caused by smoking could be influencing young people's understanding and could trigger an upsurge in black-market vaping and tobacco smoking.

“I have heard of young people who start smoking at about 13 but I never hear about that in the media. Young people smoke too but that is never talked about to the extent vaping is being talked about. It is clear that a ban on disposables will also be consequential for black market vaping and potentially tobacco smoking.”

She said the media has created a moral panic and has been blaming young people for engaging in vaping behaviour.

Prof Sanjay Agrawal, Special Advisor for Tobacco - Royal College of Physicians Consultant in Respiratory & Intensive Care Medicine said the low and incorrect risk perception was prevalent in both adults and young people as most still believe e-cigarettes and tobacco cigarettes are the same.

“A study on public perception of e-cigarettes shows that a lot of adults think that e-cigarettes are more or equally harmful than cigarettes. This is similar to children and young people, they tend to do it anywhere but with adults, this means most of them will be put off from trying to quit smoking using vaping. It is a real problem and the way it’s reported in the media is problematic,” said Prof Agrawal.

According to the ASH Smoke-Free GB Adult Surveys 2014-2023, 39 percent believe that e-cigarettes are a lot more or equally harmful than cigarettes. While in 2014, 60 percent believed that e-cigarettes were less harmful than cigarettes, the number has since plummeted to 34 percent.

Professor Agrawal added that the multi-faceted nature of tobacco control and harm reduction, made more complex by industry, media and public opinion requires constant re-evaluation to consider policy options to improve public health.

Dr Jamie Hartmann-Boyce, Assistant Professor in Health Promotion and Policy at the University of Massachusetts Amherst said, though data consistently shows that young people who vape are more likely to smoke, it is highly contested as to whether this is a causal relationship.

“Public health practitioners and policymakers have a particular interest in what happens at the population level. If, overall, vaping is contributing to more people starting to smoke than would have otherwise, then the net public health effect of vaping is going to be negative,” said Dr Hartmann-Boyce.

She added that they are also (or should be) interested in whether patterns differ based on socially stratifying characteristics, smoking rates differ by groups, and this is a leading driver of health inequalities – ‘net’ effects can sometimes mask important differences.

Meanwhile, it presents whether vaping is an effective and safe aid for quitting smoking. Professor Peter Hajek said while the general public perception is that vaping and smoking are one and the same, data shows that e-cigarettes are an effective smoking cessation tool.

“There is about a 60 percent higher chance of quitting with e-cigarettes compared with Nicotine Replacement Therapy (NRT). E-cigarettes are effective in helping smokers quit and they are more effective than NRT products such as patches, inhalers or their combination,” said Pro Hajek.

In one study, 80 percent of successful quitters were vaping for one year (although a third of them were using nicotine-free e-cigarettes). He added that some smokers can derive benefits or enjoyment from continuing use, and it may help in preventing relapse to smoking though clear evidence on this is lacking.

In terms of adverse effects, data shows that reported effects often with nicotine e-cigarettes were throat or mouth irritation, headache, cough and nausea. These effects reduced over time as people continued use. There is currently no clear evidence of harm, but the longest follow-up was two years