Australian Health Minister Mark Butler has a major policy change in vaping. The two main goals are to make it more difficult for children and non-smokers to access vapes and to give people trying to quit smoking access to nicotine vapes with a prescription.
Vaping is undeniably popular, and many who vape say they are trying to quit smoking or cut down on cigarettes. “Recreational” vapers of any age who are not interested in quitting will find themselves left out.
But can vaping really help large numbers of people quit smoking? The evidence suggests it’s unlikely.
Read more: A canned history of smoking, and how we make the same mistakes with vaping
Myth of the ‘hardened smokers’
First, let’s bust a commonly held myth. With smoking at one all time lowsome experts argue that today’s smokers are the seasoned addicts: often relapsing smokers who just can’t quit.
Whenever this hypothesis has been tested, it has been found wanting. In countries where the prevalence of smoking has fallen the most, we would expect (if the hypothesis were true) that indicators of longevity smokers (such as the average number of cigarettes smoked per day) would increase because the remaining smokers would be over-represented by heavy, addicted smokers.
But according to a 2020 review of 26 studies:
Some have argued that more emphasis should be placed on harm reduction or intensive treatment approaches, as persistent smokers are the ones less likely to quit with current methods. This review finds little or no evidence for this assumption.
In other words, there is no evidence that long-term smokers are impervious to the array of tobacco control policies and campaigns that have driven hundreds of millions of smokers around the world to quit.
Vapes don’t help smokers smoke less
The idea that vaping helps people smoke fewer cigarettes is not supported by the evidence. Studies of the number of cigarettes missed by vapers who still smoke have shown that, compared to smokers who never vape, average daily cigarette consumption is very similar.
2019 data from the UK Government’s annual report Opinion and lifestyle survey Also show the average number of cigarettes smoked daily by vaping smokers (8 per day) is very similar to that of never smokers (8.1 per day).
A paper from 2018 considered the increase in e-cigarette use in England and whether this reduced the number of cigarettes smoked at a population level across the country. The authors concluded:
No statistically significant associations were found between changes in e-cigarette use (…) during smoking and daily cigarette consumption. We also found no clear evidence for an association between e-cigarette use (…) specifically for reducing smoking and temporary abstinence, respectively, and changes in daily cigarette consumption.
If e-cigarette use (…) while smoking reduced cigarette consumption in England between 2006 and 2016, the effect at the population level was probably very small.
How effective are vaping at quitting?
The most recent Cochrane review of randomized controlled trials compared vaping to nicotine replacement therapy (such as drugs, gums and patches). It found about 82% of people who vape are still smoking when followed up six or more months later.
This was better than those using nicotine replacement therapy: 90% were still smoking.
Neither nicotine replacement therapy nor vaping are hugely disruptive to smoking. You certainly wouldn’t feel confident using a drug for a health problem with an 82-90% failure rate.
Read more: Drugs, gums or patches won’t increase your chances of quitting
Randomized controlled trials also poorly reflect how vaping and nicotine replacement therapy are used in the real world and are not representative of all smokers who want to quit.
a judgement 54 randomized controlled trials of smoking cessation, for example, found that two-thirds of smokers with nicotine dependence would have been excluded from clinical trials on at least one criterion. This may lead to participation bias, making the results less applicable to smokers in general, or even to smokers in general who want to quit.
This and other factorsmake randomized controlled trials likely to overestimate effectiveness, as I outline in chapter two of my book.
What does the real world evidence show?
The best evidence we have on how vapes perform comes from studies that track large numbers of vapers over several years. The US Population Assessment of Tobacco and Health (PATH) projectfor example, has been collecting national cohort data on 46,000 Americans since 2013.
As the PATH data shown below, when randomly selected groups of vapers are followed after 12 months, the most common outcome is that those who smoked and vaped at the start of the study period were still vaping and smoking at the end of the 12 months.
I have summarized 16 more assessments and conclusions of the expert group of evidence published since 2017. Words like “low quality”, “inconclusive”, “inadequate”, “weak”, “low level” and “limited” abound.
Probably the main effect of access to prescription vapes is that it will greatly reduce children’s access to vapes. State governments will hit retailers who sell illegally with huge fines and Border Security will do the same with importing suppliers.
Taiwan imposes fines on sellers of up to US$1.65 million, with a minimum of US$330,000. The current maximum fine in New South Wales is currently just A$1,600. Such a fine would hardly cause a stir in the small cash drawers of large retailers.
Based on the research, we could expect 10-18% of vapers using the prescription to quit within 12 months (with some relapse expected), but many more will stop without help.
Preventing new generations of children from becoming addicted to nicotine and smoking more quickly is a huge policy advance that is very welcome.
Read more: Vaping and behavior in schools: what does the research teach us?