Cigarettes carry a notorious health risk. Numbers of smokers are dwindling, but is vaping a genuinely safer alternative? Journalist John Windell reports, in the final addiction piece in the series.
In 1974, the proportion of cigarette smokers among the population aged over 16 in the UK was 45.6%: 51.4% of men and 40.7% of women. Fast forward to 2020 and the rate has fallen dramatically to 14.5%: 15.3% for men and 13.7% for women (Office for National Statistics, 2021).
While decades of health education and regulatory control have clearly had a positive effect, the burden of disease caused by smoking remains considerable. In England in 2019/20, an estimated 506,100 hospital admissions were attributed to smoking, and 77,800 deaths were attributed to it in 2019 (NHS Digital, 2020).
The problem with smoking is twofold. The first issue is nicotine, a natural alkaloid found in the leaves of the tobacco plant. It is highly addictive: the body absorbs nicotine so quickly, it provides a more or less instant hit. Reaching the brain in seconds, it stimulates the central nervous system and causes the heart rate and blood pressure to rise. Repeated use quickly leads to tolerance, craving, compulsive use and, if suddenly stopped, withdrawal symptoms. Despite their simple appearance, cigarettes have been carefully engineered to deliver nicotine in the most efficient way possible.
Smoking is linked to cardiovascular disease and lung disease, and is a major risk factor for numerous types of cancer
Nicotine’s effect is so powerful, says Julia Robson, tobacco control programme manager at the Office for Health Improvement and Disparities (OHID), that the signs of withdrawal are never far away. ‘As nicotine levels fall, smokers start to experience irritability, restlessness, lack of concentration, anxiety and craving for a cigarette. Other triggers for “I need a cigarette” include associations of smoking with the time of day, being with other smokers, alcohol or stress. As that next cigarette is smoked and the nicotine hits the brain and causes all those synapses to fire off and release dopamine, which relieves the withdrawal symptoms, the overriding feeling is “Oh, that feels better.” Smokers then mistakenly associate smoking with feeling calmer, more focused and less anxious.’
Unless taken in huge quantities, nicotine is, in itself, not especially dangerous to human health. But its addictive properties keep people lighting up the next cigarette and the next, which is where the second, much bigger problem lies: the act of burning tobacco and drawing the smoke into the lungs delivers not just the nicotine but also a thick stew of hundreds of dangerous chemicals in the form of gases and particulates. Just a few of these chemicals are ammonia, arsenic, benzene, beryllium, butadiene, cadmium, formaldehyde, hydrogen cyanide, and even the radioactive element polonium-210. Also among them is carbon monoxide, which depletes the ability of the blood to carry oxygen.
Many of these chemicals are deposited in the thick, sticky brown substance called tar, which stains the fingers and teeth and collects in the lungs. Collectively, the tar and other toxins delivered by cigarettes threaten the health of the whole body: smoking is linked to cardiovascular disease and lung disease such as emphysema and chronic obstructive pulmonary disease, and is a major risk factor for numerous types of cancer.
The smoke that goes directly into the smoker’s lungs – the mainstream smoke – is not the only threat. The sidestream smoke, which is the smoke from the burning tip of the cigarette, actually has higher concentrations of toxins. Most of the smoke in a room will consist of this sidestream smoke, which is why secondhand smoke is such a threat to anybody who finds themselves in an enclosed area with smokers.
An addiction to smoking is more than a matter of just nicotine, says Julia. ‘Most smokers pick up their first cigarette as teenagers and are in a smoking community. Their parents and friends are more likely to be smokers. Even today, with all the decreases we’ve had in prevalence, they are still likely to be in a household where it is the social norm.’ Another factor is the physical ritual of smoking, the tactile sensation of the hand-to-mouth motion to the long exhalation of smoke, along with the associated paraphernalia of lighters, rolling papers, ashtrays and so on.
Vaping lends itself easily to these factors, which might be one reason it has become such a popular alternative to cigarettes. Of course, the big appeal of the e-cigarette is that it delivers the nicotine hit without the health risk of the traditional tobacco cigarette. For Hazel Cheeseman, deputy chief executive of the charity Action on Smoking and Health (ASH), the benefits of vaping are evident: ‘They are plainly popular, they are plainly effective, they’re helping people stop smoking and they are much less harmful than continuing to smoke.’
For some, vaping is more than an alternative to smoking – it’s a way of quitting nicotine for good. ‘Many people absolutely do wean themselves off nicotine, tobacco and then the vaping device, but its key role is harm reduction,’ says Julia. ‘Within the first 24 hours of vaping, a smoker is going to feel the health benefits to their health because of the far lower exposure to the toxins found in cigarettes.’
Even so, vaping is just one potential route out of smoking, says Hazel. ‘The typical smoking cessation programme tends to last 12 weeks, and medication such as nicotine replacement therapy might be part of that. Some services also provide access to e-cigarettes alongside or instead of medication. Some people will just use medication or an e-cigarette for a short, intensive period. Other people may well use e-cigarettes or indeed nicotine replacement therapy for the rest of their lives.’ The crucial point is that they don’t go back to smoking tobacco.
The World Health Organization is less convinced about vaping and e-cigarettes, saying: ‘It is too early to provide a clear answer on the long-term impact of using them or being exposed to them’ (WHO, 2022). The main concern is that young people in particular are vulnerable to the addictive effects of vaping nicotine, and that it still carries some risk of heart disease and lung disorders. But evidence is mostly limited to short- and medium-term effects and studies assessing longer-term use are needed (OHID, 2022).
In September, OHID published its latest research on the health harm of vaping. Its headline findings were that ‘in the short and medium term, vaping poses a small fraction of the risks of smoking’, but that ‘vaping is not risk-free, particularly for people who have never smoked’ (OHID, 2022).
ASH has found that while 15.8% of 11- to 17-year-olds in Britain had tried vaping in 2022 (up from 13.9% in 2020) and 7% were current users (up from 4.1% in 2020), a substantial majority (83.8%) had either never tried or were unaware of e-cigarettes. ‘Use among never smokers remains low and mostly experimental,’ it says (ASH, 2022a).
It is suggested that much of the increase in experimental vaping among the young is explained by the availability of disposable vaping products, which are cheaper, easier to try, and highly visible on social media. While vaping is a valid route out of smoking, nobody wants it to become a route in for young people, says Hazel. ‘We don’t have a great deal of evidence to suggest that it is a gateway into smoking. While we are seeing an increased use of vaping products, there is a declining use in cigarettes. That’s got to be good. But we do need to keep a lid on those vaping products.’
ASH insists that the government needs to use existing retail laws and commit resources to enforce them. How vaping products are packaged and promoted may also need further regulation.
What key actions can community practitioners take to help smokers who might want to quit?
The first step, says Julia, is to have the right training. ‘That means accessing the NCSCT [National Centre for Smoking Cessation and Training] website and training resources, such as the Very Brief Advice [VBA] module, which focuses on the technique of Ask, Advise, Act.’
The aim of this ‘three As’ approach is to get the message across in an empowering way and to open the door to support and treatment. ‘Then the task is to link that person into a quit smoking pathway, which means you need to know the services in your local area. Talk to your local smoking cessation leadership. Also be mindful that smoking is often a very social experience or a lifestyle choice for many smokers, and that it may have become a learned coping mechanism for stress or mental ill health. But if we don’t start by always asking the questions “Are you a smoker?” and “Do you know that the best way to quit is with support?”, we’re never going to get any further in helping people access effective support to quit smoking for good.’
‘be mindful that smoking is often a very social experience or a lifestyle choice, and may have become a learned coping mechanism’
Hazel agrees that the VBA training is crucial: ‘It’s written specially for primary care.’ She adds that the proven method to help people quit is a combination of behavioural support and medication or an e-cigarette. ‘For this, stop smoking services are the gold standard. But they are not available in every community in the way that they used to be. However, they are especially good for people who are highly addicted and face barriers to stopping, which tends to be the more disadvantaged groups, such as those on low incomes or with mental health conditions. If you can help them get into those services, that’s their best chance of success.’
For Hazel, signposting people to the appropriate support and offering to refer them is a vital step towards encouraging them to stop. ‘But if that support is not widely available in your area, direct people to other effective ways of stopping, such as nicotine replacement therapy that is available over the counter, or visiting the local vape shop, or downloading the Smoke Free app to a smartphone. It is always better to tell people how to quit, not just that they should.’
- The online quit smoking information from the NHS includes links to services in Scotland, Wales and Northern Ireland nhs.uk/live-well/quit-smoking/ NHS stop smoking
- The ASH website has a wealth of detail, including factsheets, webinars, local data and information on law and policy ash.org.uk
- The charity Quit also offer resources via its website quit.org.uk, and operates the Quitline on 0800 00 22 00
- The full range of NCSCT training and other resources can be found at ncsct.co.uk
- The Smoke Free app can be downloaded from the Apple App Store or Google Play. For more on how it works, see smokefreeapp.com
Action on Smoking and Health (ASH). (2022a) Use of e-cigarettes (vapes) among young people in Great Britain. See: ash.org.uk/uploads/Use-of-e-cigarettes-among-young-people-in-Great-Britain-2022.pdf?v=1661866458 (accessed 14 November 2022).
Action on Smoking and Health (ASH). (2022b) Smoking costs society £17bn – £5bn more than previously estimated. See: ash.org.uk/media-centre/news/press-releases/smoking-costs-society-17bn-5bn-more-than-previously-estimated (accessed 14 November 2022).
Cancer Research UK. (2021) Is vaping harmful? See:
cancerresearchuk.org/about-cancer/causes-of-cancer/smoking-and-cancer/is-vaping-harmful (accessed 14 November 2022).
NHS Digital. (2020) Statistics on smoking, England 2020. See: digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2020 (accessed 14 November 2022).
Office for Health Improvement and Disparities. (2022) Nicotine vaping in England: 2022 evidence update. See:
gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update (accessed 14 November 2022).
ONS. (2021) Adult smoking habits in Great Britain. See: ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/datasets/adultsmokinghabitsingreatbritain (accessed 14 November 2022).
Public Health England. (2017) Cost of smoking to the NHS in England: 2015. See:
gov.uk/government/publications/cost-of-smoking-to-the-nhs-in-england-2015/cost-of-smoking-to-the-nhs-in-england-2015 (accessed 14 November 2022).
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