E-cigarettes and harm reduction
How the UK held off regulation that could have killed a life-saving technology.
Britain is the world leader in vaping with more consumption of e-cigarettes than in the rest of Europe. There's a thriving sector of vape manufacturers, retailers, exporters, even researchers; 1,700 independent vape shops on Britain's streets. It's an entrepreneurial phenomenon and a billion-pound industry.
The British vaping revolution dismays people who perceive it as a return to social acceptability for something that's similar to smoking but with unknown risks. Yet here the government disagrees. Public Health England says that vaping is 95 per cent safer than smoking and the majority of people who vape are smokers who are quitting cigarettes. The Royal College of Physicians agrees: "The public can be reassured that e-cigarettes are much safer than smoking."
Doctors are now recommending vaping as a way to quit smoking. It is because of vaping that Britain now has the second lowest percentage of people who smoke in the European Union. The youth smoking rate in the UK has fallen from 26 per cent to 19 per cent in only six years. How did Britain manage that?
It is partly the fault of the advertising executive Rory Sutherland — he is the Walter Raleigh of this revolution. In 2010, he walked into an office to see an old friend David Halpern, head of David Cameron's 'Behavioural Insights Team' (unofficially called nudge team). Sutherland pulled out an e-cigarette he had bought online and inhaled. By then, several countries including Australia, Brazil, and Saudi Arabia had already banned the sale of e-cigarettes — pertaining to tobacco interests or public-health pressure groups.
Halpern took notice of the opportunity. He knew the theory of harm reduction — that it is more effective to give somebody the lesser of two evils than insist unrealistically on immediate abstinence. Hence, he asked his nudge team to start digging so when public-health nannies started calling for them to be banned, Halpern made sure the government resisted.
In his book Inside the Nudge Unit, Halpern wrote: "We looked hard at the evidence and made a call: we minuted the PM and urged that the UK should move against banning e-cigs. Indeed, we went further. We argued on how we should deliberately seek to make e-cigs widely available and to use regulation to improve their quality and reliability."
The market did the rest. Entrepreneurs ranging from nightclub owners to former Royal Air Force pilots were already sniffing the opportunity to make and sell the devices. Experimental designs proliferated in Britain as nowhere else. As so often with innovators, all they required was nobody getting in their way. They knew from the start that their target market was smokers desperate to quit but who found gums, patches, acupuncture, and hectoring useless.
Professor Gerry Stimson of Imperial College, an expert on harm reduction, points out that it's much easier to persuade people to do something if it is enjoyable rather than a painful chore: "For those trying to stop smoking, e-cigarettes have profoundly changed the experience. For the first time, quitting cigarettes is no longer associated with patience and personal struggle."
Sutherland recalls the early days how he very quickly noticed that vaping could work as a substitute in a way patches didn't — the throat hit, the trigeminal nerve effect, and so on. Besides, he often hung around in vape shops and could see lines of manual workers — the toughest groups to get to quit — queuing up to 'try something cherry flavoured with a sub-ohm coil' or whatever." One of the advantages of e-cigarettes is that you don't have to finish them. Take one quick puff and put it back in your pocket. With a cigarette, you feel obliged to smoke the whole thing. Today, Britain has more than twice as high a vaping rate as the rest of the European Union: 5 per cent versus 2 per cent.
The credit for inventing the modern e-cigarette goes to a Chinese scientist named Hon Lik. He had come up with the idea specifically to help himself quit smoking. While working as a chemist at a University, he was smoking two packs a day. He tried and failed to quit by himself, tried nicotine patches in 2001, but hated them.
The idea of electronic cigarettes had been around for decades: there was a patent in the 1930s, a prototype in the 1960s, and a commercial product in the 1980s. But all came to nothing before the miniaturisation of batteries and electronics. It so happened that Hon was working in a lab with access to liquid nicotine, used to calibrate other products. He had the idea of turning the liquid to vapour using ultrasound, but it did not work well, so he switched to a heating element. By 2003 he had filed a patent on his first practical prototype. "I already knew it would be a revolutionary product," he laughed when asked about it, adding immodestly: "Some in China have called it the fifth invention — after navigation, gunpowder, printing, and paper." The product went on sale after several months of toxicology testing and soon spread to Europe and America.
Nicotine is a chemical produced by tobacco plants and others in the nightshade family as a defence against pests. In people, nicotine acts as a stimulant, but also a relaxant by promoting the release of chemical messengers between brain cells. It is addictive just like caffeine. Smoking's health risk does not come from nicotine, but from the chemicals emitted during combustion. So giving smokers nicotine without giving them any smoke just has to be safer. In 2016, a series of key scientific papers from the lab of Dr Grant O'Connell reported that smokers confined in a clinic for five days who switched to e-cigarettes got the same amount of nicotine but much less exposure to the harmful toxicants known to cause smoking-associated risks, such as nitrosamine and carbon monoxide. After five days, the measure of harmful toxicants in their blood and urine was like that of smokers who went cold turkey over the same time. The subjects also had improvements to lung and heart function. This year the team published one of the first long-term clinical studies, which monitored 209 smokers who used e-cigarettes for two years. It found no evidence of any safety concerns or serious health complications in smokers after two years of continuous e-cigarette usage.
In the 1980s, Britain pioneered harm reduction. With a growing Aids epidemic among heroin addicts the health secretary, Norman Fowler, chose a pragmatic rather than moralistic response: setting up needle exchanges and ignoring those who protested that this condoned drug use, undermined calls for abstinence, and sent the wrong message to young people. It worked — Aids among injecting drug users slowed down. By 2010, only 1 per cent of British drug injectors had HIV, compared with about 18 per cent in America and 48 per cent in Brazil.
Fortunately for vaping, some of the people involved in the needles episode were in key positions when e-cigarettes came along. They fought within Public Health England, against strong opposition from the chief medical officer and others, to get vaping seen in the same terms. In 2015, they succeeded and PHE came out with its bold statement that "e-cigarette usage is around 95 per cent less harmful to health than smoking".
Yet, despite official endorsement and the growing strength of the evidence for harm reduction, public opinion has been moving against e-cigarettes. More than 25 per cent of people now erroneously believe vaping to be at least as harmful as smoking, up from 7 per cent in 2013, thanks to tabloid headlines claiming as much. The pharmaceutical industry lobbied hard behind the scenes to defend its lucrative line of medicinal nicotine patches and gums against a new competitor. Both patches and smoking cessation services have lost about half their business' since 2011.
The European Parliament agreed to include Vaping industry in the Tobacco Products Directive (TPD) inducing a ban on high-strength e-liquids and the advertising of e-cigarettes. This directive, which came into force in 2017, has slowed the growth of vaping in the UK.
The argument that vaping cannot yet be proven safe so must be assumed to be unsafe is an example of what can go wrong with the 'precautionary principle'. If an existing technology is killing people and a safer alternative comes along to save their lives, then waiting for watertight evidence regarding the risks of the new technology is an effective culpable homicide.
Britain stumbled into world leadership of the vaping industry. It is a textbook example of disruptive innovation: a new technology, a decision not to block it, a history of harm reduction, a flowering of experiments, lots of research into the impacts, a lot of lives saved, and financial benefits shared between consumers and producers. Plus, a sudden acceleration of the race to extinguish a nasty habit, forever. And all at zero cost to the taxpayer. What's there to not like?
(Matthew White Ridley is a British journalist and businessman best known for his writings on science, the environment, and economics. The views expressed are strictly personal)