Asthma UK Centre for Applied Research

Are perceptions of unknown harms slowing potential public health improvements?

Survey in response to Centre debate suggests that clinicians could be overestimating the harm from vaping compared to tobacco smoking

In April 2023, we were delighted to welcome Professor Caitlin Notley and Dr Simon Barry to our Annual Scientific Meeting in Swansea to argue for the motion in our debate: ‘Vaping is a healthier alternative to smoking and should be promoted as a useful public health strategy’.

Professor Notley is an expert in addiction sciences and Dr Barry is the Lead for the National Respiratory Health Implementation Group in Wales. They and their colleague have recently published an opinion article in the Clinical Medicine Journal discussing clinicians’ views of vaping and the implications that misconceptions about its harms could have on wider public health.

On the day of the debate, our delegates didn’t vote in Caitlin and Simon’s favour, with concern over the unknown risks of vaping and its growing use by young people. The opposing debate team focused their argument on the assumption that vaping will lead future generations to start smoking cigarettes. However, the Royal College of Physicians’ position on vaping is that it a method of supporting current adult cigarette smokers to quit tobacco, associated carcinogens and other toxicants.

Respiratory Specialist Survey

Surprised by the debate’s outcome, in response Caitlin and Simon decided to survey clinical respiratory specialists in Wales to see whether they had the same viewpoint as the Centre members during the meeting.

55% of respondents indicated that they would not promote vaping as a tool to help people stop smoking. Of this group, 80% raised concerns over the safety of vaping. 55% were also worried about the spread of vaping to young people.

In the face of growing evidence for vapes, where have these clinical perceptions come from?

An Effective and Popular Consumer Choice

The most recent Cochrane systematic review shows that vapes are approximately 50% more effective at helping people stop smoking cigarettes than nicotine replacement therapy. As well as supporting users to move away from the harms of tobacco smoking, vaping also reduces nicotine withdrawal and can fulfil a social and identity-related need.

Further evidence from the Office for Health Improvement and Disparities has consistently shown that vaping is less harmful than tobacco smoking, with fewer carcinogens and toxicants measured in people who vape exclusively.

Additionally, vaping has been shown to be more cost-effective than other methods of smoking cessation, and are used by a higher percentage of people who are quitting smoking than the Public Health Wales Help Me Quit service.

Vaping Does Not Lead to Tobacco Smoking

The writers disagree with the argument given by their opposing debate team that vaping leads to young people becoming tobacco smokers. While they concede that experimentation with vaping among 11-17-year olds had increased from 2022 to 2023, there was no similar increase in tobacco-smoking in the same age group.

While the preferred number of young people inhaling any type of nicotine would be zero, the writers also say that this is not realistic. Teenagers will experiment with many things that are not good for their health, so why try to avoid them using a relatively low harm substance like nicotine from vapes when they could choose smoking tobacco and its real harms?

What we can all agree on is that marketing should never be aimed at children and young people, and regulation should be tightened so this it happens. However, reducing access to vapes for adults who need them to stop smoking could have serious impacts on overall public health.

A moral question?

There has been almost 70 years of evidence of the connection between smoking and early death. Despite the reduced health risks associated with vaping, is it the relative lack of evidence that is stopping clinicians from promoting it as an alternative to tobacco smoking?

A point which Professor Notley and Dr Barry raise is whether the idea of any type of addiction or dependence is morally acceptable? Does the certain very high risk of continued tobacco smoking outweigh the suggestion of a less harmful but more unknown replacement to nicotine dependence? The evidence around vaping is continuing to grow and perhaps in the future the overestimation of its harm will be reduced. 

There are many adults who need a less harmful alternative to tobacco smoking now. Encouraging vaping to adults who want to stop smoking will promote better health, reduce harm and prevent early death from tobacco.

Professor Caitlin Notley was lead author on the opinion paper. She said:

I was honoured to be invited to take part in this debate by the Centre. It was a surprise that the vote, although close, did not fall in favour of promoting vaping for smoking cessation. This highlighted to me that clinicians and researchers are influenced by media reporting and hold harm misperceptions, just as the public do. Following our survey of respiratory consultants and registrars in Wales, it seems that harm misperceptions are widely held. The concern is that this impacts discussions with patients about quitting smoking. We urge clinicians to focus on the evidence we have; that e-cigarettes are an effective quit aid and a far less harmful alternative to tobacco smoking. Giving patients who smoke this clear message is literally lifesaving.

Professor Caitlin Notley

Read the Paper

This publication is available from the Clinical Medicine Journal

Cite the Paper

Notley C, Barry S, Parrott S. Do respiratory physicians not care about people who smoke?. Clin Med (Lond). 2023;23(5):531-532. doi:10.7861/clinmed.2023-0270