England Is Handing out E-Cigarettes: Is the “Swap to Stop” Tobacco Control Scheme Harm Reduction or Harm Production?

We applaud the English government’s commitment to reduce cigarette smoking rates to <5% by 2030. However, we have reservations in regard to their approach. In their “swap to stop” scheme, the government will offer vaping starter kits, with choices of products, strengths, and flavors, along with behavioral support to 1 million individuals who smoke cigarettes. With a plan to start in 2023, local governments will individually decide who receives kits, with campaign funding expected to be £45 million over 2 years. Here, we highlight our concerns.

Disproven Assumption of 95% Risk Reduction in E-Cigarettes Compared with Combustible Cigarettes

Swap to stop is predicated on the assumption that e-cigarettes are an effective harm-reduction approach for cigarette users. Much of the argument is based on claims that e-cigarettes are 95% less harmful than combustible cigarettes. This assertion was established in 2013 by 12 experts who developed a harm index for 12 nicotine-containing products. Based on their aggregated opinions, the panel envisioned a 95% reduction in tobacco-related harm. Even though they acknowledged a “lack of hard evidence for the harms of most products on most criteria,” e-cigarette proponents continue to endorse this claim (1). In reality, the health effects of e-cigarettes, including accessorizing, flavoring, and customizing products, are unknown. Longitudinal studies demonstrate associations with an increased risk of cardiopulmonary disease (2), and flavorings have shown added detriment, being associated with enhanced inhaled particle generation and worse spirometric measurements compared with nonflavored e-cigarettes (3). There is also increasing evidence that e-cigarettes are carcinogenic. Studies show a dose-dependent formation of DNA damage in oral cells from e-cigarette users who never smoked cigarettes. Those who used sweet, mint, menthol, and fruit-flavored e-liquids showed the highest level of DNA damage (4). Additional concerns include detrimental effects on the developing brain in young people who use e-cigarettes. The belief that e-cigarettes are 95% less harmful has no scientific validity and does not describe the potential harms from their acute and long-term use.

Concern that Normalizing E-Cigarettes in Adults Will Result in Increased Youth E-Cigarette Use

Parental and adult smoking is associated with adolescent lifetime smoking and dependence. The policy to swap adult cigarettes for e-cigarettes and thus normalize e-cigarette use, rather than a policy to end nicotine addiction, runs the risk of increasing adolescent e-cigarette dependence. Despite Public Health England’s 2018 claim that “…e-cigarettes are attracting very few young people who have never smoked into regular use,” the Action on Smoking and Health youth survey in England revealed increased e-cigarette use among young people. In 2023, 20.5% of children had tried vaping, up from 2022 (15.8%) and 2020 (13.9%). Even Australia, which requires a prescription to legally access nicotine e-cigarettes, has seen a marked increase in adolescent vaping. The increase in youth uptake is not surprising given marketing to youth with flavors, social media promotion, and normalization of adult e-cigarette use. Whether young people are using combustible cigarettes or not, they are being exposed to potential harms from e-cigarettes, and data suggest that vaping increases subsequent cigarette smoking risk (5). A meta-analysis demonstrated that youth e-cigarette use was associated with increased odds of subsequent cigarette smoking after adjusting for behavioral, demographic, and psychosocial risk factors (6). Moreover, the National Academies of Sciences, Engineering, and Medicine concluded that e-cigarette use has a substantial impact on the transition from never to ever smoking. Longitudinal data from the United Kingdom and United States found increased odds of adolescent cigarette smoking among early smoking youth who had also used e-cigarettes compared with those who had not used e-cigarettes (7). From 2017 to 2022, an increase in youth e-cigarette use (from 8% to 24%) and youth cigarette smoking (from 16% to 21%) was observed in England, where tobacco control strategies strongly promote adult e-cigarette use (8).

Guideline-Recommended Treatment with Known Safety Profiles Should Be Used

Policy for smoking cessation should consider guideline-recommended pharmacotherapy with known safety profiles first. Although recent pooled data from randomized controlled trials suggest that an additional 2–6 people among every 100 would quit smoking with nicotine e-cigarettes compared with nicotine replacement therapy, 70% of successful quitters were still using e-cigarettes at 6 months (9). There are robust concerns in regard to the long-term harms of e-cigarettes and the potential for relapse with ongoing vaping. Moreover, nearly 25% of participants randomized to e-cigarette groups became dual users, which is associated with increased odds of respiratory disease compared with cigarette smoking alone.

Although randomized controlled trials indicate that e-cigarettes may have efficacy in helping people stop smoking, real-world cohort studies using e-cigarettes to assist a cessation attempt or as a substitute for cigarettes have not demonstrated effectiveness in smoking cessation (2). Furthermore, the use of e-cigarettes as a therapeutic agent bypasses the checks and balances for medicines put into place by England’s Medicines and Healthcare products Regulatory Agency. The protection of public health must include robust evidence for the benefit/harm ratio and assessment, inspection, and surveillance of the pharmaceutical quality of the product. The latter is a prerequisite that cannot be bypassed, particularly in this case because the marketplace is riddled with e-cigarettes that are far from standardized.

In summary, there is uncertainty about the long-term harms of e-cigarettes and concern that normalizing vaping might escalate the youth nicotine epidemic. We are concerned about the precedent England’s policy may set for other nations, particularly those classified as low- and middle-income nations, in which the tobacco industry has significant influence, regulatory enforcement is less robust, and youth e-cigarette uptake is likely to be greater. We urge the English government to swap out their swap to stop scheme and to protect tobacco-control policymaking from tobacco industry interference such as vape-sponsored smoking cessation conferences. However, if the swap to stop plan does proceed, England must inform the public of the gaps in our understanding of the risks of e-cigarette use, the unique circumstances and variables that adversely affect risk-reduction assumptions, and exactly what risks are being reduced, which can be approached by using policy recommendations adopted by the American Thoracic Society (10). It is critical that England monitor progress related to established key performance indicators and develop courses of action related to strategic adjustments as needed, given the serious potential ramifications of this public health policy.