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Views And Reviews

The prominence of e-cigarettes is a symptom of decades of failure to tackle smoking properly

BMJ 2019; 364 doi: (Published 14 February 2019) Cite this as: BMJ 2019;364:l647
  1. Nicholas S Hopkinson, reader in respiratory medicine, medical director12
  1. 1National Heart and Lung Institute, Imperial College London, UK
  2. 2British Lung Foundation, UK
  1. n.hopkinson{at}
    Follow Nick Hopkinson on Twitter @COPDdoc

There is a danger that debate around e-cigarettes drowns out the work needed to implement the full range of tobacco control measures

The annual Public Health England SmokeFree Health Harms campaign, now in its seventh year, focuses on the toxins present in cigarette smoke and their harmful effects on the body. A novel feature this year is emphasis on the relative safety of e-cigarettes compared with smoking. A video shows sticky yellow black sludge appearing after a few packets of cigarettes are smoked through a simulator. The same noxious material is being deposited in the lungs of smokers and the shock value of the “jar of tar” is a familiar tool. By contrast, there is no such accumulation of tar from an equivalent quantity of e-cigarette vapour. The levels of carcinogens found in people who vape are much lower than those seen in smokers,12 data which underpin estimates that vaping is no more than 5% as harmful as smoking, and that completely switching from smoking to vaping is associated with substantial health benefits.3

There are now more than 3 million people in the UK who vape.4 Almost all have smoked and more than half are former smokers. The vast majority of people who vape do so in order to cut down or quit their smoking habit. Unfortunately, a substantial proportion of the population believe, incorrectly, that e-cigarettes are as harmful as or more harmful than smoking.

We now have convincing data that e-cigarettes are an effective stop smoking aid in the context of behavioural support. Long term use of e-cigarettes will undoubtedly cause some harms, and users should be encouraged to quit vaping too, though not at the expense of relapsing to smoking. Vaping should, of course, be avoided by non-smokers. Because of controls on advertising and age limits on sale, vaping rates in children remain low in the UK and are confined almost exclusively to children who are also smokers or ex-smokers.5

But why are e-cigarettes being proposed as part of the solution to smoking, and does it matter? The first thing to acknowledge is that the ongoing tobacco epidemic is the consequence of a profound, sustained, societal failure. It is at least 60 years since unequivocal evidence of the catastrophic health harms of smoking became available.6 The solutions to this problem have also been obvious for decades—price increases, advertising bans, help for smokers to quit, health education campaigns, smoke free legislation, and excluding the tobacco industry and its lobbyists from policy making.7 Yet generations have been born, taken up smoking (mostly in childhood),89 and died, or are dying, prematurely from smoking related diseases, because action to tackle smoking uptake has been tardy, grudging, and tentative, and undermined by the tobacco industry.

Decades have been wasted getting to the point where tobacco advertising is banned, including on cigarette packaging, and where people’s right to breathe smoke free air is respected. Still, despite overwhelming evidence that passive smoke exposure harms children, more than 20% of MPs voted in 2015 against protecting children in cars from being forced to breathe tobacco smoke.

A second failure is the dismal level of stop smoking support offered across the health and social care system.10 The majority of smokers want to quit, yet provision of smoking cessation treatment—a combination of psychological support and pharmacotherapy1112—has been and remains inadequate. Public health budgets continue to be slashed, leading to widespread cuts in smoking cessation services. Although adult smoking rates are now around 15%, there is a danger of complacency, with policy makers thinking that the problem has been solved. Smoking rates are much higher in poorer people and those with mental health problems.1314 Neglect of smoking in these groups is a major driver of health inequality. Too often, clinicians consider smoking cessation to be someone else’s problem, or neglect it at the expense of interventions that appear to be more technical or condition specific; witness the relative attention given to the niceties of inhaler selection for chronic obstructive pulmonary disease, while only around 10% of COPD smokers receive quit smoking treatment.10

There are positive signs. Active lobbying15 has helped to ensure that smoking cessation features prominently in the NHS’s long term plan,16 including the provision of tobacco treatment programmes for all people admitted to hospital.13 Enthusiasm for this development is tempered by the fact that the target is to deliver this by 2023-24. Given everything that is known about the impact of smoking on health and the benefits of cessation to both the person and to the healthcare system, it is astonishing and embarrassing that we do not have this in place already.

The developing popularity of e-cigarettes is a symptom of decades of failure to make proper use of effective tools to reduce smoking, and in particular of the current failure to provide properly funded, comprehensive, evidence based smoking cessation services. Until we have maximised the offer of “conventional” smoking cessation, it is unreasonable to object to smokers adopting another strategy that can help them quit and which lowers their health risk.

A real danger, which must be acknowledged and avoided, is that debate around e-cigarettes drowns out the work needed to implement the full range of tobacco control measures.7 This is particularly the case in poorer countries, where smoking faces few restrictions and where the tobacco industry is lobbying hard to promote the false idea that availability of e-cigarettes means that tobacco control is no longer necessary. This argument has also been used to decommission smoking cessation services in the UK.


  • Competing interests: NH is a trustee of ASH.

  • Commissioned, not peer reviewed


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