Associate feature: Changing direction: vaping's role in achieving Scotland's 2034 smoke-free target

It is the hope of the Scottish Government that in just over a decade’s time it will have created a tobacco-free generation. 

The aim is for children born since 2013 – when the target was first set – to come of age in 2034 in a Scotland that will remain tobacco-free for generations to come. 

We live in a country which has a history of smoking prevention policy, as was seen from the introduction of the ban on smoking in enclosed public spaces in 2006.

However, the habit’s harms have yet to be eradicated, highlighting the need for other tools in the pursuit of the government’s goals.

One of the tools that could have a role in achieving Scotland’s 2034 smoke-free target is the e-cigarette. In fact, in 2017 NHS Health Scotland published a statement in collaboration with 21 organisations that said vaping e-cigarettes is “definitely less harmful than smoking tobacco”.

While it acknowledged their use as a “potential route towards stopping smoking”, the statement said there is still a lot that is not known about the products. 

With this in mind, Holyrood and the Scottish Grocers’ Federation (SGF) brought a number of experts and stakeholders together for a roundtable discussion to debate the concept of tobacco harm reduction, with a focus on the role of vaping. 

Kicking things off, John Lee, the federation’s head of policy and public affairs, said on the topic of vaping in retail: “We are very concerned that market might be, in some way, inhibited. 

“The Scottish Government has committed itself in this Programme for Government to bringing forward a consultation, which may very well restrict the promotion of marketing of electronic cigarettes and we would not really want that market to be prohibited in any way. 

“We think it’s a consumer market essentially, we think that retailers need to have conversations with customers about these type of products and of course, in the wider context, it may well mean if there were restrictions on these products that the potential health benefits wouldn’t be realised.”

Donald Cameron MSP, the Scottish Conservative health spokesman, stressed the importance of the process of determining the potential benefits of e-cigarettes being driven by the data, science, and research. “We all know there are conflicting accounts,” he told the roundtable. 

“Some people say e-cigarettes help reduce smoking, but for every research paper that shows that, there will be another that shows the opposite and I think it is just important to get a handle on the facts, particularly in terms of how it applies in Scotland.”

Brian Whittle MSP, a colleague of Cameron’s and their party’s public health spokesman, conceded he was a sceptic on the matter but willing to listen to the arguments. 

“I do believe that vaping has a place. I think it has a place if it’s medical practitioners that pass that on. My worry is that vaping is starting to be seen as something cool to do. If you look at the marketing and all the different flavours… a lot of that marketing is not about stopping people smoking. It’s about, in my view, encouraging people onto vaping. I think that’s a slippery road. I do think it has a medical place, but I am a sceptic in the overall scheme of things.”

It’s a scepticism shared by SNP MSP Emma Harper, a former nurse, the current deputy convener of the Health and Sport Committee in the Scottish Parliament. She said: “I have concerns that young people think it is cool and I have concerns that young people would go straight to vaping because of the smells, the taste, those other chemicals in it. We need to remember that vaping has nicotine in it. Nicotine is addictive.”

All agreed they needed more facts and Lion Shahab, professor of health psychology at University College London,  who has been doing research on tobacco control for the last 15 years and also contributed to the Public Health England report on e-cigarettes, provided some evidence from that research. 

He said: “My belief is, if you look at the impact e-cigarettes have on smoking cessation rates at population level, taken together with relatively reduced risk of harm associated with e-cigarette use, as well as the lack of evidence that e-cigarettes – either in the US or the UK – are a gateway to smoking for adolescents, that they are likely to be a public health good.”

In considering the contribution e-cigarettes can have in harm reduction in Scotland, Professor Neil McKeganey, a co-director of the Centre for Substance Use Research, said it was essential to set it in the context that combustible cigarettes “kill half of all consumers”. 

He explained: “There is no retail product which is as toxic and as responsible for more death and disease than combustible cigarettes. We know that if smokers stop smoking by age 35, their life expectancy returns to that of a non-smoker, so there are probably few public health challenges more important than stopping the onset of smoking and encouraging the cessation of smoking.

“The reduction in smoking that we’ve seen in Scotland and elsewhere has been probably an unparalleled public health achievement, almost certainly. There is no other area of public health that has achieved a greater reduction in morbidity and mortality than the reduction in smoking.

But we are not seeing the smoking end game. The level of smoking still persists at a worrying proportion and particularly in some of our poorest communities. I do think there is an obligation upon us to consider what role e-cigarettes can play in further reducing smoking prevalence.”

The harms of tobacco smoking are clear to see, as pointed out by McKeganey. Mark Oates, the director of campaign organisation We Vape, believes the story of people switching to e-cigarettes and improving their health is being lost in much of the noise generated around the topic in some parts of the media. 

“I think vaping works because it’s not top-down policy,” Oates said. “The price is a major point. Smoking is incredibly expensive. It causes massive inequality. I’ve been doing some work on the effect that smoking cost has on inequality in the UK, both health and on financials, and vaping can put £2,000 to £3,000 a year into some of the poorest people in the UK’s pockets.”

Concerns surfaced about the risk of e-cigarettes creating lung health problems themselves, which Shahab was keen to put to bed. He said emergent lung disease issues in the US could be attributed to bootleg products that contained illicit substances. 

He stressed it was not related to the use of ordinary e-cigarettes, before adding: “There are around 40 million users of e-cigarettes and e-cigarettes have been used since 2005… and there’s very little report of any lung diseases otherwise occurring, given this large number of people having used e-cigarettes for this length of time… So, if there were any serious concerns with regards lung health, one would have thought they would start to be picked up by now.”

Richard Simpson, a former GP and shadow public health minister for Scottish Labour, said that ultimately there is a “hierarchy of risk” involved with smoking products. He had described e-cigarettes as “an extremely important, relatively novel” alternative to tobacco.

He said: “If you smoke tobacco, you’re at the greatest risk. If you vape as an alternative to smoking, you’re reducing your risk. If you’re a non-smoker and you start vaping, then in the light of our current knowledge you are possibly increasing your risk.”

Simpson, who is also a former psychiatrist in addiction, highlighted a study in Dundee, which showed that a month after switching from smoking to e-cigarettes blood pressure and artery stiffness improved. “That is in one month,” he emphasised. “So, there is no doubt in my mind that vaping is better.”

The debate moved on to misperceptions around e-cigarettes, such as the idea that they are just as bad as smoking tobacco cigarettes. The previously mentioned NHS Health Scotland statement was quite emphatic in clarifying that vaping is less harmful and indeed added that it would be a “good thing” if smokers used them instead of tobacco. 

Louise Ross, the vice-chair of the New Nicotine Alliance, told the roundtable: “One of the imperatives for getting more accurate messages out is that, if you did, more people would switch exclusively rather than thinking: ‘It doesn’t matter if I vape or smoke, they’re both equally as bad’. We want to convince people that a complete switch is going to protect their health more.”

Whittle, who said he knows several vapers who have never smoked, said: “If we’re going to utilise vaping, it [should be as] part of a step-down process away from smoking, which ultimately should lead to them not vaping at the end of that process.”

SNP MSP Richard Lyle, who started smoking when he was 12 and stopped smoking cigarettes at the age of 68, believes vaping has a significant role to play in helping accelerate the reduction in smoking rates as Scotland tries to meet that 2034 smoke free target. 

He said: “I’m not knocking anyone who smokes… We’ve got to try and see what works for people. People have done patches, people have done chewing gum, I’ve done all that… But basically, vaping is the answer and how we get people to move on to that.”

While Whittle was keen to see more medical intervention in vaping, Oates believed it was important that vaping products are accessible for people. Ultimately if the products are too difficult to get a hold of then there is a risk of people reverting to tobacco cigarettes.

Towards the end of the discussion, Oates said: “I think we’ve got to be careful, because what we don’t want to see is it being harder for people who are smokers to get hold of vaping and safer nicotine products than it is to get hold of cigarettes. 

“If you were to, 10 years ago, categorise vaping as a pharmaceutical product, all the pharmaceutical companies would love it. They’d make loads of money out of it, but they would then have to go through a lot of expensive processes that would cut out a lot of individuals from being able to take part and what you’d be left with is a very boring non-innovative product. It wouldn’t have had the ability to persuade smokers to move away from smoking.”

This feature was sponsored by the Scottish Grocers’ Federation