Thirty years ago the then Secretary of State for Health Norman Fowler persuaded Margaret Thatcher of the need for radical approaches to prevent the spread of HIV infection among people who inject drugs. These included providing needles and syringes to drug users and making the heroin substitute drug methadone more widely available. Frontline staff were urged to reach out to drug injectors. Drugs harm reduction, as it was called, was a public health success and the UK avoided a major epidemic of injecting-related HIV infection.
E-cigarettes, I believe, are the harm reduction equivalent for smoking. They have the potential to dramatically reduce smoking levels in Britain. Indeed, they have already done so. According to the Office for National Statistics, more than 863,000 current e-cigarette users are no longer smokers and a further 720,000 people are both ex-smokers and previous e-cigarette users.
Public health leaders do not share my view. Their response has ranged from the extremely negative to the ultra-cautious. Some of the same people who initiated drugs harm reduction in the 1980s have opposed tobacco harm reduction. Clearly harm reduction is rather selectively applied.
Thirty years ago the then Chief Medical Officer Donald Acheson supported harm reduction. Sally Davies, our current Chief Medical Officer, worries that vape stores make e-cigarettes look cool and chic, and that cookies and bubblegum flavours are aimed at children. Only one out of 150 local directors of public health has written about the potential of e-cigarettes to bring help bring an end to smoking.
Despite this opposition the vaping movement has, in just a few years, changed the landscape of smoking cessation. E-cigarette sales have overtaken sales of nicotine replacement therapy (NRT) products. They are the most common device used to help people stop smoking. Smoking cessation services are losing business, with the number of customers who set a quit date declining 45 per cent between 2011/12 and 2014/15.
For those trying to stop smoking, e-cigarettes have profoundly changed the experience. For the first time quitting cigarettes is no longer associated with being a ‘patient’ and personal struggle. It is a pleasurable way of using nicotine without the stigma and guilt associated with smoking cigarettes.
For some becoming a vaper is an important transformation in personal identity. For those with a liking for gadgets vaping becomes a hobby. For some it’s a matter of a shared experience and fun — as demonstrated by the growing number of vaping exhibitions and festivals. There are no NRT fests.
Becoming an e-cigarette user involves helping yourself and helping others. It’s a do-it-yourself approach to switching from smoking. There is a lot of help and advice on how to vape. Awareness of e-cigarettes has spread by word of mouth and social media forums. The UK E-Cigarette Forum has a daily average of 10,000 visits — numbers to make public health leaders green with envy.
In the new landscape of smoking cessation there are nearly one million ‘frontline staff’ and ‘outreach workers’ — the new vapers who have stopped smoking and can advise their smoking friends about vaping. There are also 1,500 to 2,000 free ‘smoking cessation advice centres’ — ie vape shops.
This is an intervention which has nil cost to the state. Compare this with the annual investment in NHS smoking cessation services, which in 2014 was about £120m, or £513 per successful quit. We need a radical rethink about the need for and nature of these services.
E-cigarette makers, vaping stores, vaping forums and vapers are the new frontline in helping people switch from smoking. It is an example of public health objectives being delivered without the involvement of public health professionals.
I started off by bemoaning the antipathy shown by many public health opinion leaders. I wanted them to be involved. But now I realise they only have a small part to play. Unlike for HIV/AIDS, the role of experts is minimal — there is no need to invest in costly services.
Their main role is to endorse the use of e-cigarettes, to reassure the public of their safety, and not to create obstacles to their use. Put simply, to enable vapers to bring information to their peers. It’s vapers who are now leading smoking cessation.
Professor Gerry Stimson is director of Knowledge-Action-Change. This article is adapted from a lecture hosted by the London Drug and Alcohol Policy Forum.