UK wants to pay for your e-cigarettes. Is this a wise move?

The UK has picked its side in the long-running debate about whether e-cigarettes are a wondrous tool for reducing the harm from smoking or a gateway to damaging addiction. Britain now looks likely to become the first country in the world to prescribe vaping for medicinal use — that is, as a way for a tobacco smoker to learn to quit —  and the first to make e-cigarette use taxpayer funded.

The October 29 ruling by the UK Medicines and Healthcare Products Regulatory Agency encourages the licensing of e-cigarette products as medicines. Manufacturers of e-cigarettes would still have to jump through a series of costly regulatory hoops, and the final say on whether the National Health Service offers them rests with Britain’s National Institute for Health Care Excellence (NICE). But the welcome by health secretary Sajid Javid and other officials makes clear what the government would like to see happen.

It is an experiment that other countries will watch closely and one that seems to prejudge the answer to some key questions. Will prescription vaping have the desired impact on smokers? Will it have any undesirable, unintended consequences? Is it a good use of public funds? There is a danger that, on all three counts, the answers won’t vindicate the decision.

The logic behind the change is straightforward. Smoking is the largest avoidable cause of death and serious illness in the UK. Since e-cigarettes are considered to be substantially less harmful than smoking tobacco, the argument is that making them available through the NHS (that is, free to the user) will help smokers kick the habit and reduce the costs on an already overburdened health system.

My concern, based on the products they have developed so far, is that the tobacco industry would get products licensed that are not particularly effective. These could undermine confidence in e-cigarettes as a tool for smoking cessation.

—  Robert West, a professor of health psychology at University College London

In some ways, the licensing of e-cigarettes doesn’t seem much of a leap. The NHS already makes low-nicotine products available for smokers, including skin patches, chewing gum, nasal and mouth sprays and inhalators. And harm reduction is not a new strategy in healthcare. Methadone is used to help heroin and opioid addicts, for example. And yet, e-cigarettes are different — they come in fetching flavours such as bubblegum and vanilla custard (if that’s your thing), have a celebrity following and avid fan groups on social media. 

Research provides reasonable support for the claim that more people stop smoking, at least temporarily (nine to 14 in 100 smokers) with nicotine e-cigarettes than those who try other nicotine replacement therapies (six in 100). And yet making them available on the NHS makes sense only if it gets smokers to quit, who would not otherwise have tried them.

The evidence for that is unclear. The price of a pack of cigarettes in the UK has doubled over the past 10 years to £13.60 (R284) with the latest budget. The average annual cost of smoking is now around £4,000 (R83,800); compare that to just over £600 (R12,500) for making the switch to vaping. The cost incentive to switch is there without a taxpayer subsidy.

The other argument is that, according to University of Edinburgh professor Linda Bauld, one in three smokers in the UK have not tried vaping, mainly because of concerns about safety. If prescription vaping would convince 2-million or so of the 6-million smokers in the country to give the alternative a try, that would be a win. But if safety concerns are the barrier, why not just have GPs deliver leaflets on safety?

There is a lot we don’t know about the long-term effects of vaping. The World Health Organisation has warned that e-cigarettes are “harmful” and says children and adolescents who use e-cigarettes are more than twice as likely to smoke later.

Is there a risk that medicinal vaping means some people might decide they can smoke a bit more now, since they can always switch to vaping with a little help from their GP later? Are we headed down a slippery slope of normalisation where we’ll see vaping on planes and trains and in offices and restaurants — that is, places were smoking is prohibited?

The main worry here is about children and teenagers. The US Food and Drug Administration declared an epidemic of youth e-cigarette use in 2018 and cracked down on the sale of e-cigarettes to minors. The US surgeon general declared e-cigarette use among young people harmful and a potential gateway to nicotine dependence.

Vaping seems to have declined since its peak, and concerns about the impact of normalisation may be less a danger in the UK. About 11% of 11-17-year olds have tried e-cigarettes in Britain and regular use remains low. Users tend to be from more advantaged social groups, unlike the population of smokers. The perception among teenagers that vaping is harmful, has also been increasing.

“The situation in the UK is very different to the US, which seems to have got itself into a culture war over these products. We do not have a problem of youth taking up e-cigarettes in large numbers, and there is general recognition in the public health community that with the regulations we have on marketing this is not likely to become an issue,” says Robert West, a professor of health psychology at University College London.

And yet unintended consequences remain a concern. The NHS is akin to a religion in Britain and it’s hard to say for sure that a change in policy won’t widen access and interest among young people in general and among different demographics. And while the majority of vapers are ex-smokers (with 30% being current smokers), the growing number of long-time vapers tells us that those who pick up the practice tend to continue, so there is a health interest in understanding those long-term effects.

There is a conflict of interest here, too, when it comes to the tobacco industry, which is now heavily vested in e-cigarettes. “My concern, based on the products they have developed so far, is that the tobacco industry would get products licensed that are not particularly effective,” says West. “These could undermine confidence in e-cigarettes as a tool for smoking cessation.” It would be some time before we know and norms can change quickly.

What if the answer to the question of whether vaping is a legitimate harm-reduction tool, or a vehicle for other societal ills is, simply, yes? The state must tread very carefully when it picks sides.

Therese Raphael is a columnist for Bloomberg Opinion. She was editorial page editor of the Wall Street Journal Europe.

— Bloomberg Opinion. More stories like this are available on bloomberg.com/opinion