Smoking is the leading preventable cause of premature death, accounting for half of the difference in life expectancy between the most and least well-off segments of the population. Smoking is highly addictive and difficult to give up, and about a million people have died from smoking in the UK since 2010. High-quality randomized controlled studies have shown that nicotine-containing electronic cigarettes are an effective means of quitting smoking. Their use has been approved by NICE management, the British Thoracic Society, the Royal College of General Practitioners, the Royal College of Physicians, the Royal College of Obstetrics and Gynecology, the Royal College of Midwives, and other organizations. Providing reliable information about vaping is extremely important, because currently 43% of smokers who have not tried vaping believe that vaping is just as or more harmful than smoking.

Common misconceptions about vaping

Vaping nicotine is more harmful than smoking tobacco: NO

Over 75,000 people a year die from smoking in the UK, and smoking is still one of the biggest causes of death and disease in the UK. Passive smoking is the leading modifiable risk factor for poor birth outcomes including miscarriage, stillbirth and sudden infant death syndrome and a significant cause of death and disability in children.

In the last twelve years five fatalities linked to vaping products (2 cardiac and 3 respiratory) have been reported to the Medicines and Healthcare products Regulatory Agency. In total there were 339 reports covering 942 adverse reactions to vaping. However, the MHRA is careful to point out causation was not

proven as healthcare professionals are asked to report even if they only have a suspicion that the e-cigarette may have contributed to the adverse event.

Over 500,000 admissions to hospital a year are caused by smoking, compared with 420 for ‘vaping-related disorder’. In other words, there are over 1,000 hospital admissions due to smoking for every one linked to vaping.

Furthermore, while a diagnosis of ‘vaping-related disorder’ shows an association with vaping, causality has not been shown, and smoking behaviour has not been controlled for. Reporting in these cases doesn’t currently distinguish between possible harmful effects of legal products and harms from non-licensed products and from the vaping of illicit drugs.

In 2023 there are 4.7 million adults currently vaping in Great Britain, 93% of whom are ex- or current smokers. Use by never smokers has increased since 2021 but remains relatively rare with 1.1% of never smokers vaping in Apr-Jun 2023, amounting to 320,000 people. Around 400,000 children in Great Britain aged 11-17 are current vapers in 2023, of whom around a quarter, amounting to 100,000 have never smoked.

Among children, as among adults, smoking is a cause of much more harm than vaping. Around 5,000 children are admitted to hospital every year because of passive exposure to tobacco smoke, 38 compared with 40 admissions among those under 20 in 2022 for ‘vaping related disorder’. In other words for every admission linked to vaping among those under 20, there are 125 admissions for children caused by tobacco smoke exposure.

The levels of exposure to toxic chemicals from vaping are a tiny proportion of those from smoking. Furthermore UK regulations have, since 2016, prohibited the use of any ingredient in nicotine containing e-liquid that poses a risk to human health in heated or unheated form. Prohibited chemicals include vitamins, and diacetyl.

Diacetyl has been linked to a rare condition, bronchiolitis obliterans, also known as ‘popcorn lung’. It became known as ‘popcorn lung’ because it was thought to be caused by exposure to diacetyl used as a food flavouring in popcorn factories, although that is disputed. The idea that vaping can cause popcorn lung is frequently repeated, but although cigarette smokers are exposed to over ten times as much diacetyl as people who vape, smoking has not been shown to cause ‘popcorn lung’.

Vitamin E acetate in cannabis vapes was linked to an outbreak of serious respiratory disease in the US called EVALI. Between March 2019 and February 2020 over 2600 cases of EVALI and 60 associated deaths were reported to the US Centers for Disease Control and Prevention. An investigation by the UK medicines regulator found only 2 potential cases in the UK (both fatal), which met the US case definition of EVALI45.

There are over 70 years of evidence of the harms of smoking while vaping has only been around for 16 years since 2007, so we cannot yet be precise about the long-term risks of vaping. However, the most recent independent review of the evidence commissioned to inform the government’s policies and regulations published in 2022, concluded that vaping poses only a small fraction of the risk of smoking. The review also highlighted that vaping is not risk free and advised against people who have never smoked from taking up vaping.

Vaping is more addictive than smoking: NO

How addictive nicotine is depends on product design and the mode of use. Cigarettes carry the highest risk of addiction following initiation, due to cigarette designs that facilitate efficient and tolerable inhalation of nicotine-laden smoke deep into the lung and from there to the brain, and constituents that reinforce the

addictiveness of nicotine.

Two thirds of those trying one cigarette will go on to become daily smokers, at least temporarily. For those who manage to quit, it takes on average 30 attempts before they succeed, and many fail to succeed, with up to two thirds of long-term smokers dying prematurely from smoking-related diseases.

People addicted to nicotine because of smoking who switch to vaping may remain addicted, but they are reducing their risks of relapsing back to smoking which is far more harmful. The same is true for licensed nicotine products (NRT), which are licensed by the medicines regulator to help people stop smoking and prevent relapse back to smoking, the main reasons why ex-smokers vape.

One analysis of US surveys of youth use between 2012 and 2019 found that young people who vape but don’t smoke are much less likely to be strongly nicotine dependent than those who smoke. There has been no limit on nicotine concentration in e-cigarettes in the US, and the concentration tends to be much higher (5% or 50 mg/ml) than the 2% or 20 mg/ml maximum allowed in the UK.

However, it is important to keep monitoring this, as there are some signs that dependency on vaping products might be changing over time.

Disposable vapes deliver as much nicotine as 50 cigarettes: NO

 The claim that disposable vapes contain, and deliver, as much nicotine as cigarettes has been repeated by, for example, the Times, the Mail, the Daily Express, and Cosmopolitan sometimes citing sources, sometime not. This claim is not true.

The Sun said between 40 and 60 cigarettes,  but did at least clarify that it was not implying that this was equivalent in harm to this many cigarettes, as they don’t contain many of the harmful toxins to be found in cigarettes, which many articles fail to do.

Cigarettes generally contain 10 to 15 mg nicotine per rod, which is 200 to 300 mg per pack of 20 cigarettes. A UK standard disposable vape with the highest legal level of nicotine (20 mg/ml) contains 2 ml of liquid which amounts to 40 mg of nicotine.

On average each cigarette delivers 1.0 to 1.5 mg nicotine into the bloodstream of the smoker, a total of 20 to 30 mg for a packet of 20 cigarettes. Most of the nicotine from cigarette tobacco is delivered into the air as secondhand smoke.

On average about 50% of the nicotine contained in a vape is absorbed by the person vaping. That amounts to 20 mg of nicotine which is at the lower end of the amount of nicotine the average smoker will take in from smoking a pack of 20 cigarettes.

Moreover, only 3% of current vapers in the ASH adult survey used nicotine strengths above the legal limit of 20mg/ml of nicotine. The most frequently used strength was 1-3 mg/ml which is equivalent to between 1 and 7 cigarettes. Of the children who have tried vaping, eight out of ten say they use nicotine-containing vapes. Two thirds (64%) most frequently used at the legal limit or below, a quarter (27%) said they didn’t know. Fewer than one in ten (8%) used above the legal limit, most of whom used nicotine strengths of less than 30 mg/ml.

Furthermore, the amount of nicotine absorbed by an individual depends on how they vape, or smoke, their puffing patterns and how deeply they inhale. Those trying smoking or vaping for the first time, or who are inexperienced, are likely to absorb less nicotine.

Vaping is a proven gateway into smoking: NO

If vaping were a gateway into smoking at population level, as vaping increased smoking rates would be expected to show a reduced rate of decline or start to increase. To the contrary between 2010 and 2021 when e-cigarette use grew rapidly from a low base in England, smoking rates among children continued to fall at least as rapidly as previously, which does not support the gateway hypothesis at population level.

NHS digital data on current smoking rates among 11-15 year olds in England found that it fell from 9% in 2010 to 6% in 2016 and 3% in 2021.65 Among those aged 16+ smoking rates fell from 20% to 18% between 2010 and 2016, and 12% in 2021.

Data collected by the UCL Smoking Toolkit Study between 2007 and 2018, showed that the quarterly prevalence of e-cigarette use among the youth (16-24) population in England was not associated with detectable increases or decreases in the quarterly prevalence of smoking uptake.

Between 2021 and 2022, the use of disposable e-cigarettes in Great Britain grew rapidly, especially among younger adults, but the overall prevalence of inhaled nicotine use was stable over time, with the increase in vaping likely being offset by a decline in smoking among young adults.68 The ASH survey finds a clear upward trend in vaping among 11-17 year olds between 2013, the first year of our youth survey, and 2023, while smoking prevalence continues to be on a downward trend.

Moreover survey data shows that children who tried vaping in the US between 2014 and 2017, compared with matched children who did not try vaping, were equally likely to try a cigarette but less likely to progress to regular smoking.

However, it is important not to be complacent and to keep monitoring behaviour, particularly among the age of cohorts most associated with smoking initiation. Vaping products are continuing to evolve, and inaccurate perceptions of the risk of vaping are continuing to grow, both of which could change behaviour. Young people in particular are still dealing with the aftereffects of the COVID pandemic, and mental distress in young people has grown in recent years (mental distress is associated with higher smoking rates and greater dependency.

Furthermore, it should not be ignored that vaping could be a gateway into smoking for some individuals, although for others vaping could be a gateway out of smoking. Causation is hard to prove as some children who try vaping first may go on to smoke cigarettes, but this association works both ways, and there are

common risk factors for both behaviours (e.g., parental smoking, risk-taking and impulsivity); making it hard to prove that vaping caused subsequent smoking. The theory that vaping is a gateway into smoking is supported by some peer reviewed analyses, but not by others.

Nicotine damages brain development in young people: NO

 Nicotine Replacement Therapy (NRT) is on the WHO list of essential medicines needed to meet the priority healthcare needs of populations, because there is good evidence of efficacy, safety and comparative cost-effectiveness. NRT is licensed by the MHRA for smoking cessation, not just by adults but also by young

people from age 12 upwards, pregnant women and people with cardiovascular disease.

Systematic reviews of the evidence have concluded that evidence is insufficient or unavailable regarding the effects of nicotine and non-nicotine e-cigarette use on development in children and adolescents, and neurological conditions.

Furthermore the UK Committee on Toxicity, which was asked to review the evidence of the toxicity of e-cigarettes, concluded that no data were available on direct effects of nicotine exposure in human adolescents, and that while animal studies showed that there was biological plausibility of an impact on development, “the Committee had reservations about trying to quantify the effects of nicotine in humans from the animal studies as the relationship of the dosing to human exposures is not clear.”

Nearly 90% of lifetime smoking in the UK was initiated between 10 and 20 years of age, and there is, therefore, longer-term evidence concerning the impact on the brain of adolescent smoking. A Scottish study following up a cohort of children born in 1932 who had their IQ tested at age 11, found that at age 70 there was no difference in cognitive function between never and ex-smokers, once IQ had been controlled for, but that there was a small negative association between cognitive function and smoking in old age. If adolescent smoking doesn’t damage cognitive function, it is implausible that adolescent vaping would.

The main reason children vape is because they like the flavours: NO

The main reason children give for vaping is ‘to give it a try’, cited by a quarter (26%) of those who have smoked tobacco and more than a half (54%) of those who have never smoked. The next most common reason is because ‘other people use them, so I join in’, in other words peer pressure, cited by 21% of ever smokers and 18% of never smokers. Liking the flavours comes third on the list, cited by 16% of ever smokers and 12% of never smokers as their reason for trying vaping.

Banning or restricting flavours brings with it the risk of increased cigarette consumption. In the US where flavour bans and restrictions have been imposed on e-cigarettes, sales data have shown that although there has been a consequent decline in e-cigarette sales, there has also been a significant rise in consumption of

cigarettes. The authors noted that 38% of the impact on cigarette sales stemmed from a growth in sales of cigarettes disproportionately consumed by youth. While increased smoking among adults will almost entirely be due to former smokers relapsing back to smoking, among children it is likely to be a combination of increased initiation and relapse.

A decision tool developed by academics at the University of Bristol concluded that, based on the available evidence, a flavour ban would lead to increased smoking. As a result there would be a negative net population impact of a flavour ban, both in the general UK population and low-socioeconomic position UK population, who have higher than average smoking rates

Link: https://ash.org.uk/uploads/Addressing-common-myths-about-vaping-ASH-brief.pdf?v=1691052025