Research and analysis

Vaping in England: evidence update summary February 2019

Published 27 February 2019

1. Introduction

This report was commissioned by Public Health England to summarise evidence to underpin policy and regulation of electronic cigarettes in England. It focuses mainly on the latest evidence on prevalence and characteristics of electronic cigarette use in young people and adults in England.

The context for the report is that smoking remains the leading preventable cause of illness and premature death and is one of the largest causes of health inequalities. So alternative nicotine delivery systems, such as electronic cigarettes or e-cigarettes, could play a major role in improving public health.

Terminology

E-cigarette is a term that was commonly used when the first devices became available. These devices resembled tobacco cigarettes, but there has since been a rapid evolution of the technology and products. The shape of the products now varies enormously.

This variation means that the term e-cigarettes is no longer appropriate, and we are aware of discussions going on in the UK and internationally to develop common terminology. For this report, we continue to use the term e-cigarettes (EC) but we hope to replace this terminology in future reports, when a consensus has been reached.

2. Recent policy and guidance developments

2.1 Main changes

The National Institute for Health and Care Excellence (NICE) published guidance for health and social care workers on how to have an informed discussion about EC. The House of Commons Science and Technology Committee published a report on EC which included recommendations about harm reduction, smoking cessation, EC in mental health settings and regulation.

The Government responded with a command paper which broadly accepted the Science and Technology Committee’s recommendations. The response said the government is firmly committed to more research in this area and to a proportionate regulation system.

Following a consultation, the Committee of Advertising Practice (CAP) and the Broadcast Committee of Advertising Practice (BCAP) announced that they were lifting the blanket ban on making health claims in non-broadcast advertising for EC. It is currently unclear how the new guidance will be applied in practice.

New NHS guidance has followed recommendations on fire risks from our previous evidence reviews and placed EC in the same category as mobile phones.

The NHS Long Term Plan for England recommended a new universal smoking cessation offer for long-term users of specialist mental health and learning disability services. This will include the option for smokers to switch to e-cigarettes while in inpatient settings. Individual countries have amended their policies on EC to either further restrict their use or, in the case of Canada and New Zealand, promote their use as less harmful alternatives to tobacco smoking.

The US Food and Drug Administration announced actions to restrict the sale and marketing of EC to young people.

2.2 Implications

Overall, England continues to take small progressive steps towards ensuring vaping remains an accessible and appealing alternative to smoking.

If the House of Commons Science and Technology Committee’s recommendations are fully carried out by government, they have the potential to broaden this accessibility and appeal further, particularly in mental health settings, where smoking rates are high.

However, there is still no medicinally licensed EC in England, or anywhere else in the world. It is possible that more smokers may be attracted to vaping if a licensed EC was made available. Barriers to licensing and the commercialising of licensed products need further exploration.

3. Methods

We have used data from several surveys in the UK which assessed young people and adult vaping prevalence. We also drew on peer-reviewed publications of these surveys including any awaiting publication, for which we are co-authors.

We reviewed the international literature on vaping prevalence from 1 January 2017 to 5 November 2018 and examined data collected from local authorities on stop smoking services by NHS Digital from 1 April 2017 to 30 June 2018.

4. Vaping in young people

4.1 Main findings

In England and in Great Britain as a whole, experimentation with EC has steadily increased in recent years. However, regular use remains low, with 1.7% of 11 to 18 year olds in Great Britain reporting at least weekly use in 2018 (it was 0.4% among 11 year olds and 2.6% among 18 year olds).

Vaping continues to be associated with smoking. The proportion of young people who have never smoked who use EC at least weekly remains very low (0.2% of 11 to 18 year olds in 2018).

The latest smoking data used for measuring progress in reaching the goals of the Tobacco Control Plan for England are from 2016. The data indicated that 7% of 15 year olds were regular (at least weekly) smokers in 2016 (8% in 2014). The 2018 data is not yet available.

The proportion who haven’t smoked but have tried vaping is increasing. The extent to which these young people would have tried smoking if vaping had not been available is unclear.

The proportion of 13 and 15 year olds who have ever smoked declined steadily between 1998 and 2015, including after the introduction of EC. In this period, young people’s attitudes became more negative towards smoking. Further analyses of the period beyond 2015 are underway.

Studies from outside of the UK suggest a similar picture, with increasing experimentation and use of EC over time among youth. There is evidence from the US that increasing vaping is happening against a backdrop of reducing cigarette smoking.

4.2 Implications

Trends in smoking and vaping should continue to be monitored, particularly in the light of concerns in North America about youth smoking and vaping.

Surveillance is needed on purchase sources of EC by young people, as recommended in our previous evidence review.

More research is also needed on how young people move from EC to smoking and vice versa.

5. Vaping in adults

5.1 Main findings

Data from several representative surveys suggest that vaping prevalence among all adults in Great Britain has remained stable since 2015. In 2017 to 2018, estimates for prevalence were:

• 5.4% to 6.2% for all adults
• 14.9% to 18.5% for current smokers
• 0.4% to 0.8% for people who had never smoked
• 10.3% to 11.3% for ex-smokers (vaping prevalence declined as the time since they had stopped smoking increased)

Smoking prevalence ranged from 13.7% to 17.3% for the adult population but was substantially higher in lower socio-economic groups (for example, 35% in people living in social housing smoked).

Just over a third of all current smokers had never tried EC.

Use of EC in quit attempts is similar across socio-economic groups. Among long-term ex-smokers, EC use is higher in those from lower socio-economic groups. This suggests that those from higher socio-economic groups are using EC to quit smoking and then stop use, while those from more disadvantaged groups continue to use EC.

Overall, we found no clear association among past and current vapers between how long people use EC, the devices they used and socio-economic status.

There are possible associations between lower socio-economic groups and higher strength of nicotine, amount of liquid used and a greater variety of EC flavours used.

Over time, most vapers report either continuing to use the same nicotine strength (44.7% of participants in one survey, 54.4% in another) or reducing the nicotine strength (40.1% and 49.2% respectively in the same surveys).

One survey indicated that over time most vapers tend to stick to a single flavour type (tobacco, fruit, menthol were the most popular types).

Quitting smoking remains the main reason for vaping in all socio-economic groups. People from higher socio-economic groups were possibly more likely to vape for enjoyment than those from lower groups, who may be more likely to vape for financial reasons than those from higher groups.

Internationally, the US appears to have similar adult vaping prevalence as Great Britain. In other countries where information is available, prevalence is lower.

5.2 Implications

More research is needed to explore the use of EC by different social grades.

Trends need to be monitored, particularly of EC use by never smokers, use alongside smoking and in long-term ex-smokers.

Given the importance of stopping smoking completely, smokers using EC should be advised to quit smoking as soon as possible.

Smokers should be advised to stop smoking as soon as possible and explore all available options for support, including EC.

6. Use of e-cigarettes in English stop smoking services

6.1 Main findings

Monitoring data from stop smoking services have limitations, but such data suggest that using an EC as part of quit attempt continues to be helpful for people attending stop smoking services in England.

In stop smoking services, the proportion of quit attempts using an EC remains very small (4.1% of all quit attempts in stop smoking services).

There is inconclusive evidence to support suggestions that EC have contributed to the decline in demand for stop smoking services in England.

6.2 Implications

Combining EC (the most popular source of support used by smokers in the general population), with stop smoking service support (the most effective type of support), should be a recommended option available to all smokers. This proposal from our previous evidence review is still valid.

Stop smoking practitioners and health professionals should provide behavioural support to smokers who want to use an EC to help them quit smoking.

Stop smoking practitioners and health professionals supporting smokers to quit should receive education and training on using EC in quit attempts. Online training is available from the National Centre for Smoking Cessation and Training (NCSCT).

Local authorities should continue to fund and provide stop smoking services, in line with the evidence base.

7. Authors and citation

7.1 Suggested citation

McNeill A, Brose LS, Calder R, Bauld L & Robson D (2019). Vaping in England, an evidence update, February 2019. A report commissioned by Public Health England. London: Public Health England.

7.2 Authors

• Ann McNeill (King’s College London)
• Leonie S Brose (King’s College London)
• Robert Calder (King’s College London)
• Linda Bauld (University of Edinburgh, Cancer Research UK)
• Debbie Robson (King’s College London)