Research and analysis

Vaping in England: 2021 evidence update summary

Published 23 February 2021

Applies to England

Aim of the report

This is the seventh report in a series of independent reports commissioned by Public Health England (PHE) to summarise evidence on vaping products to inform policies and regulations.

Smoking remains the largest single risk factor for death and years of life lived in ill-health and is a leading cause of health inequalities in England and in other parts of the world.

Alternative nicotine delivery devices, such as nicotine vaping products, could play a crucial role in reducing the enormous health burden caused by cigarette smoking.

This report covers the latest evidence on prevalence and characteristics of vaping in young people and adults in England, with a particular focus on data emerging since the last vaping evidence report published in early 2020.

This report also includes an update of the evidence on the impact of vaping products on smoking cessation, last examined in detail in the 2018 e-cigarettes and heated tobacco products evidence report.

Terminology

The term ‘vaping products’ describes e-cigarettes and refill containers and e-liquids.

The term ‘vapers’ refers to people who regularly use vaping products and ‘vaping’ as the act of using a vaping product. These terms do not include cannabis vaping or the vaping of other illegal substances, which are not the subject of this report.

Recent developments

COVID-19 has had a devastating impact worldwide. For the purposes of this report, it has affected the implementation of routine surveys and has also likely affected both vaping and smoking behaviours in England.

The COVID-19 pandemic is the subject of much ongoing research and it is too early to assess its full impact on vaping and smoking at the time of writing.

The government has introduced new regulations, The Tobacco Products and Nicotine Inhaling Products (Amendment) (EU Exit) Regulations 2020, to make sure the UK meets its obligations in relation to tobacco control and vaping product policies under the European Union (Withdrawal Agreement) Act 2020. The new regulations include the notification mechanisms for the sale of vaping products in Great Britain (a new system) and Northern Ireland (the previous EU system). These regulations ensure fees are only paid once when products are notified to both databases. The government is also reviewing other regulations in relation to the European Union (Withdrawal Agreement) Act 2020.

The UK government has committed to review the Tobacco and Related Products Regulations (TRPR) (which govern nicotine vaping products) by 20 May 2021, to assess whether the regulations have met their objectives.

Since non-nicotine containing vaping products are less strictly regulated (through the General Product Safety Regulations 2005) than nicotine-containing products, they may need to be reviewed along with the review of the TRPR. As other non-tobacco nicotine products, such as nicotine pouches, emerge in England it seems appropriate to review regulations for these products at the same time.

Medicinally licensed nicotine vaping products are exempt from the TRPR and currently there is no licensed product in England.

Selling vaping products to anyone aged under 18 and buying vaping products for anyone under 18 are prohibited. Violations of the age of sale law for nicotine vaping products (and cigarettes) have been reported. A 5-year report on these regulations is due. There is a loophole in the legislation which allows free samples of vaping products to be given to people of any age.

Between 20 May 2016 (implementation of TRPR) and 5 January 2021, the Medicines and Healthcare products Regulatory Agency (MHRA) received 231 reports of 618 adverse reactions believed to be associated with nicotine containing vaping products through its Yellow Card scheme. Each report represents a person for whom more than one adverse reaction could have been reported. A report is not proof that the reaction was caused by a vaping product, just that the reporter thought it might have been.

Since 20 May 2016, the MHRA reported that there have been 3 fatalities in the UK linked with vaping products, one of which appeared to meet the criteria for ‘e-cigarette, or vaping product, use-associated lung injury’ (EVALI).

A safety review by the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) concluded that the risk of adverse health effects from vaping products is expected to be much lower than from cigarettes. The review found that exposure to particulate matter and nicotine could be associated with adverse health effects and that the effects of inhaling flavouring ingredients is uncertain. The COT also suggested people who had not smoked tobacco but vaped would likely experience some adverse health effects.

A government consultation in 2019 outlined a new ambition to go smokefree in England by 2030. It also included an ultimatum to industry to make smoked tobacco obsolete by 2030, with smokers quitting or moving to reduced risk nicotine delivery systems, such as vaping products.

The government’s tobacco control plan for England, which sets out ambitions for 2022, remains in place, although a new tobacco control plan for England is expected to be published in July 2021.

Implications

The smokefree 2030 goal, developing a new tobacco control plan and reviewing the TRPR provide an opportunity to review all vaping (and other nicotine and tobacco) regulations to ensure that they are appropriate and help smokers quit, while managing the risk of uptake for never smokers.

As outlined in the Smokefree Action Coalition’s roadmap to a smokefree 2030, becoming smokefree by 2030 will require greater resources and the coalition proposed legislating to require tobacco manufacturers finance a ‘Smokefree 2030 Fund’.

The next tobacco control plan for England provides an opportunity to set intermediate targets for smoking in different disadvantaged groups.

The lack of a medicinally licensed product needs also to be urgently reviewed.

Research is needed on the areas of concern outlined in the COT review.

Methods

The report uses 2 surveys for information on vaping and smoking among young people in England:

1. The Action on Smoking and Health Smokefree Great Britain Youth Survey of 11 to 18 year olds, 2020 (ASH-Youth, 2020).
2. The International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Survey of 16 to 19 year olds, 2019 (ITC Youth).

For information on vaping among adults in England, the report uses information from 4 surveys:

1. The Smoking Toolkit Study, 2020 (STS).
2. Action on Smoking and Health Smokefree Great Britain Adult Survey, 2020 (ASH-Adult, 2020).
3. The Opinions and Lifestyle Survey, 2019 (OPN).
4. The Internet Cohort Great Britain survey, 2019 (ICGB).

The 2019 Annual Population Survey (APS) was used to estimate smoking prevalence.

To identify the available evidence on vaping for smoking cessation and reduction, we conducted a systematic review of the available, peer-reviewed literature.

Data from NHS Digital were used to provide information on stop smoking services in England between April 2019 and March 2020.

The MHRA provided information on suspected adverse events for vaping products between May 2016 and January 2021.

Vaping among young people

Main findings

Data reported in this chapter were collected in September 2019 (from the ITC Youth survey) and in March 2020 (from the ASH-Youth survey). So, conclusions in this chapter do not consider the potential impact of COVID-19 on vaping and smoking among youth.

ASH-Youth survey data (11 to 18 year olds) showed:

• smoking prevalence (including those who smoked sometimes or more than once a week) in March 2020 was 6.7% (compared with 6.3% in March 2019) and has changed little since 2015 when it was 7.1%
• little change in levels of vaping over the last few years with current vaping (at least once per month) prevalence being 4.8% in March 2020, the same as in March 2019

The ITC Youth survey data (16 to 19 year olds) showed:

• smoking prevalence at 6.2% (defined as smoking more than 100 cigarettes in their life and having smoked in the past 30 days)
• current vaping prevalence at 7.7% (defined as vaping on more than 10 days in their lifetime and having vaped in the past 30 days)

Based on the socioeconomic status of 11 to 18 year olds, the estimates for smoking and vaping prevalence were higher among more advantaged groups in social grades A, B and C1 (7.1% for smoking, 5.3% for vaping) than for more disadvantaged groups in social grades C2, D and E (5.7% for smoking, 3.5% for vaping).

Most young people who had never smoked had also never vaped. Between 0.8% and 1.3% of young people who had never smoked were current vapers.

Most current vapers were either former or current smokers.

The main reasons for vaping were to:

• “give it a try”
• “for fun/I like it”
• “liking the flavours”

Of the 11 to 18 year olds who vaped, 11.9% reported doing so to quit smoking.

More 11 to 18 year olds who had tried vaping said they had:

• smoked first (45.4%)
• vaped before they smoked (20.6%)
• tried a vaping product and never tried smoking (28.9%)

Tank models, which are reusable and rechargeable kits that users can refill with liquid, were the most popular model of vaping product, used by 49.1% of 11 to 18 year olds who currently vaped. The use of models which use prefilled cartridges has increased from 17.6% in 2019 to 34.2% in 2020.

Fruit flavours were the most popular among current vapers. This was followed by menthol/mint, then ‘chocolate/dessert/sweet/candy’ flavours.

Three-quarters of current vapers aged 11 to 17 bought their vaping products despite sales to under-18s and proxy purchases being illegal.

Under half (43.0%) of 11 to 18 year olds who were current and former vapers reported always using vaping products that contained nicotine – 17.3% reported always using nicotine-free products. Three out of five (61.3%) 16 to 19 year olds who had vaped in the past 30 days used nicotine in their current product – 17.3% said their product did not contain nicotine.

The most common nicotine strength used by 16 to 19 year olds who had vaped in the past 30 days was under 20 milligrams per millilitre (mg/mL) (54.0%). One-fifth (19.6%) of participants did not know the strength of their vaping liquid, 18.0% used a strength of 20mg/mL or over, and 6.6% used 40mg/mL or over.

Over half (56.6%) of 16 to 19 year olds who vaped in the past 30 days currently used nicotine salts, 30.6% did not use nicotine salts and 12.8% were unsure.

Over half (58.2%) of 16 to 19 year olds who had vaped in the past 30 days did not feel addicted to vaping but 38.5% said they felt a little or very addicted.

Just under a fifth (18.4%) of current vapers aged 11 to 18 reported experiencing urges to vape almost all the time or all the time.

The proportion of 11 to 18 year olds who thought that vaping was less harmful than smoking had declined to 43.3% in 2020, from 66.7% in 2015.

Current use of heated tobacco products was rare among 11 to 18 year olds (0.5%). Among 16 to 19 year olds, 2.6% reported ever using nicotine pouches (half of those used them in the last month) and 4.1% reported ever using smokeless tobacco (a third of those used them in the last month).

Implications

Vaping and smoking prevalence among young people in England both appear to have stayed the same in recent years and should continue to be closely monitored.

Enforcement of age of sale regulations for vaping (and smoking) needs to be improved.

Misperceptions of the relative harms of smoking and vaping should be addressed.

More research is needed on the apparent differences in the prevalence of smoking and vaping in different socioeconomic groups among young people (higher in more advantaged groups) and adults (higher in more disadvantaged groups).

More research is needed on the addictiveness of different types and strengths of nicotine vaping products among young people and the extent to which they are using illegal products.

Vaping among adults

Main findings

Data reported in this chapter came from 4 different surveys. Most data were from the STS, collected between January and October 2020, and the ASH-Adult survey, collected in February and March 2020. Other data were collected in 2019.

Smoking prevalence among adults in England continues to fall and was between 13.8% and 16.0% depending on the survey, equating to about 6 to 7 million smokers.

There was some variation in smoking prevalence by socio-demographics, such as a higher prevalence among adults from more disadvantaged groups. There was also variation between surveys, most notably for smoking prevalence in young adults (24.1% in STS compared with 10.8% in ASH-Adult for 18 to 24 year olds).

Vaping prevalence was lower than smoking prevalence across all groups and continues to be around 6% (between 5.5% and 6.3%), equating to about 2.7 million adult vapers in England.

There was some variation in vaping prevalence by socio-demographic groups and smoking status. Using STS data, 7.2% of men, 7.7% of people in the north of England and 7.6% of people from social grades C2, D and E vaped. Vaping prevalence was between 17.5% and 20.1% among current smokers, around 11% among former smokers and between 0.3% and 0.6% among never smokers. Around 10% of long-term former smokers (quit for longer than 1 year) vaped, compared with 24% of short-term former smokers (quit for less than 1 year).

The proportion of vapers who also smoke has declined since 2012, from 74% to 38% in the ASH-Adult and from 92% to 51% in the STS survey. The discrepancy is likely due to different definitions of smoking status.

Among adults who had ever vaped, over half (57.4%) of never smokers had tried it once or twice and 6.1% were vaping daily. Among those who had ever vaped, more than half (56.3%) of former smokers and around 30% of current smokers vaped daily.

Among long-term former smokers, a decreasing proportion used nicotine replacement therapy (NRT) – an increasing proportion used vaping products, between 2013 and 2020.

The proportion of current vapers who have vaped for more than 3 years appears to be increasing (23.7% in 2018, 29.3% in 2019, 39.2% in 2020). The proportion of new current vapers who have vaped for less than one month in 2020 was 2.6% (5.5% in 2018, 5.1% in 2019). People who had vaped in the past mostly stopped after 6 months of use or less (59.9% in 2020).

The most common reasons for vaping reported in the ASH-Adult survey were to: quit (29.7%), stay off (19.4%) or reduce (11.2%) smoking tobacco. In the OPN 2019 survey, 52.8% of current vapers reported vaping to quit smoking.

Most vapers (around 75%) used tank models.

Strengths above those allowed by regulations (more than 20mg/mL of nicotine) were used by less than 5% of vapers. Use of non-nicotine liquids may be more common among vapers from social grades C2, D and E.

Just over half of vapers (51%) reported reducing the strength of the nicotine liquid they use since starting to vape. Just 1.1% of people who started on non-nicotine liquids moved to vaping nicotine.

Fruit (31.6%), tobacco (25.2%) and menthol/mint (20%) were the most popular flavours among vapers.

In the ICGB survey of adults with a history of smoking and vaping, vapers tended to think they were less addicted to vaping than smoking. However, a perception of being more addicted to vaping than smoking may be more common among dual users who smoke and vape and those using disposable devices or nicotine salts.

Perceptions of the harm caused by vaping compared with smoking are increasingly out of line with the evidence. The STS survey found that:

• 29% of current smokers believed vaping was less harmful than smoking
• 38% believed vaping was as harmful as smoking
• 18% did not know whether vaping or smoking was more harmful
• 15% of smokers believed vaping was more harmful than smoking

Misperceptions were more pronounced among smokers from social grades C2, D and E.

Use of heated tobacco products by adults in England was estimated at 0.3% and use of nicotine pouches at 0.5% in 2020.

Implications

The proportion of long-term vapers is increasing over time and further research into this group is needed.

As recommended in previous reports, in this series and as outlined in National Institute for Health and Care Excellence guidance on stop smoking interventions and services, all smokers should be supported to stop smoking completely, including dual users.

A greater emphasis needs to be placed on how best to communicate evidence of relative harm to smokers so that they can consider all the options available to them to quit smoking completely.

Vaping is more common among more disadvantaged adult groups in society. This mirrors smoking prevalence, and research should continue to explore the effect this has on health inequalities.

Further research should be carried out on addiction among vapers of different types of vaping products, nicotine types and flavours used.

Effect of vaping on smoking cessation and reduction

Main findings

The following are the main findings from nationally representative survey data (STS).

1. Using a vaping product is the most popular aid used by people trying to quit smoking. In 2020, 27.2% of people used a vaping product in a quit attempt in the previous 12 months. This compares with 15.5% who used NRT over the counter or on prescription (2.7%), and 4.4% who used varenicline.

2. Vaping is positively associated with quitting smoking successfully. In 2017, over 50,000 smokers stopped smoking with a vaping product who would otherwise have carried on smoking.

3. Prescription medication and licensing NRT for harm reduction were also positively associated with successfully quitting smoking. This shows how important it is for people who smoke to have access to a wide choice of cessation aids.

4. The extensive use of vaping products in quit attempts compared with licensed medication suggests vaping products may reach more people who smoke and so have more impact than NRT and varenicline.

The following are the main findings from English stop smoking services data.

1. Between April 2019 and March 2020, 221,678 quit dates were set with a stop smoking service and 114,153 (51%) of these led to self-reported quits 4 weeks after the quit date.

2. A vaping product was used in 5.2% of quit attempts. This was either using the vaping product alone, at the same time, or following use of a licensed medication.

3. Consistent with findings in our previous reports, the highest quit rates (74%) were seen when the quit attempt involved people using a licensed medicine and a vaping product one after another.

4. Quit rates were similar for people using a vaping product and licensed medication at the same time (60.0%), a vaping product alone (59.7%) and varenicline alone (59.4%).

5. Quit rates involving a vaping product were higher than any other method in every region in England. These ranged from 49% in the South West to 78% in Yorkshire and the Humber.

An ASH survey of tobacco control leads found that only 11% of local authority stop smoking services offered vaping products to some or all people making a quit attempt.

The following main findings are from systematic review data. This includes data from 6 systematic reviews and meta-analyses, 4 randomised control trials (RCTs) and 13 non-randomised studies published since the 2018 evidence review.

1. Three systematic reviews and meta-analyses of moderate to high quality included 15 RCTs that evaluated the effect of vaping on smoking cessation or reduction.

2. The 3 systematic reviews consistently found vaping products containing nicotine were significantly more effective for helping people stop smoking than NRT. This finding was supported by 2 non-randomised studies that reported higher quit rates among people using a vaping product who attended a stop smoking service, compared with those who used NRT.

3. Findings of meta-analyses of RCTs were inconclusive about whether vaping products with nicotine are more effective than those without nicotine or behavioural support. However, when studies with a high risk of bias were excluded, the pooled results of RCTs suggested that nicotine containing vaping products were more effective.

4. Quit rates among participants in the non-randomised studies ranged from 7% to 36% in participants with a clinical condition (including a mental illness, substance misuse or HIV/AIDS) and from 11% to 62% in people recruited from non-clinical settings. It is important to note that most of these non-randomised studies were single group before and after studies and so were inherently biased.

5. Many of the vaping products used in the RCTs included in the systematic reviews are now outdated and used low nicotine strength. In most studies, tobacco flavour was the most common e-liquid flavour offered and participants were not given the choice of flavours. No RCT and only one non-randomised intervention study included a vaping product with nicotine salts.

Implications

Studies show that tens of thousands of smokers stopped as a result of vaping in 2017, similar to estimates in previous years.

Compared to the 2018 review, there is stronger evidence in this year’s report that nicotine vaping products are effective for smoking cessation and reduction.

As suggested in previous evidence reviews, combining vaping products (the most popular source of support used by people making a quit attempt in the general population), with stop smoking service support (the most effective type of support), should be an option available to all people who want to quit smoking.

Local authorities should continue to fund and provide stop smoking services and all stop smoking services should have a consistent approach to using vaping products.

Further research is needed to assess whether smokers who use stop smoking services and vaping products differ from smokers who use the services and other smoking cessation aids.

Further research is needed into the barriers and enablers to using vaping products as part of a supported quit attempt in stop smoking services.

Studies including newer types of vaping products that have better nicotine delivery are needed.

As we have stated in previous reports, the strict inclusion and exclusion criteria of RCTs mean that they do not apply to many people in real-world clinical settings or people in the general population who smoke or vape. These RCTs require strict adherence to particular intervention measures (for example, type, dose, duration and frequency) which also does not reflect what happens in real life.

Vaping technology has become more sophisticated and varied, and the people who vape have become more heterogeneous. So, new and flexible ways of conducting observational studies and RCTs are needed to allow for user experimentation (for example trial and error of different types of vaping products, allowing for changes in preferences over time).

Authors and citation

Suggested citation

McNeill, A., Brose, L.S., Calder, R., Simonavicius, E. and Robson, D. (2021). Vaping in England: An evidence update including vaping for smoking cessation, February 2021: a report commissioned by PHE. London: PHE.

Authors

Ann McNeill, Leonie Brose, Robert Calder, Erikas Simonavicius, Debbie Robson.

King’s College London.