Lost in the cloud: How vaping was undermined by a moral panic

New data shows that vaping is by far the most effective way to stop people smoking. It’s about time we acclimatise ourselves to the evidence.

Photo by Giorgio Trovato on Unsplash

Vaping is one of the most successful public health products of the last decade.

It is the single most effective way to get people to stop smoking. It has the ability to save millions of lives and may have already done so. And yet it is maligned, mocked, scolded, restricted and and sometimes banned. Even in a relatively tolerant regulatory environment like the UK, vaping is so unpopular that politicians will attack it to boost their popularity. “Who actually asked for this?” Andy Burnham said on Instagram recently. “Another vape shop… another dodgy business opening where something useful used to be.”

The social disdain towards vaping is not just foolhardy, it is actively harmful to public health. I have listened many times, grinding my teeth, as smokers tell me that they wouldn’t dare switch to vape because it’s too dangerous. A madness. I have visited several countries which literally have a tougher regulatory regime against vapes than they do against cigarettes. Insanity.

In spring, I went to Australia. I travelled via Doha in Qatar on my journey out and then, because of the Iran war, via Kuala Lumpur in Malaysia on my way back. Throughout that trip, I did not touch foot in a country where vaping is fully legal and accepted. In Qatar, vapes are banned. In Australia, they can only be sold in a pharmaceutical setting. In Malaysia, they were very heavily restricted and the government recently approved a full nationwide prohibition. And yet in every single one of these countries, cigarettes are freely available. That is a lunatic state of affairs. No-one with even a cursory grasp of the science would ever propose such a thing.

People will give you all sorts of reasons why they dislike vaping. They don’t like the sickly sweet smell of it when someone unleashes a cloud on the street. They worry about it introducing a new generation to nicotine addiction, they worry about the waste, they worry that vaping allows tobacco companies to access a new consumer base. These are all valid, to various degrees. But the real reason vaping is unpopular is much simpler. It is because it is pleasurable.

Somewhere deep in our minds is an inflexible Protestant assumption that quitting an addiction must be painful. We imagine the raw-dog sobriety, the empty flat with a mattress on the floor and hallucinatory images of horror-babies crawling across the ceiling, the tension and suffering, the virtue that comes from purity and denial.

We imagine suffering and assume that suffering must be a core part of the cleansing process provided by abstinence. This is because we project onto drugs many of our own neuroses about our lack of discipline and gluttony.

This is a problem and not just because it is puritanical and quasi-religious and utter fucking nonsense. It’s a problem because it is ineffective. As I’ve written before, the best first step to draw someone away from a drug is not to demand that they stop doing it. It is to get them to change the delivery mechanism. This separates their simple addiction to the substance from all the associations which they have with it - the ritual, the social scene, the smell, the connected physical effects.

For many people, abstinence provides salvation. But for most, the best way to break an addiction is to transition to a close approximation of the thing they like while removing as many of the harmful effects as possible. In the case of nicotine this is actually fairly easy to achieve, because the drug itself is harmless - it is the associated effects of smoking that are dangerous.

Vaping is therefore a tremendously helpful invention. It heats a liquid - usually comprising propylene glycol, glycerin, nicotine and flavouring and the resulting aerosol is inhaled by the user. This closely replicates the cigarette experience, but without the toxins or the combustion. No tar, no known carcinogens, no carbon monoxide.

The history of vaping is essentially the history of trying to replicate the act of smoking as closely as possible, initially visually and ultimately through the bodily experience. There have been three waves. The earlier models were called cig-a-likes, and were typically designed like fake cigarettes. They looked the part, but had very low nicotine levels. Later, vapes were primarily sold with tanks, which users could fill with a liquid of their choice - mixing flavours and nicotine strengths. This was much more effective, but aesthetically and sensually it pulled them further from the cigarette experience. It was also very DIY, a techie hobby with notes of wine tasting.

Then came nicotine salt. This was the holy grail. The salt allowed for the delivery of higher nicotine levels with an instant impact on the brain, replicating almost exactly the pharmacokinetic profile of nicotine delivery from cigarettes. They felt like a cigarette: in the draw, in the throat, in the mind, in the blood. And they could do so with small batteries, meaning they were light and small. This is when brands like Lost Mary took off and vapes began to move from specialist shops to the till at the newsagent.

Naturally they became popular with teenagers as well as adults. This is not good. Vaping should be for people quitting smoking, not for people looking for fun. But we need to remember that teenagers often smoke. Less so than before, and in often dwindling numbers, but they do. We are therefore not starting at a baseline of zero. Many of these kids would have otherwise started smoking, but now they start vaping, which is much safer. Should we be complacent about it? No. Should we try to stop it? Yes. But also we should not adopt the naive but seemingly very popular view that this is some fresh new epidemic, rather than a partial substitute for what would have been happening anyway.

The success of vaping triggered an associated moral alarm about colourful packaging and flavours. A recent Mirror article, for instance, stated without the remotest critical assessment that vapes were “being targeted at children with bright colours and fruit flavours”. Then-health secretary, Wes Streeting, who really is quite staggeringly foolish on this issue, said that kids were “no doubt enticed by bright packaging, sweet flavours and aggressive promotion”.

The packaging of vapes is garish and ugly. I would actually welcome some kind of modest regulation in this area because it might lead to more sophisticated packaging. But there is something a bit weird about the idea that coloured packaging and fruit flavours appeal only to children. Look at the other products on a supermarket shelf. Look at the magazine rack. Look at the list of TV shows on a streaming service. They have colours.

The same is true for fruit flavours. I am 44 years old. I eat mangos. They are nice. Mangos are not the preserve of pubescent children. Fruit flavours are enjoyed by adults and children alike. The government will likely ban fruit flavoured vapes soon, but this is a testament to the growing hysteria around this issue rather than any kind of rational analysis.

In 2019 there was a health scare. Some 2,800 people were hospitalised and 68 people died in the US from severe lung injury connected to vaping. At the time, experts were baffled. None of the data pointed to this kind of immediate severe health risk. Eventually it was discovered that there were rigged black market drug vapes - cannabis products adulterated with vitamin E acetate. But the popular impact was severe, around the world. This is the point where people started believing that vapes were much more dangerous than they really were. I remember vaping next to a woman outside a bar in the US. “You should be careful,” she told me, as she put her cigarette in her mouth and lit it. “Those things will kill you.” I felt as if I was losing my mind.

There’s been a raft of anti-vaping legislation around the world. Bans, sure, but also pointless prohibitions. The EU Tobacco Products Directive, for instance, does not allow sales of liquids with nicotine content higher than 20 mg/mL. This is simply a very silly thing to legislate for. Nicotine itself is not harmful. Upping the nicotine level is precisely what helps smokers make the switch. It’s the kind of thing you do if you adopt an Old Testament view towards the horror of addiction as a concept, rather than embrace the goal of harm minimisation.

This week, the Cochrane Library released its latest review of vaping as a method to help people quit smoking.

Cochrane reports are the gold standard, they are Christmas for nerds. Cochrane provides arguably the highest tier in evidence-based medicine. This is because it is a systematic review - a synthesis of all available evidence using randomised controlled trials on a specific clinical question. It therefore escapes the problems with single studies - a defect there, a lack of data here. Instead, it brings the existing quality evidence base together for an overview.

Cochrane has been running this review since 2014. The latest update includes an additional nine studies, bringing it to a total of 80, representing 29,861 participants. Forty studies were conducted in the USA, 16 in the UK, six in Australia, five in Greece, and then a smattering from Italy, New Zealand, Canada, Belgium, Finland, the Netherlands, the Republic of Korea, Switzerland and Turkey.

The core purpose of the project is to find out what is most effective to get people off cigarettes: Vaping with nicotine, vaping with no nicotine, nicotine replacement therapy like the traditional patches or gum, or no help at all except for behavioural support - the raw dog approach. It also aims to see whether there are any negative health effects from vaping.

The introduction to the report highlights the specific point on the role of pleasure and why we might try to replicate it rather than condemn it. It is rational, clear-sighted and concerned truthfully about reducing smoking rather than enforcing a purification ritual.

Until vapes were invented, smokers were handed these little packs of nicotine-replacement-therapy-hell by the NHS: gum, patches, and in my case, back in the day, a stress ball. It was that final item which let me know, with utter certainty, that the person who devised this pack had never smoked. It was like trying to cure someone’s loneliness by giving them a photo of a human face.

“One of the limitations of traditional nicotine replacement therapies,” the Cochrane review found, “is that, apart from providing nicotine more slowly and at lower levels than smoking, none adequately addresses the sensory, behavioural, and/or social aspects of smoking that people who have smoked miss when they stop (e.g. holding a cigarette in their hands, taking a puff, their enjoyment of smoking, and feeling part of a group).” In other words: the pleasure.

Interestingly, qualitative studies found that vapers shared a sense of identity with other users and report pleasure and enjoyment of use. This, the authors found, suggests that electronic cigarettes “may be viewed less as medical cessation aids but rather as acceptable alternatives to tobacco smoking”.

That right there is the sweet spot. That’s exactly where we want to be: with someone who wants to give up smoking, wondering if they’ll ever be able to do it, looking at one of these devices in the newsagent and thinking - fuck it, might as well give it a go. Someone thinking of this act not as denial but as alternate pleasure.

There was never any moral panic about nicotine gum. Why? Because it never gave anyone any pleasure. But this, of course, was also why it was ineffective. There is a panic about vaping, because it does give pleasure. But the very variable which makes it so objectionable is precisely why it is so effective.

The results of the review are strong. It found that nicotine vapes were more effective than nicotine replacement therapy, increasing the success rate by about 60%, from around six in every 100 managing to quit smoking to one in every ten.

For what it’s worth - and I appreciate this is me shooting my mouth off rather than science - I suspect even this is an underestimate. Anyone who knows smokers would report that vaping helped more than one in ten get off cigarettes. You get a sense of why that might be when you delve into the individual studies in the Cochrane review. Twenty‐three studies, for instance, exclusively recruited participants who were not motivated to quit smoking. That’s a harsh dataset. One study provided users with a vape that had nicotine levels so low the researchers just went ahead and incorporated it into the non-nicotine vape studies. That’s unlikely to be particularly effective to help someone off cigarettes.

This is not a flaw in the Cochrane review, it is an advantage. It’s the kind of thing which makes the results so convincing, by showing how tough the system is to game. With that breadth of data, any positive result shows really strong signs of validity. And what we can now say with a very high degree of certainty, on the basis of the Cochrane review, is that vaping is hands down the most effective method of getting people off cigarettes.

How harmful is vaping? There are three basic conclusions. First, that it is safer than smoking cigarettes. Second, that we do not yet know the long-term effects. And third, that we need more data.

Levels of toxicants are substantially lower than in cigarettes. A report by the Royal College of Physicians found, on the basis of existing knowledge of liquid constituents and patterns of use, that vaping is likely to be much safer than smoking. It concluded: “The hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed five per cent of the harm from smoking tobacco.” The US National Academies of Sciences, Engineering, and Medicine reached a similar decision. It said: “Laboratory tests of e-cigarette ingredients, in vitro toxicological tests, and short-term human studies suggest that e-cigarettes are likely to be far less harmful than combustible tobacco cigarettes.”

This is a new consumer product and the findings are therefore necessarily uncertain. “Moderate‐certainty evidence does not show a difference in serious adverse effects for the nicotine electronic cigarette compared to nicotine replacement therapy comparison or in adverse effects for the nicotine electronic cigarette compared to non‐nicotine electronic cigarette comparison,” the Cochrane review concluded. “For all other outcomes in this category, evidence is of low or very low certainty. Imprecision remains a key issue for these outcomes.” Ultimately, we need more time and more data. “Longer‐term health effects are unknown,” the report said. “This uncertainty should reduce as more studies become available.”

Vaping could well turn out to be dangerous. There is some tentative evidence of elevated respiratory risk and impaired blood vessel function. We should be clear though: An absence of evidence does not mean that we can treat all outcomes as equally likely. This need for further data has let opponents of vapes insinuate a degree of risk which is unreasonable given the existing evidence base and to produce excessively high thresholds for satisfying that risk assessment.

Here’s Streeting again: “While we do not know the long-term effects of many vape ingredients or the harms inhaling the contents and flavouring of vapes, given their widespread use is relatively recent, the expert advice is clear they are unlikely to be beneficial.”

That is simply not a sane test of how we should evaluate this product. No-one is claiming vapes are beneficial. And anyone looking at this area aiming for benefit rather than harm prevention has lost the right to act as a decision-maker, because they clearly have no idea what they’re saying.

Simply because we cannot yet say something with any certainty does not mean that we know nothing. We can come up with expectations of risk by virtue of what we know about the substances and use-patterns. That is why there is a strong expectation that the danger levels are so much lower than for cigarettes: Because of our existing knowledge about carcinogens, tar, and the impact of liquid constituents.

Some countries have decided it is not worth the risk and banned vapes until we know for sure they are safe. This would make sense if vaping were taking place in a vacuum or if it functioned as a replacement for something harmless. If this were a new kind of raisin, for instance, or a different type of tea then it would make sense to take a precautionary approach. But it is not. It is a replacement for a product which we know is harmful. And not only that, it is the most effective replacement for that product. In that context, taking a precautionary approach is a kind of madness, a fundamental inability to weigh risk.

There is now a ruinous gap between the science and the media debate on this issue. We have a technology here that can save millions of lives, but countries around the world are regulating it out of existence, or restricting it so aggressively that it is kept out of reach of the people who need it. The UK is a comparatively enlightened regulatory environment in this area and even here the media debate is overwhelmingly critical.

At the heart of this discrepancy is our view of pleasure and our refusal to accept arguments about harm minimisation rather than moral judgement. It is our reluctance to accept the following proposition: A slighter safer pleasure is often the best way to address a dangerous one.

People will look at vapers, exhaling their great big cloud of smoke, and subconsciously clock that they are enjoying it, and thereby conclude that this is dangerous. In fact, it is precisely the fact that they are enjoying it which makes it an effective way of reducing that danger.

Odds and sods

This is your last call for Origin Story Live on Tuesday night - there’s still a few tickets left as I write this - where we will chart the decline of the right wing press through the story of one newspaper: the Daily Telegraph. It’s the story of how journalistic standards were betrayed, readers’ comments dictated the editorial agenda, and reporters lost their autonomy. Come drink some wine and revel in the complete epistemological breakdown of British conservatism in one of the most beautiful venues in London. Little taste below. Tickets available here. See you there.

We’ve got a new Origin Story this week on Section 28: the law which halted progress on gay rights and drove it into reverse. Nearly every moment in this story - the moral panic, the press hysteria, the bad actors, the political cowardice - resembles what is happening now to trans people. But it is ultimately a story of hope and how you organise resistance. As someone on BlueSky said: “Genuinely got quite emotional listening to this. I’m 34. I can remember the Section 28 debate and that cursed shite lasted in spirit for some years after it had been repealed. However we won. We fucking won.” Also there’s a bloke in it called Viscount Buttmaster.

My column in the i paper this week was on Andy Burnham’s policy towards Israel and the need for a tough response to the E1 settlement programme. You can read it here.

Cultural highlight of the week, without competition, was seeing Jack White in Hammersmith. Before we went in I told my partner that he is the last true rock star. This was a mistake, because I think she was imagining someone who looked very different. But what I really meant was that this man has a complete and unshakable conviction in the guitar. His gigs are basically a crunchy, snarling, sweaty act of worship towards this one musical instrument, a form of mass devotion.

The whole thing was thrillingly old-fashioned - no phones allowed, paper tickets - but really there is something timeless about him, as if he operates in a continuum between the 1950s and today. And to watch him perform is kind of to get lost in time.

I’m celebrating the missus’ birthday next week with a short trip away, so it’ll be an Ask Me Anything, then back to earth with a crash for the proper return of the political season. I’ve got plenty of left-over questions from last time but if you’ve any extra, send them my way by replying to this email. State if you want your name to remain anonymous.

Right, off we go kids - fuck off etc.