Burning issue: Vaping can help adults quit smoking – but is it a gateway to cigarettes for kids?

Vaping exposes you to about 2,000 chemicals, which seems a lot — but it’s way below the toxicant count of 7,000 chemicals in tobacco smoke. 

“Vaping poses a small fraction of the health risks of smoking,” says a spokesperson for the Nicotine Research Group, King’s College London.

The New Nicotine Alliance Ireland aims to “promote mature discussion on the potential of safer nicotine products to reduce harms from smoking”. 

Damian Sweeney of NNA Ireland says: “Vaping [unlike conventional smoking] doesn’t involve combustion, and any potentially harmful products are vastly reduced compared to smoking.”

NNA Ireland’s website says: it “accepts funding donated by private individuals and organisations. We do not accept donations from the tobacco industry, the electronic cigarette industry or manufacturers/distributors of other nicotine products.”

Ireland has the third highest per capita spend on e-cigarettes in the world, according to a 2018 Euromonitor report. This was pointed out in the Irish Vape Vendors Association (IVVA) 2021 pre-Budget submission. Based on these figures, it said spending on e-cigarettes was almost €70m in 2018.

“I talk to ex-smokers all the time who never thought they could give up ’til vaping came along,” says Joe Dunne of Respect Vapers, which claims to represent vapers in Ireland and is funded by the Edmund Burke Institute. Ninety-five per cent of the people Respect Vapers represents are aged over 35, he says.

“Some switch to vaping and then continue smoking until they get used to vaping, and then they transition fully to vaping. A lot start with a higher strength of nicotine. About 65-70% would lower the strength over time with a view to then going down to a very low level,” Dunne explains.

According to the Healthy Ireland 2022 study, 3% of the population currently use e-cigarettes, with a further 3% reporting they’ve tried them in the past but no longer use them. Use of e-cigarettes is highest among under-25s, with 6% in this age group currently using them.

Meanwhile, 2019 figures show that 38% of those who tried to quit smoking used e-cigarettes during the attempt, according to the IVVA. 

“It’s always great news when someone chooses to quit smoking,” says Mark Murphy, advocacy manager (environmental health and tobacco) with Irish Heart Foundation. “It’s the best thing you can do for your health.”

Murphy says the Irish Heart Foundation recognises that long-term adult smokers have quit, using e-cigarettes. But he cautions that many who use vaping to quit conventional smoking, continue to use e-cigarettes long after they’ve kicked their smoking habit. A 2019 study published in New England Journal of Medicine found that 19% of participants who used e-cigarettes to quit smoking were no longer smoking a year later, but 80% of them were still vaping.

And while vaping bypasses the harmful combustion involved in conventional smoking, it is not harm-free, warns Murphy, pointing to a 2019 study in the European Heart Journal. “It showed e-cigarette smoking can damage the heart, the brain, the lungs, and blood vessels. We just don’t know what the long-term health consequences of vaping are.”

Smoking is an addiction

Dr Paul Kavanagh, HSE public health medicine lead with the Tobacco Free Ireland Programme, says make no mistake about it — smoking is an addiction. 

“It’s not a choice. It’s not a bad habit. It’s a physical and psychological addiction to nicotine. And as with any addiction, we need to get the right supports to break it — help with the physical and psychological components.

This, he says, is where “the safe, effective, clinically-sound” supports offered by the HSE Quit Programme come in. “The approach is a combination of speaking with a stop smoking advisor, as well as a safe, effective, licensed stop smoking medication, like nicotine replacement therapy. Using these services increases chances of stopping smoking four-fold.”

In early 2022, Ireland’s first national stop-smoking guidelines were published. Developed under the governance of the Department of Health’s National Clinical Effectiveness Committee, Kavanagh says they used a robust, comprehensive, evidence-based process. “So we can stand over these guidelines as being the most clinically-sound approach to stop smoking.”

Key questions were asked when trying to decide whether e-cigarettes could be recommended as a way to stop smoking. First: are they an effective way?

“We found mixed results. Some studies had positive findings, some negative, many had methodological weaknesses. There was quite low confidence in the evidence to say e-cigarettes were effective in helping people stop smoking.”

The second question was whether e-cigarettes are a safe tool to stop people smoking. 

“We found they’re associated with a number of harms across different body systems, and they contain carcinogens that cause lung, mouth, oesphagus, and bladder cancers. The carcinogens relate to the heating and inhalation of the chemicals in e-cigarettes,” says Kavanagh, adding that long-term follow-up is needed to establish definitively their harm profile.

Pointing out that e-cigarettes are a consumer product, not a licensed medicine, he says: “As a doctor, when I recommend the HSE stop smoking medicine, I know it has been through a rigorous system of [medical] checks and balances. A consumer product doesn’t benefit from those checks and balances.”

In November, the Government approved proposals to ban the sale of e-cigarettes to under-18s. The proposals will be incorporated into the Public Health (Tobacco and Nicotine Inhaling Products) Bill, which it’s hoped will move through all legislative changes this spring.

But currently, there’s no legal protection to safeguard young people and adolescents from the sale of e-cigarettes. 

“Ireland is a real outlier in this. If a teenager were to walk into a shop anywhere they could be sold an e-cigarette, and the liquid, without any accountability for the retailer,” says Kavanagh.

For this reason, he believes any recommendation around e-cigarettes’ potential role in helping people quit smoking has to be balanced against the “very insufficient protection from harm” current Irish law offers children/young people when it comes to e-cigarettes.

Kavanagh also points to certain medical situations — for example, patients with cancer — where risky treatments are offered in the absence of any safer alternative. But when it comes to e-cigarettes and their stop-smoking role, he says we have “a whole range” of safe, clinically-sound alternatives. “So why would we consider taking all the risk and uncertainty of e-cigarettes when there are so many free clinically-tested alternatives?”

Anyone, regardless of medical card status, once they come to the free face-to-face consultation with a stop-smoking adviser, can avail of free nicotine replacement therapy — patches, sprays, lozenges or gum.

Kavanagh says many HSE Quit stop smoking advisers, working countrywide, have told him they’ve been approached by parents/teachers increasingly worried about e-cigarette use in children. An email he received one evening last year told of a parent with a child in their early teens. “He’d become addicted to the nicotine in vaping and was so addicted he found it difficult to sit still in class because he was suffering withdrawal from nicotine.”

The 2019 ESPAD study, which looks at the prevalence of substance abuse among European teens, has reported an increase in e-cigarette use among young people in Ireland. 

Among 15/16-year-olds, the number who ‘had ever’ used e-cigarettes went from 23% in 2015 to 37.2% in 2019. And figures for ‘current use’ rose from 10.1% in 2015 to 18.1% in 2019.

It’s quite a concern that in five years e-cigarette use among mid-teens almost doubled,” says Kavanagh, adding that — four years on again — he strongly suspects the situation is even more worrying than in 2019.

While vaping is considered by many ex-smokers as having been their gateway out of smoking, the worry is that for many vaping children/under-18s it may well be a gateway into smoking conventional cigarettes. 

Kavanagh points to a Health Research Board study that found an association between a child’s e-cigarette use and their then starting to use combustible cigarettes. 

“Children who hadn’t smoked but who started vaping were three to five times more likely to smoke conventionally combustible cigarettes than children who never vaped.”

“If a child starts smoking early, it’s incredibly harmful to their health. If they start in adolescence, they’re likely to become very firmly addicted and being a lifetime smoker,” he warns.

The Government’s Tobacco Free Ireland 2025 strategy aims to reduce prevalence of smoking to five percent or less by 2025. However, the decline in smoking rates among the general population and teens has stalled and reversed in the past few years.

For the first time in 25 years smoking among 15–16-year-olds has increased. The rate was 41% in 1995, fell to 13.1% in 2015 and has now increased to 14.4%.

The Tobacco 21 Alliance is calling for the legal age of sale of all forms of tobacco, and e-cigarettes, to be increased from 18 to 21, as evidence shows it reduces youth smoking and deters initiation.

Worrying level of youth vape use

At the Irish Heart Foundation, Murphy points to the normalising of the hand-to-mouth action, common to vaping and to conventional smoking. He too has heard anecdotal reports of teachers and students worried about youth vape use. And he believes the Government should be doing much more to protect young people from e-cigarettes.

“E-cigarettes are very cheap. They can be easier to hide because they don’t have the [tobacco] smell. We [at Irish Heart Foundation] believe there should be a complete ban on flavoured vapes and on bright packaging.”

With the WHO counting 16,000 different flavours of vapes — bubblegum, gummy bears and banoffi pie to name a few — Murphy says these attract young people, initiate them into vaping and suggest they’re not harmful. “They’re so easily available to young people and they come in bright packaging. They look like a box of starbursts.”

Dr Garrett McGovern, medical director and GP specialising in addiction medicine at Priority Medical Clinic, Dundrum, says an age restriction on e-cigarettes “should be implemented without delay”, but he cautions against throwing the baby out with the bathwater.

“Probably about 70% of people using e-cigarettes choose flavours. If you’re going to ban flavours without any evidence that young people wouldn’t then go for tobacco, you might be taking them from the smokers wanting to quit and who they can help.”

According to the IVVA, 99% of vapers in Ireland are either smokers or ex-smokers — and ‘never smokers’ make up less than 1% of users. So in working to protect “a small group of vapers” and take away flavours, McGovern says we don’t want to do so “to the detriment of people who need them”.

So how do we balance the needs of two sectors? The smokers who use them to quit and for many it is an effective gateway out — though there are safe, clinically-sound alternatives — versus the children and teenagers whose use of e-cigarettes is growing and where vaping may well be a gateway into tobacco smoking. 

This debate is set against the backdrop of a very hazy picture when it comes to vaping’s long-term potential adverse effects. And these we simply don’t know yet.

• HSE Quit Programme is easy to access, with no waiting list, and is free. Phone 1800 201 203

This article was first published on February 17, 2023.