If you’re trying to quit smoking, instead of a stick of nicotine gum or an adhesive square to slap on your upper arm, your doctor could soon hand you an e-cigarette. England could be the first country in the world to allow prescription e-cigarettes, following an announcement on October 29 that the UK Medicines and Healthcare Products Regulatory Agency, the United Kingdom’s medicines regulator, is now inviting manufacturers to submit products for approval.
If an e-cigarette device passes the steps required for licensing, doctors will be able to prescribe it to patients who want to quit smoking. E-cigarettes are thought to outperform traditional smoking cessation aids for a number of reasons: They are more effective at alleviating tobacco withdrawal symptoms (grouchy mood, intense cravings to smoke, poor concentration), users can tailor the device to receive specific nicotine doses, and it gives smokers the sensation of smoking, in that they can hold something between their fingers and take a drag—all without the deadly smoke and tar that cigarettes deliver. And providing a medically licensed e-cigarette on prescription could tackle the barriers that put smokers off from trying them, such as cost or safety concerns. “Opening the door to a licensed e-cigarette prescribed on the NHS has the potential to tackle the stark disparities in smoking rates across the country, helping people stop smoking wherever they live and whatever their background,” said Sajid Javid, the UK’s health and social care secretary, in the news release.
Smoking still reigns supreme as a leading cause of preventable death in the UK and the US. Every year, more than 8 million people globally die prematurely due to tobacco use, meaning we lose the equivalent of the population of Switzerland annually to a preventable death. “There’s been a global pandemic that’s now more than half a century old, which kills vastly more people than Covid. Nobody’s really treating it anymore as an emergency,” says Vaughan Rees, director of the Center for Global Tobacco Control at Harvard University. Efforts to depopularize smoking have been eclipsed by population growth, meaning that the number of smokers is now at an all-time high, at 1.1 billion. Without support to stop, only 4 percent of smokers quit for good.
But prescriptions will only go ahead if an e-cigarette product designed for smoking cessation proves to be commercially viable to manufacture and sell, which has yet to happen. Manufacturers have been able to submit devices to the MHRA for approval for years but haven’t, “probably because they would struggle to provide sufficient evidence of effectiveness,” says Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine.
Although a contentious issue, the research does suggest that e-cigarettes are an effective tool to quit smoking. A randomized trial in The New England Journal of Medicine found that e-cigarettes do help people quit, and were more effective than traditional smoking cessation aids, such as patches and gum. The latest Cochrane review concluded that nicotine e-cigarettes probably do help people to stop smoking for at least six months, and they probably work better than nicotine replacement therapy and nicotine-free e-cigarettes.
The announcement is yet another hint that the tide may be turning on the demonization of e-cigarettes. On October 12, the Food and Drug Administration in the United States announced that, for the first time ever, it was authorizing a tobacco-flavored e-cigarette from the company Vuse to be sold in the US as an alternative for smokers who want to quit cigarettes. “The FDA determined that the potential benefit to smokers who switch completely or significantly reduce their cigarette use, would outweigh the risk to youth,” the agency’s statement read. But the FDA did not authorize other flavored Vuse products for smoking cessation, including the fruity variants that teens tend to have a penchant for.
Much of the distrust toward e-cigarettes can be traced back to the youth vaping crisis that plagued the US; a study published in 2019 found that more than one in four high school students in the US were using e-cigarettes. The country also saw thousands of cases of vaping-associated lung injuries, with dozens of deaths, although many of the cases were linked to an ingredient called vitamin E acetate, often found in pods containing THC, the psychoactive ingredient in marijuana. (In Europe, the substance is banned from e-cigarettes.)
And nicotine, while substantially less harmful when not delivered through a cigarette, is not risk-free. It is highly addictive, and satisfying its addiction entails ingesting various dangerous chemicals in the process. Nicotine is also thought to harm brain development in young people. And one of the biggest arguments against e-cigarettes is that their use could be a potential gateway to smoking. A US study found that young people who experiment with e-cigarettes were three times more likely to become daily cigarette smokers a few years later than those who never dabbled.
But while the US has cracked down on the devices, and other parts of the world are even more skeptical—30 countries have banned the sale of all types of e-cigarettes—the UK has consistently been more accepting of e-cigarettes as a way of helping people to quit smoking. In fact, in 2019, two hospitals in England allowed an e-cigarette company, Ecigwizard, to open vape shops on their premises.
This follows a theory known as harm reduction: Encouraging smokers to swap their source of nicotine for a healthier alternative is better than forcing users to go cold turkey. “What we’re not saying is that e-cigarettes are 100 percent safe; what we’re saying is that smoking is uniquely deadly, and people can reduce their harm,” says Jamie Hartmann-Boyce, a senior research fellow at the Centre for Evidence-Based Medicine at the University of Oxford.
Much of the debate over e-cigarettes can be boiled down to: Do we help adults quit smoking, or do we protect young people from starting? “I think that’s just the completely false dichotomy of worth,” says Hartmann-Boyce. “When we talk about them as mutually exclusive, we’re missing a really big trick, and we’re also ignoring all the harm that is caused—particularly to less advantaged kids—by combustible tobacco use.”
The prescription initiative is most notably at odds with the World Health Organization’s stance that e-cigarettes are harmful to health. The agency’s hesitation comes much to the chagrin of many tobacco control researchers: In October, a hundred global experts signed an open letter to the WHO berating its anti-vaping attitude, and calling on the body to “modernize” its approach to tobacco policy.
“The World Health Organization is taking a fairly narrow view of the problem,” says Rees, who welcomes England’s move. “I think that it sends a strong signal that e-cigarettes represent something more than just a recreational device,” he says of the prescription initiative. “That’s an extremely important message, and something that I think the UK has got right, and I’d like to see that proliferate in other parts of the world.”
But the decision also presents an ethical quagmire: Many of the big e-cigarette products are, in fact, manufactured by tobacco firms. Vuse is owned by R. J. Reynolds, one of the world’s biggest cigarette companies; Altria, which owns the US division of Philip Morris, the world’s largest multinational tobacco company, has a 35 percent stake in Juul, the vaping giant. “One of the concerns from the tobacco control community is that the e-cigarette market will end up dominated by the tobacco industry, who have a long and sordid history of distorting science and damaging public health,” says Hartmann-Boyce. Jumping through the hoops required for medical licensing takes a significant amount of money, time and research—resources that the tobacco industry will much more likely be able to front than independent e-cigarette companies. “So we might end up in a situation where, inadvertently, the tobacco industry products are being favored.“
On the other hand, Rees argues, it may not necessarily be a problem if tobacco manufacturers quit selling combustible cigarettes and switch to something like e-cigarettes. “If this is the next best option, I suppose, reluctantly, I would be inclined to embrace it,” he says.