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WHO versus Public Health England over e-cigarettes

Controversy over the World Health Organization’s publication in January of negative information on e-cigarettes, has been followed by a new Public Health England report on 28 February 2021 that e-cigarettes help smokers to quit and are 95% safer than smoking, writes MedicalBrief.

Another key finding of the review by Kings College London, is that vaping products containing nicotine were the most popular smoking cessation aid in England last year.

In January, Science reported that new warnings about vaping from WHO prompted strong pushback from public health experts in the United Kingdom, who accused WHO of spreading “blatant misinformation” about e-cigarettes.

To add to the confusion, several studies have reported that use of e-cigarettes among youth is a gateway to adult cigarette use. One study, from the University of California – San Diego – reported that young people who used e-cigarettes were three times more likely to become daily cigarette smokers than those who did not.

In the United States, the rise of vaping among young people in recent years has sparked public and health sector outrage. This has continued even though the proportion of young Americans who vape has since declined. The health messages to the public have remained highly negative, backed up by reams of research that begs to disagree with PHE.


Public Health England Report: E-cigarettes help smokers quit

A new report from Britain’s top public health organisation adds to the growing mountain of evidence that vaping, e-cigarettes and ‘heat-not-burn’ alternatives are effective tools for getting cigarette smokers to quit, significantly lowering their health risks, writes Michael McGrady for InsideSources on 28 February 2021.

The new evidence update recently released by Public Health England (PHE) also reconfirms that health risks from vaping are 95% lower than for traditional combustible cigarettes. It is a message many anti-tobacco activists in the US continue to resist.

This is the seventh independent review of data by tobacco control and substance abuse experts at King’s College Londonon behalf of the PHE, the British government’s equivalent to the Centers for Disease Control and Prevention. One key finding: vaping products that contain nicotine were the most popular aid products used by smokers trying to quit in England in 2020.

According to InsideSources, the report also found more than 50,000 smokers stopped smoking in 2017 through the aid of a vaping product. This despite the fact 38% of smokers still erroneously believe vaping is as harmful as traditional smoking. Indeed, 15% believe vaping is more harmful.

“The best thing that a smoker can do is to stop smoking completely and the evidence shows that vaping is one of the most effective quit aids available, helping around 50,000 smokers quit a year,” said John Newton, the director of health improvement at PHE.

“The evidence has been clear for some time that, while not risk-free, vaping is far less harmful than smoking.”

Newton’s remarks are profound, considering the sentiments surrounding e-cigarette use in the United States, InsideSources points out. Former President Donald Trump presided over policy that directly harmed the product category and its potential as a risk-reduced nicotine product.

“Today’s report from Public Health England is great news for vapers,” Michael Landl, the director of the World Vaper’s Alliance, told InsideSources. “We have further confirmation [that] vaping is a way out of smoking. Those who continue to claim that vaping is a gateway to smoking should take the time to read the science.”

Though he represents a consumer group based in the European Union, Landl notes that PHE’s findings run counter to the alarmist messages many governments use to curtail cigarette use.

“‘Listen to the science’ is something we’ve heard a lot lately with COVID but hopefully those that continually criticise vaping will this time,” said Landl. “They cannot continue to pick and choose the science that suits them.”

Many anti-tobacco advocates concede that moving from traditional cigarettes to other options, like ‘heat-not-burn’ and vaping, is an improvement for adults. However, they claim vaping presents a risk to children – teens in particular.

“Rightly, since e-cigarettes emerged as an alternative to smoking, the government has sought to strike a balance between helping smokers to quit and protecting children,” said Deborah Arnott, the CEO of ASH UK — a tobacco control advocacy group in England.

InsideSources continues: “As ASH research included in the report for PHE shows, e-cigarette use among 11 to 18-year-olds has to date remained low, but on the downside, their potential as an adult quitting aid has not been fully realised.”

Still, anti-tobacco groups continue to lobby against vaping and other smoking alternatives, despite the significant difference in health risks. Their approach is to promote total prohibition, rather than risk reduction.

David Sweanor, a professor of law at the University of Ottawa in Canada, told InsideSources: “With there being so much manufactured confusion and media focus on scare stories and bad science, there is a huge need for a highly reputable health authority to provide an authoritative summary of the facts.”


Vaping in England: 2021 evidence update summary

Public Health England

Published on 23 February 2021

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

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.

Link to the Public Health England report below.


Science – WHO warning on vaping draws harsh response from UK researchers

New warnings about vaping issued this week by the World Health Organization have prompted strong pushback from public health experts in the United Kingdom, who charged that WHO was spreading “blatant misinformation” about the potential risks and benefits of e-cigarettes, wrote Jennifer Couzin-Frankel in Science on 22 January 2021.

The pointed exchange comes amid growing controversy over the value of e-cigarettes, and how to weigh their role as a smoking cessation tool against their potential harms, especially among young people for whom vaping has soared in popularity.

The statements align with others made by UK public health officials in recent months, which have generally supported vaping as a useful alternative to traditional cigarettes. In contrast, WHO’s cautions about vaping echo those voiced by the US Centers for Disease Control and Prevention and some US scientists, who are expressing alarm over both known and still-uncertain hazards from vaping.

The Science article continues: After an outbreak of severe lung disease that’s still being investigated and is linked to THC-containing e-cigarettes, CDC now recommends that e-cigarettes of all kinds “never be used by youths”.

In a just-published document, WHO expressed reservations about the value of e-cigarettes and grave concerns about their risks. The organisation stated that “there is no doubt” that e-cigarettes “are harmful to health and are not safe, but it is too early to provide a clear answer on the long-term impact of using them or being exposed to them.”

WHO also suggested “there is not enough evidence to support the use of these products for smoking cessation,” and urged smokers looking to quit to try nicotine patches or gum, or other tools such as hotlines that counsel smokers.

The UK response was harsh, Science reports. “The WHO has a history of anti-vaping activism that is damaging their reputation. This document is particularly malign,” Peter Hajek, who directs the Tobacco Dependence Research Unit at Queen Mary University of London, wrote in a statement released today by the UK Science Media Centre.

“There is no evidence that vaping is ‘highly addictive,’” he said. “Less than 1% of non-smokers become regular vapers. Vaping does not lead young people to smoking – smoking among young people is at [an] all-time low. … There is clear evidence that e-cigarettes help smokers quit,” Hajek continued.

E-cigarettes are “clearly less harmful” than tobacco, said John Britton, director of the UK Centre for Tobacco & Alcohol Studies and a consultant in respiratory medicine at the University of Nottingham, in similarly critical comments. “WHO misrepresents the available scientific evidence,” he charged.

Also in January, a team of six experts disputed PHE’s 95% claim in a publication in the American Journal of Public Health. The authors, said Science, suggested there is an “accumulation of evidence of potential harm” from e-cigarettes and “growing evidence that e-cigarette use is associated with subsequent cigarette smoking.”

The short- and long-term risks of e-cigarettes continue to be investigated; whereas many believe the products are lower risk than cigarettes, others say the jury is still out.


WHO information – Tobacco: E-cigarettes

The World Health Organization issued the following information about e-cigarettes on 29 January 2020. It is in a Q&A format, with nine questions clicking through to WHO information, after the introduction below:

There are many different types of e-cigarettes in use, also known as Electronic Nicotine Delivery Systems (ENDS), with varying amounts of nicotine and harmful emissions. ENDS emissions typically contain nicotine and other toxic substances that are harmful to both users and those exposed to the vapours second hand.


Youth using e-cigarettes three times as likely to become daily cigarette smokers

Age at first use and number of tobacco products consumed also increases addiction risk, according to material published by the University of California – San Diego, in January 2021.

An analysis of a large nationally representative longitudinal study by the university’s Herbert Wertheim School of Public Health and Human Longevity Science report that starting tobacco products, including e-cigarettes, before the age of 18 is a major risk factor for people becoming daily cigarette smokers.

Reporting in the January 2021 online edition of Pediatrics, researchers found that in 2014 people age 12 to 24 who used e-cigarettes were three times as likely to become daily cigarette smokers in the future. Among those who reported using a tobacco product, daily use increased with age through age 28. Daily cigarette smoking nearly doubled between 18 to 21 year olds (12%) and 25 to 28 year olds (21%).

“This is the first paper that actually looks at progression to dependent cigarette smoking among young adults. In these data, e-cigarettes are a gateway for those who become daily cigarette smokers,” said the study’s first author, Professor Emeritus John P Pierce.

“The start product has changed from cigarettes to e-cigarettes, but the end product has stayed the same. When users become dependent on nicotine, they are converting to cigarette smoking.”

Researchers used data from the Population Assessment of Tobacco and Health (PATH) Study, a longitudinal study of tobacco use and its effect on the health of people in the United States.

The PATH Study, undertaken by the National Institute on Drug Abuse and the FDA Center for Tobacco Products under contract to Westat, enrolled a nationally representative sample of 12 to 24 year olds between in 2013 and 2014 and re-interviewed them annually for four years to explore progression to daily use among experimenters of 12 tobacco products.

In the first year, 45% of study participants reported using at least one tobacco product in their lifetime. By the fourth year, as participants aged, 62% reported some tobacco experimentation.

Among those who have ever experimented with tobacco, 73% had tried cigarettes and 72% had tried e-cigarettes. Further, more than half tried hookahs and cigarillos. Traditional cigars, filtered cigars, smokeless products, pipes and snus were each tried by more than10% of study participants.

The analyses revealed that, by year four, 12% of participants were using tobacco products daily – half of whom became daily users after the first year. Seventy percent of daily users smoked cigarettes and most of them (63%) used cigarettes exclusively. Of those who smoked cigarettes and used another tobacco product, half vaped e-cigarettes on a non-daily basis.

Among the 17% of daily users who were vaping every day, almost half were also non-daily cigarette smokers. Further follow-up will determine whether these young daily tobacco users continue to use both products or whether they settle on a single product, said Pierce.

“What we’re seeing is that the proportion who are daily e-cigarette users did not increase with age. Whereas with cigarettes the number of users jumps up rapidly with age,” said Pierce. “This rapid increase with age only occurred with cigarettes, not with any other tobacco products.”

Less than 1% of study participants who experimented with just one tobacco product progressed to daily cigarette smoking. People who had tried five or more products increased their risk of becoming daily cigarette smokers by 15%age points.

“Trying e-cigarettes and multiple other tobacco products before the age of 18 is also strongly associated with becoming daily cigarette smoking,” said senior author Karen Messer, professor at UC San Diego Herbert Wertheim School of Public Health and Human Longevity Science and director of biostatics at UC San Diego Moores Cancer Center.

“We know that e-cigarette use among high school seniors, most under the age of 18, increased from 38% in 2016 to 45% in 2019. These results suggest that recent rapid growth in adolescent e-cigarette use will lead to increased daily cigarette smoking among young adults in the United States, reversing decades of decline in cigarette smoking.”


Electronic cigarette use and risk of cigarette and smokeless tobacco initiation among adolescent boys: A propensity score matched analysis

Brittney Keller-Hamilton, Bo Lu, Megan E Roberts, Micah L Bermande, Elisabeth D Root and Amy K Ferketich

Author affiliation: University of California, San Diego; Ohio State University, United States.

Published in Addictive Behaviors, Volume 114, March 2021.



  • Causal inference methods were applied to observational, longitudinal research.
  • E-cigarette use increased risk of smoking cigarettes among adolescent boys.
  • E-cigarette use also increased risk of using smokeless tobacco.


Electronic cigarette (e-cigarette) use among adolescents is associated with increased risk of subsequent cigarette smoking initiation in observational research. However, the existing research was not designed to answer causal questions about whether adolescent e-cigarette users would have initiated cigarette smoking if they had never used e-cigarettes.

The current study used a causal inference framework to identify whether male adolescent e-cigarette users were at increased risk of initiating cigarette smoking and smokeless tobacco (SLT) use, compared to similar boys who had never used e-cigarettes.


Boys from urban and Appalachian Ohio (N = 1220; ages 11–16 years at enrollment) reported use of e-cigarettes, cigarettes, and SLT at baseline and every six months for two years. A propensity score matching design was implemented, matching one e-cigarette user to two similar e-cigarette non-users.

This analysis was completed in 25 multiple imputed datasets to account for missing data. Risk ratios (RRs) comparing risk of initiating cigarettes and SLT for e-cigarette users and nonusers were estimated.


Compared to non-users, e-cigarette users were more than twice as likely to later initiate both cigarette smoking (RR = 2.71; 95% CI: 1.89, 3.87) and SLT (RR = 2.42; 95% CI: 1.73, 3.38).

They were also more likely to become current (i.e., past 30-day) cigarette smokers (RR = 2.20; 95% CI: 1.33, 3.64) and SLT users (RR = 1.64; 95% CI: 1.01, 2.64).


Adolescent boys who used e-cigarettes had increased risk of later initiating traditional tobacco products when compared to similar boys who had never used e-cigarettes.


[link url=""]InsideSources article – Public Health England Report: E-Cigarettes Help Smokers Quit (Open access)[/link]


[link url=""]Public Health England – Vaping in England: 2021 evidence update summary (Open access)[/link]


[link url=""]Science article – WHO warning on vaping draws harsh response from UK researchers (Open access)[/link]


[link url=""]World Health Organization guidelines – Tobacco: E-cigarettes (Open access)[/link]


[link url=""]University of California, San Diego, material – Youth Using E-cigarettes Three Times as Likely to Become Daily Cigarette Smokers (Open access)[/link]


[link url=""]Addictive Behaviors article – Electronic cigarette use and risk of cigarette and smokeless tobacco initiation among adolescent boys: A propensity score matched analysis (Restricted access)[/link]




[link url=""]The health pros and cons of e-cigarettes – Evidence ambivalence[/link]


[link url=""]Australian GPs willing to prescribe e-cigarettes to help patients quit[/link]


[link url=""]JAMA editorial: Research strengthens case for e-cigarettes for smoking cessation[/link]


[link url=""]Oxford review: E-cigarettes versus traditional nicotine replacement therapies[/link]


[link url=""]E-cigarettes are no better than alternative aids to quit smoking – US study[/link]



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