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Do e-cigarettes have the potential to make a significant contribution to a

reduction in smoking rates in the UK? What are the barriers and facilitators?

Student: dah00069

Student Number: 2433309

Word count excluding references: 3130

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As an innovative form of electronic nicotine delivery system (ENDS), encouraging the

uptake of e-cigarettes among more deprived communities could offer a way to reduce

the devastating disease and economic burden of tobacco across social gradients.1 As

well as policy interventions to prevent the uptake of smoking, sustained reductions in

smoking rates can only be achieved by limiting initial experimentation with tobacco

and supporting smokers to quit. Yet beyond national-level population data on the use

of e-cigarettes as a form of nicotine replacement therapy, little is known about their

relationship with deprivation in the UK. This essay explores the current inequities

literature to understand what barriers and facilitators are created by e-cigarettes

among deprived groups. As it is difficult to account for deprivation in research, often

requiring a proxy of low educational or socioeconomic status, this essay defines

deprivation as individuals meeting any criteria within the indices for multiple

deprivation used in England2 and Scotland3. These indices cover inequities in income,

employment, health, education, housing, crime, living environment and geographic

access to services. To this end, it does not look explicitly at the relative effectiveness

of e-cigarettes in relation to other NRT4 5, the emergence ‘heat-not-burn’ products, or

the harm-reduction narrative of tobacco industry actors in the e-cigarette debate6 7 8:

these are important questions that influence smoking cessation, but are either a

different form of ENDS or being explored in the literature elsewhere.

Using a frame of proportionate universalism, reducing smoking rates in the UK

to achieve an ‘end-game’ ambition and improve health outcomes will increasingly

require targeted interventions for vulnerable groups alongside population level

policies. And with smoking rates remaining stubbornly high among routine and manual

occupations in Great Britain9 10, a failure to support these smokers to quit has resulted

in the largest cause of social inequities in the UK, responsible for up to 11,000 extra

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preventable lung cancer deaths per year in England.11 12 With neighbourhood

deprivation associated with reduced willingness to use, complete and successfully quit

through a Stop Smoking Service in England, deprived groups may not be being

adequately targeted with existing cessation strategies.13 14 And given the growth and

sustained popularity of e-cigarettes, the declining but high prevalence of cigarette and

tobacco smokers in the UK15, and the prevailing evidence that e-cigarettes are less

harmful than smoking16 17 18, there is an opportunity to encourage deprived groups,

where smoking rates remain stubbornly high, to reduce cigarette smoking or make a

quit attempt with an e-cigarette. This essay emphasises the drawbacks in the

research, societal and political environments preventing this benefit – and the potential

for e-cigarettes in a harm-reduction strategy19 – from being realised, and proposes

opportunities to facilitate their use.

The most recent data for Great Britain demonstrates that 36% of current

smokers – 3.46 million people – have never used an e-cigarette.20 With the burden of

smoking falling mainly on the most disadvantaged, communicating the role of e-

cigarettes in a harm reduction approach could offer valuable opportunities for smoking

cessation. Yet, despite the current evidence showing e-cigarettes are far safer than

smoking, concerns about the perceived harms of e-cigarettes are a clear barrier to

uptake. At just 15%, Great Britain is experiencing the lowest level of public belief that

electronic cigarettes are a lot less harmful than smoking since data collection started.21

Evidence shows there is considerable uncertainty among participants about the

constituents, safety and harms of e-cigarettes among Scottish22 and British23 smokers

and ex-smokers. Despite advice from Public Health England (PHE) to encourage Stop

Smoking Services (SSS) to be supportive of, and provide advice on e-cigarettes24,

these concerns are reflected by SSS service staff. Here, staff have low levels of

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positive opinions about e-cigarettes and concerns they are detracting from service

footfall with only 2% of clients using e-cigarettes to quit25 26, and these concerns are

reflected in international research with quit-line staff.27 These concerns are shared by

service users, where evidence in England has found uncertainty and

misunderstanding around information on e-cigarettes as a cessation aid, particularly

among never users.28 29 Despite guidance on the benefits of services that support e-

cigarettes to promote cessation, a lack of compliance is problematic. And while only

the Scottish analysis of multiple deprivation factors access to services as an indicator,

the literature showing barriers to harm reduction for deprived groups also

demonstrates a need to consider geographic access to service provision when

discussing health deprivations in England. Overcoming this barrier requires a growth

in research about best practise of including e-cigarettes in cessation services. This

can inform national guidance and explore any unintended consequences specific to

deprived groups.

In addition, studies exploring the carcinogenic compounds of e-cigarette

vapour30 may dissuade individuals from uptake. But with smokers likely to have been

exposed to household, parental or environmental smoking cues as a trigger for

uptake31 32, reinforcing e-cigarette smoking behaviours could help to reduce smoking

rates by removing such cues. As well as replacing traditional smoking cues with e-

cigarette cues, re-inforcing negative smoking cues such as embarrassment or the cost

of cigarettes could also encourage deprived smokers to quit.33 To translate these cues

into meaningful quit attempts, and overcome concerns about misinformation over

relative health harms as a barrier to uptake, three approaches are required. Firstly,

building on Kozlowski’s work on updating the tobacco control narrative34,

communicating the extreme lethality of tobacco smoke is needed to educate users on

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the relative safety and lower perceived harms of e-cigarette vapour to reassure

smokers. 35 36 Secondly, understanding that every contact counts is vital, particularly

given more deprived smokers more reliably seek support from pharmacies than

SSS’s.37 This requires structured information that facilitates belief in the safety and

cessation potential of e-cigarettes, and promotes self-efficacy to switch, delivered by

smokers and health professionals alike as a valuable opportunity to cessation. And

finally, understanding which influencers best promote uptake of e-cigarettes as a

cessation aid in the UK is a non-existent area of research. Exploring these approaches

is vital to establish the touchpoints and tailored messages that invoke a quit attempt

using an e-cigarette among more deprived groups.

While 36% of smokers in Great Britain have never used an e-cigarette, there is

also no comprehensive data on the behaviours of the 64% who have. Not capturing

this data is a barrier for deprived groups to use e-cigarettes as a cessation aid, by

failing to understand variations in consumption patterns, teachable moments to

promote a quit attempt, or tracking motivations to quit. Similarly, despite research

identifying a need to understand variations in the use and awareness of e-cigarettes

by deprivation and lifestyle status38 39 40 only one statistical bulletin – the Opinions and

Lifestyle Survey41 – explores both tobacco and e-cigarette smoking behaviours. This

has made it difficult to understand the relationship between frequency of e-cigarette

use and socioeconomic status. Such research in Britain has typically been restricted

to adolescents. With only one study in Britain indicating higher adult use with increased

socio-economic status42 and only one more identified in press43, there is a clear need

for a British general population study and frequent cross-sectional time-series data to

establish sustained relationships with deprivation. This lack of understanding is also

reinforced by conflicting American evidence.44 45 One problem here may be that

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national surveys fail to link demographic variables like age, gender, education, race

ethnicity and smoking status to indices of multiple deprivation.46 47 There are also no

frequent longitudinal data on the use of e-cigarettes to reduce smoking rates with

important cohorts more at risk of deprivation, such as black and minority ethnic

(BAME) groups or those not in education, employment or training (NEET). Similarly,

this essay identified no literature exploring the benefits of e-cigarettes of reducing

smoking rates by LGBT status, risky sexual behaviour, disposable income or those

with existing morbidities. Specific methodological improvements to be addressed are

a standardised questionnaire to understand the benefits of e-cigarettes as a cessation

aid among deprived groups, and controlling for social desirability in self-reported

behaviours.48 With most research with deprived groups done through focus groups or

cross-sectional surveys, these improvements are necessary. This is particularly

apparent when data limitations are already impacting on research, with low statistical

power cited as a barrier to assess the association between e-cigarette availability and

area of deprivation in the UK.49 Addressing these methodological issues can remove

bias and establish an overdue set of standards for research that understand the

benefits of targeted cessation interventions using an e-cigarette.

As well as inadequacies in the evidence base, another barrier to encouraging

deprived smokers to use e-cigarettes and reducing smoking rates is the problematic

communication of the existing evidence base. Lower socioeconomic groups and

smokers, who typically have a lower health literacy50 51, may require lay-friendly and

concise information to promote a quit attempt. International evidence with

socioeconomically disadvantaged communities has suggested positively perceptions

of e-cigarette safety and effectiveness are associated with trying e-cigarettes and

higher levels of motivation to quit. 52 Accurately representing the e-cigarette evidence

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base and addressing concerns of social stigma from inaccurate coverage may provide

an environmental cue for smoking cessation. 53 But this accuracy requires overcoming

barriers. Firstly, content analyses of UK newspapers shows a frequent disagreement

over the use of e-cigarettes in public, fuelled by concerns over renormalizing or vapour

harms, confusion among the media itself and an unclear division between paid

advertising and news reports54 55. This confusion is furthered by sensationalist

misreporting of studies, such as presenting in vitro research on toxicity of propylene

glycol56 57 or acetaldehyde58 as causing real-world harms. Similarly, statistical

misreporting by using relative rather than absolute risks can infer disproportionately

high uptake in children,59 while Public Health England’s widely-publicised ‘95% safer’

statistic has also been criticised as implying absolute health harms rather than

explaining it reflects social and environmental considerations60. Finally, rare events

such as explosions61 or child consumption62 are highly publicised and could dissuade

from someone making a quit attempt, despite these also being problems for tobacco.

63

This lack of clarity has failed individuals seeking information about e-cigarettes.

But it also exists in academic and regulatory discourse, with high-profile disagreement

between restrictive positions adopted by the World Health Organisation (WHO), and

a Cochrane Review finding potential for e-cigarettes as a cessation aid. 64 This

disagreement predicates inconsistencies in the regulatory context, with restrictive

proposals on outdoor vaping in the Public Health (Wales) Bill65 directly contradicting

the evidence base. With research demonstrating UK adolescents in deprived

communities support sensible e-cigarette regulation in pursuit of positive health

outcomes66, there is a scope for deprived groups to overcome this barrier by taking an

increased role influencing policy decisions. In addition, supportive e-cigarette policies

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can increase awareness of the relative health harms of e-cigarettes compared to

tobacco67, and this impact should be better considered in public policy debates.

Embracing the role of policy to increase health awareness also offers an opportunity

to effectively communicate changes to e-cigarette marketing through the EU Tobacco

Products Directive, and support a narrative which promotes smoking cessation but not

glamorising products to children. Particularly for those of low health literacy, reframing

social attitudes towards e-cigarettes as a positive tool for harm reduction will be a vital

precursor to reduce smoking rates. To make e-cigarette a more appealing options for

deprived smokers to quit, sustained tobacco control policy activity such as the tobacco

duty escalator and comprehensive efforts to tackle the illicit trade can also reduce

access to ultra-low price forms of tobacco and limit environmental smoking cues. This

mitigates the price-sensitivity of more deprived groups to access other forms of

cheaper tobacco, and maintains a cost incentive for uptake.

This essay notes a conceptual barrier that as well improving as the quality of

information, how deprived groups disseminate and engage with cessation literature is

an important and under-explored area of research. Knowledge and engagement with

information about e-cigarettes is likely to differ by socioeconomic status, with

international research suggesting less deprived users search for information about e-

cigarettes, while those of lower educational status are more likely to share or promote

content.68 With smoking behaviours typically developed in adolescence, and heavy

users of social networking sites more likely to smoke, this is a window of opportunity

to prevent initial experimentation that could predicate long-term smoking behaviours.69

Defining these behaviours and key influencers with a UK cohort can inform a strategy

for message dissemination. Furthermore, communicating the health risks of smoking

as gain-framed or loss-framed will illicit different behavioural responses, with an

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international cohort expressing loss-framed messages about the relative harms of

tobacco, particularly among lifetime e-cigarette users and women.70 Furthermore,

considering preliminary evidence that YouTube is a popular avenue to promote the

harm reduction benefits of e-cigarettes71, the media consumption patterns of lower

socio-economic status groups favouring smartphone and video platforms72, pervasive

e-cigarette advertising and opportunities for data mining across Twitter73 and Reddit74,

and the intention of deprived e-cigarette users to promote content, there is a clear and

untapped opportunity to target cessation information using an e-cigarette to deprived

groups. These remain opportunities that extend beyond the traditional clinical framing,

and are under-explored in research.

A final barrier relates to economic concerns about the prohibitive start-up costs

of e-cigarettes. One hypothesis is more deprived groups can only afford poorer-quality

or earlier generation e-cigarettes, with cost associated as an issue for unemployed

young adults in Scotland.75 However, there is no evidence monitoring how deprivation

status influences purchase behaviours of different generations, the impact of free

promotions on intentions to quit, or evidence to support a start-up cost barrier. Though

a review of novel nicotine replacement therapy products has suggested new and

sophistically products are unlikely to be substantially cheaper than existing NRT76,

increased demand establishes the innovation, accessibility and relative affordability of

e-cigarettes. International research also suggests communicating this innovation

favourably could contribute to wider uptake.77 Communicating the financial benefits of

using an e-cigarette also present a ‘gain-framed’ prevention message. While the

particular appeal of this message has only been associated by age and smoking status

rather than deprivation status78, it can create a positive cue for price-sensitive deprived

smokers to quit. With 9% of e-cigarette users in Great Britain citing their main reason

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for vaping is the cost benefit, this question of cost is an opportunity to explore.79

But with the same survey showing 53% of current e-cigarettes users giving their

main reason to help quit smoking, there remains vast untapped potential to increase

smoking cessation. Despite a relatively small scope of 13 completed trials and only

two that addressed e-cigarettes as a cessation aid, a Cochrane Review demonstrates

there is evidence that using an e-cigarette with nicotine could help increase long-term

cessation chances compared to no nicotine.80 Preliminary international evidence

appears that deprived communities, from the homeless81 to illicit drug users82 and

prisoners83, are interested in the possibility of e-cigarettes as a cessation aid. While

UK evidence with priority groups is almost non-existent, and international evidence

has inferred a limited effectiveness of NRT-only interventions among indigenous

communities84, the prevalent evidence suggests e-cigarettes can offer an opportunity

to reduce smoking rates among deprived groups in the UK. They also offer the specific

benefit of improved health outcomes beyond non-communicable diseases, for

conditions where deprived groups are likely to be more at risk. This includes avoiding

negative changes in mental health85 86, understanding the harms of exposure to

second-hand tobacco smoke87, improved psychological wellbeing to tobacco cues88,

and promoting behaviour change through tackling poor self-efficacy89. Evidence is

also appeasing concerns that e-cigarette use re-normalises the behaviour of smoking,

with no evidence supporting it found in a comprehensive review.90 E-cigarette use

among deprived adolescents mirrors the trend for teenagers’ tobacco smoking in

England91, with sustained low levels of experimentation and regular use confined to

those who also smoke tobacco.92 Finally, to overcome lacking data on the economic

benefits of e-cigarettes discussed above, new models are being developed to better

assess their costs, benefits and public health impacts, though without methodological

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consistency.93 94

Finally, there are two research questions of particular interest that could

become facilitators for deprive groups to use e-cigarettes, and reduce smoking rates,

in the future. Firstly, UK data has suggested that daily e-cigarette use is associated

with reduced number of cigarettes smoked and increased cessation attempts, but not

with increased permanent cessation.95 While nicotine replacement products can be

used in complement to nicotine absorption from smoking96 it remains unclear whether

‘dual use’ improves cessation outcomes. Furthermore, this relationship is particularly

unclear for deprived groups, with conflicting international evidence on who dual users

are, either being of lower educational attainment, unemployed or out of work97, or

newer research with a larger sample suggesting dual users are more educated and

motivated to quit.98 Establishing this relationship could mean that even if the decline

in smoking rates were to stall, the number of cigarettes consumed by each smoker

can be reduced. Secondly, building on comments about smoking cues, the relationship

between smokers and vapers different generations of e-cigarettes with developing an

‘e-cigarette identity’ remains largely undefined. Understanding this identity can help

contextualise specific barriers or challenges for reducing smoking prevalence. It could

also facilitate improved message communication by understanding stigmas about

using an e-cigarette, and work to prevent e-cigarette users feeling disenfranchised

from influencing the policy context. Preliminary research suggests e-cigarettes may

be viewed favourably by smokers as a cessation aid, but that it threatens to undermine

their profile as a smoker.99

In short, this essay concludes e-cigarettes can offer an opportunity to reduce

smoking rates among deprived groups. However, doing so requires significant

barriers in the research, societal and political environments to be overcome. Personal

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barriers to ensure perceptions of individual harm are diminished through clear and

coherent communication of appropriately targeted information across peer and clinical

influencers. This communications is reliant on both the quality of information, but

establishing the most effective key influencers and communication strategies to appeal

to the health literacy of deprived smokers, which are likely to differ from less deprived

subsets of the population. Promoting self-efficacy for deprived groups to use e-

cigarettes and reduce smoking rates is vital, and can also be achieved by a supportive

policy environment for tobacco control to a) discourage tobacco consumption and b)

encourage the transition from smoking to e-cigarettes, and c) ensure smoking

cessation services are adequately tailored to respond to the needs of e-cigarette

users. Ultimately, this environment will only be achieved with a strong evidence base,

and significant reductions in smoking rates can only be evaluated through

comprehensive and sustained data collection. Underpinning all other factors is a need

for methodological consensus about how data on the relationship between deprivation

and e-cigarette use is collected and reported, and specific barriers in the literature that

must be overcome. To facilitate the vast opportunities to rid the most deprived up and

down the UK from the lethal grip of tobacco, this should be sought with urgency.

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