Not Invented Here #4 - Smoking

This is the fourth in a series of articles about how ideological interest groups react when their institutional preferences are challenged by practical solutions. 

The risks of smoking could hardly be better known. Combustible tobacco is estimated to kill 80,000 people each year in the UK alone. Smoking has been recognised as the leading cause of lung cancer since the 1950s and cigarette packs have had health warnings on them since the 1960s. These have been followed by educational campaigns, graphic warnings, plain packaging and a host of policies designed to deter anyone from ever taking up the habit. 

Despite public understanding of the risks being almost universal and despite exceptional levels of regulation and taxation, it is estimated that 1.1 billion people smoke cigarettes globally, including six million in the UK. It would appear that a large minority of the population are unresponsive to ‘public health’ messaging and continue to consume nicotine in the most dangerous way because they enjoy it or are addicted to it or both. 

Fortunately, there are now a number of low-risk alternatives available to people who want to avoid the health hazards associated with cigarettes but want to consume nicotine. They include e-cigarettes (vapes), snus, nicotine pouches and heated tobacco. Not only have these products been proven to be much less harmful than smoking, but they have substantially reduced smoking rates in countries where they have become popular. This month, Sweden became the first country to become technically ‘smoke-free’ (i.e. with a smoking rate below 5%) thanks to the use of snus. In Japan, cigarette sales almost halved between 2016 and 2023 as heated tobacco products became popular. In Britain, where vaping is commonplace, the smoking rate has nearly halved since 2011 and the rate among 18-24 year olds - who used to be the most likely to smoke but are now the most likely to vape - has dropped by 60%. 

You would think that anti-smoking campaigners would be delighted to find something that gets millions of people to stop smoking and offers an alternative to those who otherwise would have started. But you would be wrong. Although some ‘public health’ professionals have embraced reduced-risk products, the response from the global tobacco control movement has been suspicious and hostile from the start. E-cigarettes have been banned in 34 countries, snus is banned in all EU countries except Sweden and some countries have even banned nicotine pouches, which contain no tobacco and are as safe as a nicotine product is ever likely to get. The World Health Organisation encourages member states to subject vapes and heated tobacco to heavy regulation or total prohibition.  

In the USA, where vapes are perversely classed as tobacco products, harm reduction is seen as a threat to orthodox tobacco control. The latest Surgeon General’s report - published this week - claimed that ‘true harm reduction’ could only come from a further clampdown on e-cigarettes. In Australia, the sale of all e-cigarettes is banned, including those which do not contain nicotine. Even the UK, widely regarded as a world leader in tobacco harm reduction, has started to go backwards. Its Tobacco and Vapes Bill proposes banning people born after 1 January 2009 from not only ever buying cigarettes but from ever buying heated tobacco products, snus, shisha and cigarette papers. It also promises a new clampdown on vapes and nicotine pouches, although the exact measures have yet to be announced.  

All of this has been actively promoted by pressure groups and academics claiming to be acting in the name of ‘public health’. Why? The veteran tobacco control campaigner Dr Michael Siegel, who supports harm reduction strategies, believes it is a classic case of Not Invented Here Syndrome. Writing in 2015, he said: 

‘… the concept of using a cigarette-like device that delivers nicotine without using or burning tobacco as a smoking cessation strategy came from outside the tobacco control movement. We did not think of it. We did not develop it. It was essentially thrust upon us suddenly and without warning. And it is precisely because the strategy appeared to be so successful, with exponential growth of the market, that we felt threatened. It is because this technology has the potential to completely transform the nicotine market by producing drastic reductions in combustible tobacco use and an unprecedented improvement in the public's health that we feel a threat to our status. After all, we have been working for decades to reduce smoking and now suddenly outsiders come along and develop a new strategy that appears to be more effective, or at least as effective, as the strategies that we developed.’ 

By the time e-cigarettes went mainstream in 2012, tobacco control academics were openly talking about ‘endgame strategies’. The institutional preference was for increasingly draconian laws on the sale and consumption of cigarettes until the smoking rate was low enough for full prohibition to be politically feasible. Options included incrementally reducing the number of shops that could sell cigarettes, steadily restricting the quantity of tobacco that was allowed to be sold, reducing the amount of nicotine in cigarettes to almost zero and gradually increasing the age at which cigarettes could be bought. Some anti-smoking campaigners warned that ‘a move towards prohibition is misguided, for both political and practical reasons’ and even the most enthusiastic prohibitionists acknowledged that people would need access to ‘non-smoked nicotine delivery devices’ if the ‘endgame’ was to have any success. 

All of the endgame policies focused on the supply side and there was a recognition that they were likely to cause unintended consequences such as ‘increased smuggling, theft, illegal sales and short-to-medium-term aggravation of some social inequalities’. Skip forward a few years and we can see the rising prevalence of these problems in countries that have very high tobacco taxes - most dramatically in Australia which has the highest cigarette taxes in the world and has banned vapes, heated tobacco, snus and nicotine pouches. Until recently, New Zealand had a higher smoking rate than Australia but that all changed when the Kiwis legalised vapes in 2020. New Zealand’s smoking rate has since halved and is now just 6.8%, nearly as low as that of snus-friendly Sweden and one of the lowest in the world. 

Despite the obvious success of reduced-risk nicotine products in numerous countries, the bulk of tobacco control activists remain wedded to the neo-prohibitionist model and are opposed to the harm reduction approach. A free market solution has encroached on what they see as their turf, but it is not necessarily a solution to what they see as the real problem. If you take issue with people enjoying themselves, they are not the solution. If you are against habit-forming activities, they are not the solution. If you want to destroy the tobacco industry, they are not the solution. And if you just don’t like anything that looks like smoking, vapes and heated tobacco are not the solution. They are only the solution if you want to improve the health of the nation in a pragmatic way that does not require coercion or government spending. For everyone else, there is an endgame plan that you can stick to, regardless of the consequences.