Introduction
In line with many other high-income countries, smoking rates in the United Kingdom, once some of the highest in the world, have been falling for decades. The UK was the country where key research demonstrating the link between smoking and lung cancer was first undertaken and published. But, while Government was initially slow to respond to the challenges of smoking, by the 2000s the UK was acknowledged as a global leader in tobacco control. More recently it has also been at the forefront of ambitious plans to achieve ‘smokefree’ status via a range of initiatives including the use of vapes to help people to quit smoking. This Briefing Paper explores the UK’s progress towards becoming smokefree, highlighting both the successes and the challenges.
What is the history of tobacco use in the UK and what impact has it had?
The UK has a long history with tobacco, dating back to the 1500s.[i] The earliest methods of consuming tobacco involved the use of pipes, though snuff (a powdered form of tobacco that was inhaled through the nose) and cigars were also popular before the introduction of machine-rolled cigarettes in the late 19th century.
By 1948, 82% of men in Britain were smoking some form of tobacco.[ii] This is reported to be the highest smoking prevalence recorded in the UK and it included pipes, cigars and cigarettes, with the latter being the most common (65%).[iii] In the same year, 41% of women smoked tobacco, with most using cigarettes.
Two years later, in 1950, the UK was the country where the link between smoking and cancer was first established. Following a significant increase in the number of deaths attributed to lung cancer in the country, epidemiologists Sir Richard Doll and Sir Austin Bradford Hill carried out studies which confirmed cigarettes were the cause.[iv] This was followed just over 10 years later, in 1962, by the publication of the Royal College of Physicians’ landmark report “Smoking and Health” which used Doll and Hill’s data.[v] Arriving at a time when the dangers of smoking were little understood by the public, it was the first report published anywhere in the world to widely publicise information about the negative effects of smoking on health, and it is considered to be a turning point in the history of public health in the UK.[vi] Its significance was underscored three years later, in 1965, when it was revealed the UK had the highest lung cancer death rate of any major country, with smoking being responsible for nearly 50% of the deaths of men in middle age.[vii]
In 1974, the Government began collecting data on smoking prevalence in the UK as part of the General Household Survey (since renamed the General Lifestyle Survey).[viii] Compiled by the Office for National Statistics (ONS), it shows that smoking rates in 1974 were 51% for men and, again, 41% for women. This was a significant fall from the 1948 peak, and the subsequent 50 years of the survey reveals there has been a steady downward trend in smoking rates in the UK.[ix]
But even with cigarette use falling, the effects of smoking continue to be significant. It is estimated by the UK Government that around 80,000 people die every year in the country due to smoking.[x] The Government also says that smoking is both one of the main causes of health inequalities in the UK, with the harm being concentrated in some of the country’s most disadvantaged communities,[xi] and the largest preventable cause of death and serious disability.[xii] Cancer Research UK states that nearly three in every four lung cancer cases in the UK are caused by smoking (72%).[xiii]
While the rate of deaths attributable to smoking in England has decreased in recent years, from 244 per 100,000 between 2013 and 2015, to 202 per 100,000 between 2017 and 2019,[xiv] smoking continues to have a substantial impact on the National Health Service (NHS). Looking again at just England, in 2019 to 2020, there were around 506,000 smoking-related admissions to hospital, or roughly 1,400 per day,[xv] and those who smoke see their GP 35% more than those who do not.[xvi] Smoking is also estimated to cost the NHS and the economy around £17 billion a year.[xvii]
What safer nicotine products are available in the UK and how have they fared so far?
A wide range of safer nicotine products (SNP) are currently on the market in the UK. To those who use high-risk tobacco products, such as cigarettes, SNP offer the chance to switch to products that pose significantly fewer risks to their health. These include nicotine vapes (e-cigarettes), heated tobacco products (HTP), nicotine pouches, nicotine replacement therapies (NRT) and snus, though the latter is banned in the UK.
NRT were the first alternatives to emerge and have been an option for those looking to quit smoking in the UK since the 1980s.[xviii] The initial products made available were nicotine chewing gums before nicotine patches arrived in 1992.[xix] NRT products were officially licensed for harm reduction in the United Kingdom in 2005[xx] and now gums, patches, nasal and mouth sprays, inhalators, tablets, oral strips and lozenges can be bought from pharmacies and some shops. NRT products are also available on prescription from doctors or NHS stop smoking services,[xxi] and the UK NRT market was worth €165.4 million in 2019.[xxii]
Nicotine vapes first arrived in the UK around 2005,[xxiii] a couple of years after they had been invented in China. Some of those who had previously failed to quit smoking became early adopters of these emerging vaping products.[xxiv] Long before any tobacco industry involvement, the UK vaping community was growing rapidly. In-person vape meets and shows started to take place, while users could discuss kit, flavours and modding (modifications to devices) in multiple online forums and discussion boards that told the stories of lives improved by switching to vaping.
To begin with, nicotine vapes were regulated as consumer products in the UK.[xxv] This meant they were subject to existing product safety legislation enforced by Trading Standards, but, in 2010, the UK’s Medicines and Healthcare Products Regulatory Agency (MHRA) opened a consultation on bringing vaping devices within the medicines licensing regime.[xxvi] Fearing that the licensing of vaping products as medicines would effectively remove them from the market, more than a thousand people who vaped submitted responses to the consultation and the following year the MHRA announced its intention to take no further action regarding the status of vaping products, while committing to further research and assessment.[xxvii] In 2015, it became illegal to sell vapes to anyone under the age of 18, under the Nicotine Inhaling Products (Age of Sale and Proxy Purchasing) Regulations.[xxviii] Then, in 2016, the regulation of vapes came under the Tobacco and Related Products Regulations, which implemented, in full, the European Union Tobacco Products Directive from two years earlier.[xxix] These controls included minimum standards for the safety and quality of all e-cigarettes and refill containers, as well as advertising restrictions, and by 2015, just 10 years after they had become available, 2.6 million people were using vapes[xxx] as part of a consumer-led movement that was revolutionising nicotine use in the country.
Around this time, HTP were introduced to the UK. HTP are regulated as novel tobacco products in the UK and are subject to certain requirements under current tobacco legislation, including sale to over 18s only.[xxxi] Despite being popular in some parts of Europe and Japan, these products have so far not played a significant role in helping people to switch away from smoking. This could be because they are also subject to the same advertising and display bans as combustible cigarettes, a potentially serious issue for a new product entering the market. Indeed, an evidence review from 2017 found that awareness and ever use of heated tobacco products in the UK was “very rare”[xxxii] and they remain a small player in the country, arriving as they did after nicotine vapes had become established.
Nicotine pouches have an even shorter history as they first entered the UK market in 2019,[xxxiii] and, like vapes in the period immediately following their arrival in the UK, nicotine pouches are only subject to consumer product safety regulations. Among other things, this means there are currently no age-limit requirements regarding their sale and they can be bought by those under 18.[xxxiv] This looked set to change after the previous Conservative Government launched its Tobacco and Vapes Bill in 2023, which stated nicotine pouches would be outlawed for children,[xxxv] and at the time of writing it is not known if the new Labour Government will continue with these plans. But looking at the most recent available data, a 2022 survey revealed that 3.9% of adults in Great Britain had ever tried nicotine pouches, and only 0.7% were current users, while 48% of adults had never heard of them.[xxxvi] Other research confirms the uptake of pouches is relatively low, but it did find usage among UK adults doubled between November 2020 and October 2021, going from 0.14% to 0.32%.[xxxvii]
As previously mentioned, the only major SNP that cannot be bought or sold in the UK is snus, a pasteurised oral product mainly used in the form of a small tobacco-containing pouch inserted into the mouth. Particularly popular in Scandinavia, snus has been banned throughout the EU, except Sweden, since 1992,[xxxviii] a move that came in response to the controversy surrounding the UK launch of a brand of moist smokeless tobacco. Called Skoal Bandits, this particular product was similar to snus as it comprised small pouches of moistened, powdered chewing tobacco,[xxxix] and unfounded fears linking it with mouth cancer, together with concerns it was being targeted at teenagers, led to a UK ban on such products, which was then mirrored by the EU banning snus.[xl] At the time of writing, this ban remains in place, even though the UK is no longer part of the EU, and the previous Conservative Government’s proposed Tobacco and Vapes Bill sought to reinforce this position.
How have smoking and vaping rates changed during the last 10 years and why have people switched?
While smoking rates have been falling since the Government started collecting data in 1974, nearly a quarter of UK adults were still smoking when vapes first became available in 2005 (23.7%).[xli] Ten years later, in 2015, 5.4% of UK adults were vaping[xlii] and 17.2% of adults were smoking.[xliii] By 2015, half of those who were smoking at that time had used vapes.[xliv] Then, as the proportion of adults vaping rose by one third to 7.1% in 2019, the prevalence of smoking fell again to 14.5%. By 2022, figures showed that 8.7% of the population, or 4.5 million people, were vaping,[xlv] while the number who were still smoking totalled 12.9% of adults, or 6.4 million people. This means that the proportion of adults who smoke in the UK has nearly halved since vaping became an alternative for those looking to switch. The ONS subsequently released new figures to show that in the UK around 6 million people aged 18 years and over (11.9%) smoked cigarettes in 2023.[xlvi] This is 11.9% of adults.
The latest data, from August 2024, shows the proportion of adults vaping has increased again, to 11%, or 5.6 million people.[xlvii] These figures come from a survey conducted on behalf of Action on Smoking and Health (ASH), which also found that more than half of those who gave up smoking in the last five years said they had used a vape in their last quit attempt. This amounts to 2.7 million people.
Our own projections, based on ONS and ASH data, show that the proportion of adults smoking in the UK will continue to drop to just above 10% by 2025, a year in which the proportion of adults vaping will exceed the number who smoke for the first time.
An evidence review on vaping in England, commissioned by the Office for Health Improvement and Disparities (OHID) in 2022, found that vaping products were the most common aid used by people to help them to stop smoking.[xlviii] It also revealed that in stop smoking services in the period 2020 to 2021, quit attempts that involved a vape were associated with the highest rates of success (64.9% compared with 58.6% for those attempts that did not involve a vape). It is worth noting that this report also found fruit flavours were the favourite option for most current vapers (35.5%), while 22.5% preferred menthol/mint flavours.
Another ASH survey, from 2023, provides some insight into why people vape in the UK.[xlix] The top reason given by those who used to smoke was that vaping helped them to quit cigarettes (31%). This was followed by those who said vapes helped them to prevent a relapse to smoking (22%), while 14% enjoyed the experience and 12% said they wanted to save money. Indeed, while both cigarettes and vapes are subject to VAT at 20%, the tobacco duty on a packet of 20 cigarettes is currently 16.5% of the retail price plus £6.33.[l] This is in contrast to vapes which currently have no additional duty applied to them. The VAT for vapes regulated as medicines would be theoretically reduced to 5%,[li] though no medicinally licensed vapes are currently on the market.
Research from 2019 found that people who completely switched from smoking cigarettes to using vapes could save around £780 a year.[lii] It should be noted, though, that before they lost the election in July 2024, the former Conservative Government had proposed to introduce a new tax on vapes “intended to discourage young people and non-smokers from vaping, while maintaining the current financial incentive to choose vaping over smoking”.[liii] Under these plans, the price “increases in line with the strength of the liquid, so that products in the highest strength band are progressively more expensive, when compared to low or nicotine-free products. The products remain significantly cheaper than tobacco products in equivalent quantities”.
For those who continue to smoke cigarettes, ASH’s survey found they mainly vaped to cut down on smoking (19%) or to try to help them quit (17%). Meanwhile, among those who had never smoked, respondents said they mostly vaped as they enjoy the experience (39%) while 27% said it was just to give the vapes a try.
Other research found that 59% of those who smoked and had taken up vaping did so to decrease the amount of cigarettes they smoked, while 49% said a key reason for them starting vaping was to help them stop smoking.[liv] This survey about the UK vaping market, commissioned by HM Revenue and Customs, also revealed that 37% vaped as they considered it to be a healthier alternative to smoking.
How has the UK approached tobacco control?
Despite being at the forefront of research revealing the harms of smoking during the second half of the 20th century, the UK’s approach for much of the time up until the 1990s was one of limited policy intervention.[lv] There were certain developments, though, such as the banning of cigarette commercials on television in 1965 and a steady increase in the taxes imposed on cigarettes.[lvi] In 1984, a National No Smoking Day was launched to encourage people to quit smoking and, in 1999, local stop smoking services were established in England as part of the Government’s commitment to help smokers to quit. These services are reported to have helped more than four million people to successfully quit for at least four weeks.[lvii]
A year earlier, the UK had taken one of its most significant step so far to address the issue of tobacco consumption with a 1998 Government white paper titled “Smoking kills” that proposed what it called “the most comprehensive strategy to tackle smoking embarked upon anywhere in the world”.[lviii] Key measures included: an end to tobacco advertising, promotion and sponsorship; a £60 million investment in new NHS services to help people to quit smoking; a week's free NRT on the NHS, with starter packs of nicotine replacement therapy being made available, free of charge to the worst off, alongside “specialist support to help motivated quitters get on the fast-track to giving up for good”; and changes to pubs and restaurants to introduce facilities in these venues for both those who smoked and those who did not.
But it was not until the mid-2000s that any significant tobacco control measures were introduced. The Smoking, Health and Social Care (Scotland) Act 2005 and The Prohibition of Smoking in Certain Premises (Scotland) Regulations 2006 came into effect in March 2006, which, for the first time, prohibited smoking in certain public places in Scotland which were 'wholly or substantially enclosed', including the majority of workplaces.[lix] England, Wales and Northern Ireland introduced similar legislation shortly after.
During the next couple of decades, as people switched from smoking to vaping in increasing numbers, the UK also achieved a steady reduction in smoking prevalence using a range of policy tools to bring about the denormalization of tobacco. These included “measures dealing with price, promotion, education and health warnings, plain packaging, and the regulation of ingredients, sales, who can smoke and where they can smoke”.[lx] These changes combined to help the UK lead the recent rankings of the European Tobacco Control Scale, alongside Ireland and France.[lxi]
It should also be noted that in 2019 the Conservative Government announced a bold ambition to become ‘smokefree’ by 2030.[lxii] This would be achieved if adult smoking prevalence fell to 5% or less. The new Labour Government will also pursue the previous administration’s plans to make UK the first country in the world to progressively raise the age at which people can buy cigarettes, meaning those born after January 1, 2009 would never be able to purchase them legally.[lxiii] This would also apply to HTP. It also appears that the new Labour Government will adopt the previous administration’s plans to deter youth use of vapes by increasing enforcement on under-age sales and introducing powers to restrict flavours, as well as banning disposable vapes and increasing taxes on vapes.[lxiv]
What role has the Government and NHS played to encourage the uptake of vaping?
The UK Government has not only taken steps to help people to stop smoking, it has also increasingly embraced the potential of vaping as a safer product for those people who want to switch away from cigarettes but are either unwilling, or unable, to stop using nicotine.
A year after the first vape-friendly local stop smoking service was launched in 2014 by Louise Ross, the then manager of Leicester Stop Smoking Service,[lxv] a key development was the landmark independent evidence review published by OHID’s predecessor, Public Health England (PHE), that concluded nicotine vapes were around 95% less harmful than smoking.[lxvi] Now referenced around the world as the foremost example of the relative safety of vaping, this 2015 report concluded vapes had the potential to help people quit smoking, as well as finding no evidence that vapes acted as a route into smoking for children or those who did not already smoke. In the decade that followed, annual evidence reviews have demonstrated the initial findings remain unchanged, and both the Government and the NHS have launched, or provided funding for, a series of initiatives to encourage people to switch from smoking to vaping.
One of these was the Stoptober campaign which included vapes in its advertising for the first time in 2017.[lxvii] Originally launched in 2012, by PHE, Stoptober aimed to inspire people who smoked to make a quit attempt from October 1 and maintain it for at least 28 days. Then, in 2018, PHE called for vapes to be available on prescription, adding that hospitals should be able to sell vapes and have areas where patients could vape.[lxviii]
A year later, vape shops opened in two NHS hospitals in the West Midlands.[lxix] Run by Sandwell and West Birmingham Hospitals NHS Trust, both sites also allowed the use of vapes as long as this took place away from doorways, despite smoking on the premises resulting in a £50 fine.
In 2021, the Medicines and Healthcare products Regulatory Agency (MHRA) published updated guidance that paved the way for medicinally licensed e-cigarette products to be prescribed to those who wished to quit smoking, meaning England would become the first country in the world to prescribe vapes licensed as medical products,[lxx] though, at the time of writing, no vaping products that have been licensed as stop smoking medicines are currently on the market in the UK.[lxxi] They are also not available on prescription from the NHS or from a General Practitioner, but local stop smoking services may offer a free vaping starter pack.
Also in 2021, a new trial launched by the University of East Anglia, and funded by the National Institute for Health Research (NIHR), saw vaping starter kits being given to people who smoked when they attended hospital emergency departments.[lxxii] This initiative followed updated evidence from the Cochrane Review, led by the University of Oxford, which showed that nicotine vapes were more effective than NRT in helping people to stop smoking for at least six months.[lxxiii] That year also saw another NIHR-funded study investigate whether vapes could help people experiencing homelessness to quit smoking. This project, run by researchers from University College London and London South Bank University, aimed to find out whether supplying free vaping starter kits at centres for people experiencing homelessness could help to reduce the high rates of smoking seen in this population.
Then, in 2023, in one of its most radical steps yet, the Government announced that one million people who smoked would be encouraged to switch from cigarettes to vapes.[lxxiv] As part of the ‘swap to stop’ campaign, a world-first national scheme, around one fifth of those who smoked would be provided with a vape starter kit, alongside behavioural support, to help them quit.
Alongside these Government initiatives, the NHS provides a wealth of evidence-based advice to those who smoke about the relative safety of vapes compared to cigarettes. As well as stating that nicotine itself is “not very harmful and has been used safely for many years in medicines to help people stop smoking”, national and local NHS websites advise people in the UK that “nicotine vaping is substantially less harmful than smoking” and is “one of the most effective tools for quitting smoking”.[lxxv] The NHS does say that vaping is not completely harmless and it only recommends vapes for adults who smoke to help them quit cigarettes. But it adds that vaping “exposes users to far fewer toxins and at lower levels than smoking cigarettes”, and states “switching to vaping significantly reduces your exposure to toxins that can cause cancer, lung disease, and diseases of the heart and circulation like heart attack and stroke”. The NHS is also clear that the full benefits of vaping are only achieved by those who manage to stop smoking cigarettes completely.
Takeaways and look to the future
While smoking rates had been falling in the UK for many decades, the near 50% reduction in the proportion of adults who smoke that has taken place since vapes were introduced to the country shows the positive potential of tobacco harm reduction. The UK experience adds further evidence that when appropriate, acceptable SNP, such as vapes, are made accessible and affordable, those who smoke will make the choice to switch to them in increasing numbers.
Consumers have led this dramatic growth in vaping, but the Government has, to date, also played a role by publishing the science on the safety of vapes relative to smoking, as well as both endorsing and promoting their use as a smoking cessation tool. The UK has to a large extent, so far, avoided the moral panics about vaping that have influenced political decisions in some countries, and has not experienced the degree of anti-vaping rhetoric and policy influence of prominent but ill-informed philanthropic foundations that has affected other parts of the world.
The UK experience also adds to the evidence from Japan, Sweden, Norway and New Zealand of substitution effects in the nicotine market, showing that vapes are replacing cigarettes. Indeed, our projections suggest that as the number of people who smoke continues to decline, the proportion of the adult population that vapes will exceed those who are smoking by 2025.
For further information about the Global State of Tobacco Harm Reduction’s work, or the points raised in this GSTHR Briefing Paper, please contact [email protected]
About us: Knowledge·Action·Change (K·A·C) promotes harm reduction as a key public health strategy grounded in human rights. The team has over forty years of experience of harm reduction work in drug use, HIV, smoking, sexual health, and prisons. K·A·C runs the Global State of Tobacco Harm Reduction (GSTHR) which maps the development of tobacco harm reduction and the use, availability and regulatory responses to safer nicotine products, as well as smoking prevalence and related mortality, in over 200 countries and regions around the world. For all publications and live data, visit https://gsthr.org
Our funding: The GSTHR project is produced with the help of a grant from Global Action to End Smoking (formerly known as Foundation for a Smoke-Free World), an independent, US non-profit 501(c)(3) grant-making organisation, accelerating science-based efforts worldwide to end the smoking epidemic. Global Action played no role in designing, implementing, data analysis, or interpretation of this Briefing Paper. The contents, selection, and presentation of facts, as well as any opinions expressed, are the sole responsibility of the authors and should not be regarded as reflecting the positions of Global Action to End Smoking.
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