Smoking and vaping

Adult smoking prevalence in the United Kingdom, the United States and most of Western Europe is at a record low of around one in ten, having halved since the millennium. That is behavioural science's clearest success. The deaths follow with a lag of two to three decades, so tobacco still accounts for roughly one death in eight to ten in high-income countries. Lung cancer mortality is still falling in men and only now is starting to turn in women. The remaining smokers are concentrated: by deprivation, by mental illness, and in the countries and regions where prevalence fell least. That concentration is the largest remaining question. Smoking is now among the largest single causes of the gap in life expectancy between rich and poor.

Vaping could move the trend either way. As a route out of smoking, it has the best evidence of any cessation aid in the randomised trials, and England has made it a key plank in public health policy. As a route into nicotine, it has spread fast among people who never smoked. Regular use among adolescents reached around one in ten in several countries before the first restrictions on flavours and disposables. Its long-term harm is unknown because it is just too new, and the trials that would settle whether adolescent vaping leads to smoking cannot be run. Heated tobacco has taken a large share of the Japanese market, and nicotine pouches are rising in Sweden and the United States. Each shifts harm without removing it, by amounts the evidence does not yet give.

The generational sales ban — no tobacco sale to anyone born after a chosen year — has no track record at all. It has been legislated in the United Kingdom, repealed before it took effect in New Zealand, and proposed elsewhere. The measures that do have one are price, plain packaging, smoke-free places and advertising bans, and their effects are well measured and mostly banked.

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