In research looking at the reasons why smokers are not interested in trying an e-cigarette, despite knowing that these devices are much less harmful than combusted tobacco, one of the most powerful reasons cited was the fact that the person actually enjoyed smoking. Hard as it might be to acknowledge that many smokers actually enjoy smoking that realization may explain why more than a third of smokers in Great Britain have not even tried an e-cigarette, despite their being a substantially less harmful than smoking, and nearly seven in ten of those that have tried e-cigarettes do not go on to use the devices long term (ONS 2015).

It is not only the public health doctors that may be discomforted by the recognition that many smokers enjoy smoking. Ironically the tobacco industry itself may struggle with that realization. The biggest hitters in the tobacco industry have come out in favour of electronic nicotine delivery systems. Within a new fangled world of tobacco heating systems and e-cigarettes, lighting up a combustible stick of leaf tobacco can seem frankly out of date. The tobacco companies that are investing heavily in the new technology have wisely (as far as their shareholders are concerned) refused to identify a date when they will have moved out of the smoked tobacco business. Their hesitancy in that regard may be justified given that so many of their current customers are saying they actually enjoy smoking.

For those from a tobacco control perspective, the smoker who enjoys smoking is something of an anomaly since, in effect, that person is saying they enjoy engaging in what is known to be a harmful activity. But it should surprise nobody that people are prepared to put themselves at risk of harm. Every weekend in schools across the country pupils engage in rugby and other risky contact sports, we go skiing, rock-climbing, ride horse and swim in the sea -all activities that carry some level of risk. Similarly, we find entertainment in watching risky sports and handsomely rewarding boxers for putting themselves in harms way and using their consummate skills to inflict greater harm on their opponent than they experience themselves. We live with risk and harm. If it were otherwise, and we were truly risk averse, we would never leave our bed. And if that lifestyle were to appeal it’s worth noting that in the US alone 450 people die every year falling out of bed.

Smoking is harmful – perhaps the most harmful consumer activity we can engage in. But still some like the experience and, crucially, will choose to persist in that experience irrespective of the alternatives offered. So in a climate where smoking has become increasingly stigmatized we face a difficult question; is it not the right of the individual to engage in harmful behaviour if he or she so chooses- knowing the risks and harms involved? In a world where freedom and liberty are valued we may answer yes to that question. In a world where some risks (but not others) are deemed unacceptable -even for consenting adults -we face a reality in which personal freedom is compromised in favour of health protection.

So what does this tell us about the likely success of the tobacco alternatives that are now appearing on the market? It tells us that however attractive those devices are there will still be smokers who prefer their traditional cigarette. So the choice facing the tobacco industry will be one of continuing to meet all of their customers needs (both those who wish to continue smoking and those that do not) or leading their customers enthusiastically or grudgingly down a road of tobacco harm reduction and away from their preferred combustible products. At which point the greatest irony of all may be the cigarette paper’s difference that emerges between tobacco control and the tobacco industry. It will only be possible to affect this transition if companies succeed where they are presently falling short, namely in developing a product that is not only associated with lower harm than smoked cigarettes but which is just as appealing and just as pleasurable to smokers.

Neil McKeganey Ph.D
Centre for Substance Use Research