An outbreak of a vaping-related illness in the United States has sickened hundreds and may be linked to the deaths of seven people, and an epidemic of youth vaping there has been called a "public health crisis."
President Donald Trump's administration moved to ban e-cigarette flavors and there are warnings to avoid vaping altogether. But in the UK, there doesn't appear to be an outbreak of vaping-related sickness. Neither has vaping popularity soared among young people who never smoked. Rather, e-cigarettes have been embraced mostly as a way for adults to quit combustible cigarettes. Indeed, health authorities in the UK stand by their support for e-cigarettes as a cessation tool.
"If you don't smoke, don't vape," said John Newton, director of health improvement at Public Health England. "But if you smoke there is no situation where it would be better for your health to continue smoking rather than switching completely to vaping.
"PHE's advice remains that e-cigarettes are a fraction of the risk of smoking, and using one makes it much more likely you'll quit successfully than relying on willpower alone."
What's different? Regulation, especially on advertising and promotion, and the levels of nicotine in vaping products. "In the UK the culture is that this is a replacement and not an initiation product," said Bonnie Halpern-Felsher, a professor of pediatrics in Stanford Medicine's Division of Adolescent Medicine.
In a review last year, Public Health England found that vaping is 95% less harmful than smoking conventional cigarettes and was helping 20,000 people quit a year. The agency was concerned that more than half of smokers "falsely believed that vaping is as harmful as smoking."
"There is much public misunderstand about nicotine," the body said, with "less than 10% of adults understand that most of the harms to health from smoking are not caused by nicotine."
It also said that concern about e-cigarette use as a gateway to smoking among young people wasn't supported by evidence in the UK, where regular vaping among young people who've never smoked is less than 1%.
"Similar choice of flavors exist in the US and UK and yet we do not have the same levels of youth vaping here. Our much lower rates are due to our much stricter advertising regulations and possibly our lower nicotine cap," a spokesperson for Public Health England said Thursday.
Halpern-Felsher noted those differences, too. "In the UK, first of all, they are not allowing advertisements in the same way and so you don't get advertisements to young people," Halpern-Felsher said. Outdoor advertisements on buses, for example, are allowed, but "e-cigarette companies just don't have the presence on social media and in the TV or radio."
In the United States, more than a quarter of high school students were current e-cigarette users in 2019, according to preliminary numbers from the National Youth Tobacco Survey revealed last week.
In the UK, 3.3% of 11-to-18-year-olds use e-cigarettes "less than weekly" and 1.6% use them at least weekly.
The EU's Tobacco Products Directive, which took effect in 2016, lays down rules on the manufacture, presentation and sale of e-cigarettes in member countries. This includes restrictions on labeling, packaging and advertising. An EU report on the health and environmental risks of e-cigarettes is due by the end of 2020.
EU regulations also restrict e-cigarette liquids used in vaping devices to a nicotine strength of no more than 20mg/ml but in the US, some Juulpods contain 59 mg/ml, making them more potent.
A 5% nicotine Juulpod contains "the amount of nicotine found in two packs of cigarettes -- one and a half to two packs," Halpern-Felsher said. "Whereas the UK would not allow that."
Juul says a 5% strength Juulpod is designed to replace one pack of cigarettes in terms of the number of puffs and the nicotine strength. The company says its studies "have consistently shown that use of JUUL products with 5% nicotine strength results in a nicotine uptake similar to, but lower in concentration than, a cigarette," and that Juul's "nicotine experience" was developed to help adult smokers transition from combustible cigarettes.