2026 Session 2 Seminars

Clinicians increasingly face a strange position regarding alternative nicotine products: recommending products that work but aren't medicines. The evidence for e-cigarettes as a smoking cessation aid is now high-certainty and shows they outperform licensed nicotine replacement therapy in head-to-head trials. Yet the products themselves sit outside the regulatory category clinicians are trained to trust. They are reviewed for population-level benefit rather than approved as safe and effective for the individual patient. That distinction isn't a technicality. It shapes how confident a clinician feels about raising the option, how exposed they feel doing so, and, in some jurisdictions, whether professional guidance actively discourages the conversation altogether.

This talk uses e-cigarettes as the clearest example of a broader and growing problem, one that will only become more pressing as evidence accumulates on nicotine pouches and heated tobacco. Drawing on a recent JAMA position paper and the professional debate it provoked, I will examine why this discomfort exists, how professional bodies and national systems have resolved it differently (the UK and New Zealand embracing these products within cessation pathways, the US and Australia largely resisting), and what underlies much of the disagreement: an unresolved question about whether we are treating nicotine dependence or combustible tobacco harm. I will close with what this means in practice for clinicians navigating patient conversations in the absence of a prescription pad.

The presentation will begin with results from the Cochrane review of ‘E-cigarettes for smoking cessation’, focusing on our new outcome of long-term e-cigarette and combustible tobacco use among people who have used e-cigarettes to help them quit smoking. It will then consider what longer-term vaping means in practice, including why people may continue to use e-cigarettes longer than other cessation aids, the potential benefits of this approach for underserved groups, and the importance of avoiding premature vaping cessation, which could increase the risk of returning to smoking. The presentation will recognise that long-term vaping is not necessarily the preferred outcome for everyone, and that concerns about prolonged use could discourage some people from choosing vapes as a cessation aid in the first place. It will conclude by focusing on data from the ‘Interventions for quitting vaping’ review, presenting evidence on strategies to help people stop vaping, while also considering potential unintended consequences and the need for continued monitoring and updating of the evidence.

Population-level smoking and vaping trends are central to how we understand tobacco use, evaluate policy and identify who is being left behind. But what if the evidence we rely on does not tell the whole story?

This talk brings together two strands of our work that show how our understanding of tobacco use can be distorted in different ways. First, I will consider the debate over whether e-cigarette use acts as a gateway to smoking. Using triangulation of evidence across different study designs and analytical approaches, we will examine whether the observed relationship between vaping and subsequent smoking initiation is consistent with a causal gateway effect. I will explore what these different sources of evidence tell us, where they converge and where important uncertainties remain, emphasising the need to look beyond any single study or apparent association when addressing complex causal questions. I will then turn to a less visible problem: the people who are missing from the data altogether. Our recent research estimates that around 1.9 million adults in the UK live outside the sampling frames of household surveys, including people living in communal establishments and those experiencing homelessness or temporary accommodation. Smoking prevalence in these populations is substantially higher than in the general population, meaning their exclusion may lead us to underestimate both the scale of smoking and the inequalities associated with it. Together, these examples raise a broader question: what do we need to consider when interpreting the evidence we use to guide tobacco control? I will argue that we need to look beyond headline prevalence estimates and apparently straightforward associations, paying greater attention to causality, population coverage, measurement and who is, and is not, represented in our data. If we want tobacco control to reduce inequalities rather than simply improve averages, we need to understand not only what the data tell us, but also what they might be missing.

The portrayal of nicotine as harmful and the focus on youth vaping has distracted us from what should still be our number one public health priority: stopping smoking. The Tobacco and Vapes Act introduces a generational ban on tobacco sales and puts the aim of making smoking history within our grasp. But as smoking prevalence continues to fall at a population level, it remains stubbornly high in priority groups, and this presents us with our biggest challenge: to make sure that nobody is left behind. This presentation will address these two distinct but related challenges.