Image by haiberliu from Pixabay
Smokers have been trying to quit since smoking started, and there have always been opportunists trying to cash in on those hopes. A 1923 book published in Melbourne, Secret Recipes, described an “anti-smoking mixture” where 36 grains of silver nitrate were mixed with 475ml of water for use as an aversive mouthwash after meals. A medical advice column in the Detroit News from 1949 also recommended the same path, “One trying to quit smoking should exclude from his diet meat soups, broths or extracts, highly seasoned sauces or dishes. He or she should eat freely of apples, baked with meals or raw the first thing for breakfast and the last thing at night.”
Such folksy hokum persisted for decades in leaflets and tip sheets often provided by health departments. For example, this Ugandan advice from 2004 counselled: “Nature has the remedy. Stretch out your arm and pick up a carrot. Chew it and smile. Within a few hours, all your distress will be gone. This orange root has large amounts of charm that is appropriate for those who wish to give up smoking.”
Enter NRT
The advent of prescription-only nicotine replacement therapy (NRT) from the late 1980s and its more than 30 years of subsequent widespread use, marked the first time that large-scale efforts promoted medication to assist quitting. Prior to NRT, those who ‘took something’ to help them quit used preparations that made money for the patent medicine spruikers selling them, but none of the snake oils touted by their commercial and moral evangelists ever saw them in widespread use.
However, very large numbers of smokers began quitting when news reports of the first serious case-control studies started being published from the early 1950s. In 1955, just five years wide news publicity was given to Wynder and Graham’s historic study in JAMA of smokers and lung cancer in the same year as the BMJ Doll and Hill paper on smoking and lung cancer, 7.7 million Americans aged 13 and over (6.4% of the population) were former smokers. Ten years later in 1965, following further widespread publicity surrounding the 1964 US Surgeon General’s Report, the number of ex-smokers had ballooned to 19.2 million (13.5% of the population aged 13 and over were ex-smokers). At the Second World Conference on Smoking and Health held in London in 1971, Daniel Horn, the director of the US National Clearinghouse on Smoking and Health, presented results of a cohort of 2,000 US smokers interviewed in 1966 and again in 1970. Twenty six per cent of men and 17% of women had stopped smoking for a year or more across this time. Horn noted that 99% had done so without any formal help: “The level of change in smoking habits in the United States has become quite massive and I regard it as a change in health behaviour that is largely dependent on individual decision.”
By 1975, 32.6 million Americans (19.4%) had stopped smoking. Quitting smoking had become a major phenomenon. In 1979, the then director of the US Office on Smoking and Health noted in a National Institute of Drug Abuse Monograph “In the past 15 years, 30 million smokers have quit the habit, almost all of them on their own.” Many of these quitters had been very heavy smokers.
The only tobacco control policy in place for around a decade from the mid 1960s in a tiny handful of vanguard nations were tepid, general and very small health warnings on cigarette packs and low-key and poorly funded education via posters and pamphlets. The main drivers of all the quitting described above had been news publicity about the dangers of smoking. This gave millions a why to quit. They figured out the how for themselves and nearly all of it was unassisted.
Reportage of the 1986 US national Adult Use of Tobacco Survey was set against the dramatic fall in smoking prevalence from 40% in 1965 to 29% in 1987. Yet again, the central finding was that smokers who quit overwhelmingly did so unaided:
“About 90% of successful quitters and 80% of unsuccessful quitters used individual methods of smoking cessation rather than organized programs. Most of these smokers who quit on their own used a ‘cold turkey’ approach.”
“Double your chances of quitting”
I worked in tobacco control in the years when NRT first appeared in the 1980s. The big pitch repeated endlessly in pharmaceutical company publicity for decades was that smokers could “double their chances” of quitting if they used NRT, then the only potentially mass-reach method of quitting. But what this beguiling soundbite concealed was that this “doubling” was the relative increase compared with placebo or those in trials who used no aids. The absolute increase was utterly dismal: at 6 to 12 months follow-up, those using NRT and other pharmaceutical aids typically did only marginally better than those smokers not using them, with the bottom line being that there were few drugs in the whole of medicine which had such an abject “success” rate.
As I wrote in an earlier blog summarising a Cochrane meta-analysis of vaping vs NRT randomised controlled trials “if we take 100 smokers participating in an RCT, 90 would still be smoking six months later if they used e-cigarettes, compared with 94 who used NRT, and 96 who just tried to quit alone or got some “behavioural support”… If you went along to your doctor for a health problem and were told ‘here, take this. It has a 90% failure rate. But I’m describing it as successful.’ …what would you think?”
My (free, open-access) 2022 book Quit Smoking Weapons of Mass Distraction explores at length the history and determinants of the cessation dogma that smokers are foolish to try to quit unaided, despite the paradox that this is exactly how two-thirds to three quarters of all long term ex-smokers have finally succeeded in stopping.
Enter the “hardened” smoker
In the first decade of this century, debate began about whether, after four decades of widespread publicity on the dire risks of smoking, and burgeoning tobacco control policies designed to reduce smoking, those who still smoked should now be best described “hardened”. The “hardening hypothesis” proposed that as the prevalence of smoking in a population declines, those still smoking will be hardened: average number of cigarettes smoked daily will be rising, fewer smokers will be making successful quit attempts and measures of nicotine dependence will be heading north.
Since that time many studies have tested this hypothesis. Two recent reviews of these have concluded that the hypothesis is now well and truly dead and buried.
A 2020 review by smoking cessation maven John Hughes of published studies on hardening found that in none of the 26 studies he examined was there any evidence for a reduction in conversion (or transition) from current to former smoking, in the number of quit attempts, or success on a given quit attempt, with several studies finding that these measures increased over time. These results appeared to be similar across survey dates, duration of time examined, number of data points, data source, outcome definitions and nationality. Hughes concluded “These results convincingly indicate hardening is not occurring in the general population of smokers” in nations where smoking prevalence is falling.
A 2022 systematic review of three reviews and ten repeat cross-sectional studies found all but one concluded a lack of hardening. Most found softening within the smoking population, consistent across hardening indicators, definitions, countries (and tobacco control environments), and time periods examined.
The authors concluded: “Based on the weight of the available evidence, the “hardening hypothesis” should be rejected and the reality of softening accepted.” So as smoking falls in a population, we see the exact opposite of hardening: the remaining smokers smoke less than in eras when smoking was more prevalent, make more successful quit attempts.
Enter vaping
Those promoting vaping have been ignorant of or undeterred by the death of the hardening hypothesis. They have dug up its grave, put lipstick on the corpse and announced ad infinitum that today’s smokers simply “can’t” quit smoking either on their own or with any other available method. Their evidence is always anecdotal in the form of passionate testimonies from those who read from the hardening script.
It is undoubtedly true that there are some – even quite a lot – of highly nicotine dependent smokers whose failed quitting history and wish to quit is difficult to dispute. In Australia, these smokers are able to access nicotine vapes via prescription, with the same ease that 315 million prescriptions for all drugs were dispensed in a population of 25 million.
But importantly, when we look at the young adult age groups which vapes the most, we find a huge number of Australians who currently vape (i.e. in the last month) who have never smoked. Then there are dual users (smokers who also vape), many of whom dual use for many years showing no sign of this being a transitory phase in an eventual switch to vaping. I’ll be covering this in a forthcoming blog. Health minister Mark Butler calls these “recreational users”: vapers who either have never smoked or who vape and continue smoking across several years, showing no obvious resolve to quit (they are “won’t quits”, not “can’t quits”).
The table below shows AIHW smoking and current vaping data for 2019 in Australia, with ABS population data for the same year.
| Age Numbers | Smoking % Numbers | Non-smoking % Numbers | Current vaping by smokers % Numbers | Current vaping by non-smokers % / Numbers |
| 18-24 2,392,094 | 13.7 327,717 | 86.6 2,071,553 | 18.7 61,283 | 2.9 60,075 |
| 25-29 1,808,561 | 14.6 264,050 | 85.4 1,544,511 | 13.7 36,175 | 3.2 49,424 |
| 18-29 4,200,655 | 591,767 | 3,616,064 | 97,458 | 109,499 |
What’s obvious here is that while a much greater proportion of young smokers vape than do non-smokers, because there are so many more non-smokers, even their lower vaping rates translate into there being more numbers of non-smokers who currently vape than smokers who currently vape (53% v 47%).
More recent data (2022) for those aged 18+ are also available for Victoria. In that study, a quarter of all current e-cigarette users were never smokers (25.0%), 28.7% were former smokers, and almost half (46.3%) were also current smokers (ie dual users).
The proportion of never smokers who currently use e-cigarettes increased 4.5- fold from 0.6% in 2018-19 to 2.7% in 2022. This represents approximately 77,200 never smokers who reported currently vaping, of which 44,534 (more than half – 57.7%) were under the age of 25 years. These data would bring great delight to vaping manufacturers, particularly those tobacco transnationals which sell both cigarettes and vapes. Here was a product that not only had little impact on helping smokers quit in the population, but one that caused many smokers to now purchase both cigarettes and vapes. As if this was not huge enough, it also – without precedent – was demonstrably drawing more non-smokers into nicotine addiction, than it was keeping smokers in theirs.
Other blogs in this series
Vaping theology: 1 The Cancer Council Australia takes huge donations from cigarette retailers. WordPress 30 Jul, 2020
Vaping theology: 2 Tobacco control advocates help Big Tobacco. WordPress 12 Aug, 2020
Vaping theology: 3 Australia’s prescribed vaping model “privileges” Big Tobacco WordPress Feb 15, 2020
Vaping theology: 4 Many in tobacco control do not support open access to vapes because they are just protecting their jobs. WordPress 27 Feb 2021
Vaping theology: 5 I take money from China and Bloomberg to conduct bogus studies. WordPress 6 Mar, 2021
Vaping theology: 6 There’s nicotine in potatoes and tomatoes so should we restrict or ban them too? WordPress 9 Mar, 2021
Vaping theology: 7 Vaping prohibitionists have been punished, hurt, suffered and damaged by Big Tobacco WordPress 2 Jun, 2021
Vaping theology: 8 I hide behind troll account. WordPress 29 Jun, 2021
Vaping theology: 9 “Won’t somebody please think of the children”. WordPress 6 Sep, 2021
Vaping theology: 10: Almost all young people who vape regularly are already smokers before they tried vaping. WordPress 10 Sep, 2021
Vaping theology: 11 The sky is about to fall in as nicotine vaping starts to require a prescription in Australia. WordPress 28 Sep, 2021
Vaping theology: 12 Nicotine is not very addictive WordPress 3 Jan 2022
Vaping theology 13: Kids who try vaping and then start smoking,would have started smoking regardless. WordPress 20 Jan, 2023
Vaping theology 14: Policies that strictly regulate vaping will drive huge
numbers of vapers back to smoking, causing many deaths. WordPress 13 Feb, 2023
Vaping theology 15: The government’s prescription vape access scheme has failed, so let’s regulate and reward illegal sellers for what they’ve been doing. WordPress 27 Mar 2023
Vaping theology 16: “Humans are not rats, so everybody calm down about nicotine being harmful to teenage brains”. WordPress 13 Jul, 2023
Vaping theology 17: “Vaping advocates need to be civil, polite and respectful” … oh wait. WordPress 3 Oct, 2023
Vaping theology 18: Vaping is a fatally disruptive “Kodak moment” for smoking. WordPress Oct 30, 2023
Vaping theology 19: Vaping explosions are rare and those who mention them are hypocrites. WordPress 17 Nov, 2023
Vaping theology 20 : Today’s smokers are hard core nicotine dependent who’ve tried everything and failed – so they need vapes. WordPress 14 Dec, 2023
Vaping theology 21: Australia’s prescription vapes policy failed and saw rises in underage vaping and smoking. WordPress 10 Jan, 2024
Vaping theology 22: “Prohibition has never worked at any point for any other illicit substance”. WordPress 17 Mar 2024
Vaping theology 23: “84% of the Australian public are opposed to the way the government will regulate vapes” WordPress 2 Apr, 2024
Vaping Theology 24: “Tobacco control advocates are responsible for vape retail store fire bombings and murders. WordPress 27 May, 2024
Simon Chapman AO 