How the headlines have changed: British smokers urged to start vaping by health officials; E-cigarettes ‘should be prescribed on the NHS’. An expert independent evidence review from Public Health England (PHE), recognises that e-cigarettes are not only practically harmless, they are already helping people to give up smoking and are, to quote the author of the review, a “game changer” for the public’s health.

Vaping, says the review, is 95% safer than smoking cigarettes. Who could object to the view that smokers be encouraged to get vaping, especially if they are already thinking of giving up what is well understood to be a bad habit?

But the World Health Organisation and European Union are set on banning e-cigarettes, and just a couple of months ago the Welsh government announced it wanted to ban e-cigarettes in enclosed spaces, arguing that they act as a “gateway” to the tobacco-filled variety. These dubious claims – rubbished in PHE’s review of the evidence – have been used to justify threatened clampdowns.

Meanwhile in Britain, something like 2.5 million smokers have taken the lead by switching to this much safer alternative. In other words, they have proved more adept at looking after their own health than those charged with the public’s health. As many as half a million smokers, according to Ash, have switched in the last year alone. On the face of it, a section of the public health establishment has come to its senses and followed suit.

But while making e-cigarettes available on prescription is quite a turnaround, it is more in keeping with the urge to regulate than to promote smokers’ health. Indeed this new-found enthusiasm for vaping is as likely to raise prices, as e-cigarettes acquire medicinal status, as help smokers do what they are already doing anyway.

The case of vaping is not atypical of a confusion at the heart of health policy. On the one hand, promoting people’s “independence, choice and control” has become a mantra in health (and social care) circles. On the other, the assumption that the public cannot be trusted to make even the most basic decisions about how they live their everyday lives dominates public health thinking. As one GP pleaded recently, her waiting room of patients is already impossibly demanding without also “trying to remember that [she’s] meant to tell smokers to stop smoking, drinkers to stop drinking, and to wave a wand at obesity” too. And that’s just three items on a very long list.



Hasn’t general practice got enough to do without having to prescribe e-cigarettes as well? The controversy over vaping is just one of many instances where public health dogmatism is coming up against people’s autonomy. With the exception of GPs helping those patients who need it to manage a long-term condition, or to prevent one getting worse, are the lifestyles of patients really anybody else’s business?

It is one thing to rightly insist that the NHS change from being a “sickness service” that reacts rather than prevents (reducing infections, preventing falls and avoiding unnecessary hospital admissions). It is quite another to insist that people must be kept well whether they like it or not. The health service is supposed to be in the business of promoting, not robbing people of, their capacity to run their own lives – and that means recognising their ability to make unhealthy choices.

There is a contradiction at the heart of the policy agenda, where a rhetorical commitment to patient choice turns out to be fatally compromised by a paternalism that the health service claims to have abandoned. Patronising people and protecting them from themselves just won’t wash anymore. If we choose to smoke or vape, or drink or eat too much, that should be up to us.