E-cigarettes entered the global tobacco and nicotine market between 2003 and 2008. Within a decade, they had spawned a battle royal focused on both evidence and values. This book focuses on the three countries that have played a central role in global debate over e-cigarettes. It is an examination of three different, influential countries that shaped debate in a way that gives us a more granular view of how policy climates develop and evolve (Montez, 2020). Indeed, it has its origins in a more distant history of tobacco policy. Those who were familiar with public health histories saw a paradox in country policy responses to e-cigarettes. The UK and Australia have had a long history of cross fertilisation of public health policy. Australian responses to HIV, for example, influenced those in the UK while British anti-smoking policies and culture influenced those in Australia. There was also movement of leading public health personnel between Australia and the UK. Why then, did Australia’s response to e-cigarettes differ so much from that in the UK? The UK welcomed e-cigarettes as a form of harm reduction while Australia imposed stringent restrictions on smokers’ access to protect youth. Discussion of why this was brought the British and Australian authors together. We then called on our collaborators in the US for an analysis of e-cigarette policy in a comparator country with a long history of both anti-tobacco activism and a “war” on illicit drugs. How did the US response to e-cigarettes fit within its history of policy responses to different types of substance use?

1 A Note on Our Methods and Analysis

Our approach used a combination of the methodology of historians and policy analysts. We used contemporary history approaches that use documentary sources to analyse the story of debate in each country. We also reviewed the arguments and evidence cited in major reports and policy statements by government agencies and in submissions to government inquiries. We examined public statements made by leading public health bodies and non-government organisations (e.g. cancer councils, medical organisations and heart foundations) in each country and supplemented these with analyses of arguments presented for and against ENDS policies in the media and leading medical journals in each country. Finally, we conducted key informant interviews with leading figures in policy in each country to understand their perspectives on the challenges and the evidence.

The discussion of policy in this area has often been framed in terms of “the evidence” which is assumed to be a value-free concept and the use of the precautionary principle or the concept of harm reduction to deal with the uncertainty left by evidence gaps or contradictions. While both evidence and values have been key in both national and global debate, we show that they intersected in different countries in different ways: very different responses and constellations of arguments arose within specific national contexts and histories. Our analysis accordingly emphasises the pre-history, the historical context, of the policy issues raised by e-cigarettes and places the policy debate within the contexts of regulatory bodies and the networks of researchers and lobbyists who influenced policy. This opening chapter accordingly sets the scene for the events which have unfolded in each country in tobacco control in the twentieth century.

Our analysis focuses on the justifications provided for these policies by key policy actors. We also paid attention to the pre-history of harm reduction policies on HIV/AIDS and drugs and drew upon histories of tobacco control policy in each country to understand the origins of these differences in policy approaches to e-cigarettes (often called electronic nicotine delivery systems [ENDS]), between the three countries. Commonalities and differences between countries were compared in a multi-day face-to-face meeting between the investigators. The meeting arrived at a consensus through a discussion of commonalities and divergences in historical approaches to nicotine policy in Australia, the UK and the US. Summaries of the policy situation in each country were prepared and used to produce this book.

There have been different policy views in constituent countries of the UK, notably England and Scotland, so England is our main focus in the case of the UK. Some agencies are UK-wide and European Union (EU) regulation applies to the whole of the UK, so at times a UK policy perspective is unavoidably taken.

2 National Policies Towards E-Cigarettes

Electronic cigarettes remain the subject of public, media and regulatory attention in the UK, US and Australia. How much has evidence (of what kind, and with how much uncertainty) shaped public policy in these countries? Should e-cigarettes be banned? Should they be regulated, and if so, should they be regulated as recreational consumer products, tobacco products, medicines or some a combination of these approaches? These debates have centred on whether e-cigarettes encourage or discourage smoking in aggregate. Very different policies have been justified by invocations of precautionary and harm reduction principles depending on how countries framed risk to different groups within each country.

In the UK, the tradition of harm reduction using nicotine has shaped majority support for a policy that has endorsed e-cigarettes for smoking cessation and harm reduction. This has not been without considerable controversy in the public health field.

In the US, despite an abstinence-oriented, anti-tobacco agenda, there has been a debate about the trade-offs between the risks of youth vaping and the benefits to current smokers. Australia, by contrast, has effectively banned the sale of e-cigarette products containing nicotine by making them a “prescription only” medicine, a policy that has made it difficult for smokers to access e-cigarettes. Each nation has justified its policy by appeals to “evidence.”

We use these countries to provide comparative case studies of how policies towards e-cigarettes have been made and why they have come to be so different. This book argues that their varied responses are the outcomes of the history of public health, and health policy more generally, and different policy making traditions and institutions in the three countries. This book thus throws light on the relationship between history and the role of evidence and science and policy more generally.

This introductory chapter of the book sets the scene for key events in tobacco policy in the three countries over the half century since the 1950s. We consider how thinking about public health has changed since World War II and how tobacco smoking came to be treated as a central public health problem. We then examine how nicotine as a harm reduction tactic figured in tobacco policy before the advent of the e-cigarette. We start by looking at public health and the role of tobacco and nicotine in the three countries.

3 The UK

Britain, as the world’s first industrial nation, developed a public health movement in the mid-nineteenth century. This emphasised the role of sanitary reform in the prevention of infectious disease epidemics, such as cholera, via the provision of drains and the general improvement of the living environment. Such actions, which were limited until the third quarter on the nineteenth century, were underpinned by miasmatic or contagionist views of disease. After the Public Health Act of 1875, a cadre of state bureaucrats developed, the Medical Officers of Health (MoHs). They operated at the local level and were responsible for the removal of nuisances, building standards and the regulation of food production. From the late 1880s, they also enforced notification and isolation in the case of infectious diseases.

Germ theory emerged in the second half of the nineteenth century. It became the dominant explanation of infectious diseases and produced a shift in the focus of public health away from improving the environment to improving the health of individuals, and especially mothers, in the home. Eugenic ideas focused on “racial poisons” such as venereal disease, alcoholism and tuberculosis. After World War I, a “public health empire” developed in the UK in which the MoH ran a whole range of local government-based services that in the inter-war years promised to form the basis for a new national health service.

But after World War II, the national health and welfare services that were introduced in the UK were not run by public health. Changing patterns of disease from infectious to chronic, known as the epidemiological transition, and changes in the organisation of health services, encouraged those in public health to seek a new way of thinking about health. The idea of social medicine as holistic way of thinking about public health began in the inter-war years and continued into the 1940s. It produced a more restricted vision of public health that focused on chronic diseases of lifestyle and the role of quantitative methods in investigating risk behaviours for these diseases. Public health practitioners focused on the role of long-term risk factors which might not cause disease immediately but would produce chronic ill health in the future. They began to use a new language, that of “lifestyle”—individual behaviour or habits—and to discuss how it might be modified (Berridge, 2016).

Tobacco smoking encapsulated the new approach to public health. The original research was carried out by Richard Doll and Sir Austin Bradford Hill at the London School of Hygiene and Tropical Medicine and by Wynder and Graham in the US. The rise in deaths from lung cancer led the British Medical Research Council to commission Doll and Hill to investigate the causes. A questionnaire administered to cancer patients in London hospitals revealed that heavy smoking was common in those with lung cancer but not in those with other forms of cancer. The American study produced similar findings. Doll and Hill then designed a prospective study of British doctors that related their chances of acquiring lung cancer and other diseases to their smoking habits. The final report from this doctors’ study was published in 2005. By then, the health hazards of smoking were widely accepted.

The publication of the Royal College of Physicians (RCP) report, Smoking and Health in 1962, was the first to bring the issue to worldwide attention, with the assistance of television coverage. It was followed two years later in 1964 by the US Surgeon General’s report on smoking in the US.

New techniques of health advocacy began to be used, and mass media campaigns were instituted that drew on behavioural science to influence the behaviour of populations. Activist groups such as ASH (Action on Smoking and Health) in the UK used the mass media in a self-conscious way, basing its tactics on the American consumer movement and the UK housing action movement.

The early tobacco activists in the UK were not anti-industry. In fact, members of the Royal College of Physicians committee worked with tobacco-funded organisations. The industry-funded Tobacco Research Council (TRC) provided the statistics for the first RCP report. A shared research and policy agenda that extended into the 1960s and 1970s aimed to identify the substances that caused harm in cigarettes and to remove them.

In the 1970s, this objective crystallised in the search for what was known as the “safer cigarette.” Cigarette filters were investigated, as was a reduction of tar and nicotine levels with appropriate labelling. New Smoking Material (NSM) was launched in 1977 but proved a failure because it was unpopular with smokers and opposed by health agencies such as the Health Education Council. Anti-tobacco activism was stimulated by the discovery of “compensatory smoking,” which involved smokers consuming more low-tar and low-nicotine cigarettes, potentially leading smokers to take in more rather than less tar.

By the end of the 1970s, public health support for cooperation with industry and for modification of smoking came to an end. The new public health position, common to other public health approaches such as diet and heart disease, aimed to eliminate smoking and opposed collaboration with industrial interests. This was a wider agenda for public health in the 1970s, shown in the British government’s policy documents on prevention (Berridge, 2007).

Over the next twenty years, the aim of eliminating smoking was dominant. In many respects, hostility continued and deepened during the 1980s. The arrival of “passive smoking” as a scientific fact codified what had been a moral issue—the selfishness of smokers in polluting the atmosphere for non-smokers—into a scientific one. The publication of papers by Hirayama and others in the British Medical Journal in 1981 showing that the non-smoking wives of heavy smokers had a much higher risk of lung cancer provided an epidemiological case, a scientific justification for greater restrictions on smokers (Hirayama, 1981). The institution of a ban on indoor smoking in commercial venues in 2007 was in some sense the culmination of the focus on the restriction of public space for smoking.

The arrival of passive smoking on the scene in the 1980s underpinned a more aggressive stance on the part of anti-tobacco campaigners, enabling them to draw attention to the widening of risk. This was risk to others rather than just to smokers. Smokers threatened others rather than just themselves. It involved “innocent victims”, among them women and children. It was concerns such as this which led to the smoking ban in public places and to the UK’s participation in the Framework Convention on Tobacco Control set up through WHO in 2003.

But alongside this public health stance on smoking, other developments within public health saw what was termed harm reduction come onto the policy scene. The advent of HIV/AIDS in the 1980s brought harm reduction overtly into drug policy, reversing the “war on drugs” stance adopted from the US at the beginning of that decade (Berridge, 1996). And the development of nicotine as a treatment therapy for smoking also saw the beginnings of harm reduction approaches within the smoking field, as will be discussed in Chapter 2.

4 Australia

As a former British colony, Australia’s approach to public health in each of its states followed the lead of England well into the twentieth century (Lewis, 1989, 2007). After the colonies Federated in 1901, the Commonwealth government’s responsibility for health was limited to border quarantine; state government health departments were primarily responsible for health services and public health (Lewis, 1989).

There was no Commonwealth Department of Health until 1921 (Lewis, 1989). State public health services ensured clean water and sanitation services, and food safety and were responsible for the detection, isolation and treatment of persons with infectious diseases (Lewis, 2007). The Commonwealth’s health role expanded after World War II when it took responsibility for regulating and funding pharmaceuticals. In the 1970s, the Commonwealth also began to subsidise primary health care and private medical practice and fund state hospital services and to take a role in providing public health advice, including that on the risks of smoking.

Cigarette smoking in Australia, as in Britain and the US, was widely adopted by Australian troops in World War I and World War II (Tyrrell, 1999; Walker, 1980). Attitudes towards smoking by women changed in the 1920s as cigarette advertising began to target them. The large number of women in the workforce during World War II also increased cigarette smoking rates among women. By the end of World War II, three quarters of men and over a quarter of Australian women smoked cigarettes.

As in the UK, cigarette smoking was recognised as a major cause of premature mortality and morbidity in Australia in the late 1950s after the publication of Doll and Hill’s epidemiological studies (Tyrrell, 1999). In 1957, the National Medical Research Council (NMRC) accepted that smoking caused lung cancer and called on the federal government to fund anti-smoking campaigns and ban tobacco advertising (Walker, 1984). The findings of the 1962 report of the Royal College of Physicians on tobacco smoking were endorsed by the Australian Colleges of Physicians, Pathologists and General Practitioners and the Australian Medical Association (Lewis, 2007; Tyrrell, 1999; Walker, 1984). These medical bodies accepted that cigarette smoking was a cause of lung and other cancers and heart disease. They advocated government-funded public education campaigns to inform smokers of these health risks on the optimistic assumption that this would be sufficient to encourage smokers to desist (Tyrrell, 1999). They also advocated for restrictions on tobacco advertising (Lewis, 2007).

A major obstacle to effective tobacco control policies in Australia was the Liberal-Country Party (LCP) coalition government that was in power federally from 1949 to 1972 (Tyrrell, 1999; Walker, 1984). The LCP government was ideologically opposed to “interfering” in smokers’ “personal choices” and it was protective of the economic benefits of the tobacco industry (Walker, 1984). In 1965, for example, the Cabinet rejected a proposal from the Commonwealth Department of Health to fund public health campaigns to discourage smoking because the Department of Primary Industry argued that there were major economic benefits from tobacco production (Tyrrell, 1999).

The tobacco industry also enjoyed considerable protection from the Country Party (later the National Party) that represented the interests of tobacco growers (Tyrrell, 1999). The print and other media strongly opposed any advertising bans because tobacco advertising was a major source of their revenue; they refused to print anti-smoking advertisements into the 1970s to avoid offending the tobacco industry (Walker, 1984). Treasury also obtained a substantial amount of tax revenue from tobacco excise. For all these reasons, Australia lacked any effective public health policies to reduce the prevalence of cigarette smoking until well after the end of conservative rule in 1972 (Walker, 1984).

In the 1960s, the Australian public health community followed the example of the UK in supporting a form of tobacco harm reduction. The Anti-Cancer Council of Victoria (now Cancer Council Victoria) campaigned to reduce cigarette tar yields (King et al., 2003), and the NMRC recommended that cigarette packs include information on tar content. The tobacco industry voluntarily implemented this policy in 1982, and the government made disclosure mandatory in 1994. The industry knew that low tar yields were misleading because filter ventilation (introduced in the 1970s) enabled smokers to engage in compensatory smoking (King et al., 2003). This early failure of tobacco harm reduction led the Australian public health community to follow the UK in focusing on encouraging smokers to quit and stopping adolescents from initiating smoking (Berridge et al., 2021).

Advocacy for more vigorous tobacco control in the 1970s and 1980s came from NGOs and activists who worked outside government (Chapman, 2008). They campaigned for bans on cigarette advertising on television and billboards; government-funded media campaigns to encourage smokers to quit bans on smoking in public places and workplaces; and higher tobacco taxes to encourage smokers to quit and discourage young people from smoking (Chapman & Wakefield, 2001, Tyrrell, 1999).

The campaign for more effective tobacco control policy in the 1970s was under the leadership of state cancer societies and Australian medical colleges (Walker, 1984). These bodies followed the UK lead in establishing an Australian Action on Smoking and Health (led by Steven Woodward) that campaigned for increased tobacco taxes and an end to cigarette promotions on television, in print advertising and via sports sponsorships.

The Victorian Anti-Cancer Council played a leading role under the leadership of the physician Nigel Gray and the psychologist David Hill (Tyrrell, 1999). Gray and Hill published data on the prevalence of smoking, the most influential of which included the “killer fact” that the preferred cigarette brand among Australian adolescent smokers in each of Australian states was the brand that sponsored the most popular football teams in each state (Gray, 1989). Gray also persuaded the Victorian State government to use state tobacco taxes to replace tobacco industry sports sponsorship which helped to end tobacco industry use of sports to promote smoking (Tyrrell, 1999).

An Australian innovation in tobacco control was civil disobedience campaigns by the group Billboard Utilising Graffitists Against Unhealthy Promotions (BUGA-UP) founded in 1979. BUGA-UP activists attracted public attention by defacing cigarette billboard advertisements. Some were prosecuted but only lightly fined by sympathetic magistrates (Lewis, 2007; Tyrrell, 1999). In combination with the media advocacy of Simon Chapman, Nigel Gray, Steve Woodward and others, the tobacco control movement had their first victory in ending tobacco industry sports sponsorship, cigarette advertising on billboards and, much later, the print and television advertising of cigarettes (Chapman, 2008).

In the 1980s and 1990s, legal actions were successfully brought against employers for tobacco-related diseases in non-smokers who had been exposed to tobacco smoke in the workplace. These actions forced employers to ban smoking in workplaces. They later led governments to ban smoking in public transport and, later still, in public spaces such as restaurants and bars and public transport.

In the early 1990s, the Australian tobacco control community secured a ban on the commercial importation of smokeless tobacco products, such as chewing tobacco, oral snuff and snus (Greenhalgh & Hanley-Jones, 2023). During the 1980s, some states banned the sale of these products because their use had increased among young people in other countries (Gartner & Hall, 2009). In 1991, the federal government banned the sale of all smokeless tobacco products, including chewing tobacco, using the Trade Practices Act Greenhalgh and Hanley-Jones (2023). The ban aroused little opposition because very few Australians used these products. Individuals were allowed to import up to 1.5 kilograms of smokeless tobacco products for personal use, but tobacco import taxes made this very expensive (Greenhalgh & Hanley-Jones, 2023). In mid-2006 there was a significant increase in taxation on these products, from 2.30/kg to 300.39/kg, 3 taking the customs duty into line with that in all other tobacco products.

In Australia, smoking cessation support has been provided by general practitioners and state-based telephone counselling Quitlines. The main focus has been on motivating smokers to make a quit attempt without medication, an approach advocated by Simon Chapman who argued that quitting by going “cold turkey” was the most effective approach to cessation (Chapman, 1985; Chapman & MacKenzie, 2010). NRT has been available for over-the-counter sale in Australia as a transdermal patch form since 1997 and in gum form since 1998. Bupropion and varenicline were publicly subsidised in 2000 and 2008, but NRT was only subsidised in 2011, in response to evidence that smoking was becoming concentrated among socially disadvantaged Australians (Greenhalgh et al., 2016).

In Australia, as in the US, the tobacco industry campaigned to undermine public health efforts to educate smokers about the health risks of smoking. Australian subsidiaries of US and British global tobacco companies used many of the same tactics to reassure Australian smokers and raise doubts about the health risks of smoking. These included marketing filtered, light and low nicotine cigarettes; using visiting “experts” to question the risks of cigarette smoking (Carter & Chapman, 2003); and opposing the introduction of smoke-free policies by attacking research on the risks of environmental tobacco smoke (Chapman & Penman, 2003). They also later opposed tobacco pack health warnings and took legal action in the High Court in a failed attempt to block mandated plain packaging of cigarettes.

Successful tobacco control policies reduced the adult prevalence of cigarette smoking from 35% in 1980 to just over 20% in 2010 before e-cigarettes became available and to 14.7% in 2019 (Greenhalgh et al., 2020). As we will show, the steady decline in the prevalence of cigarette smoking been used to argue that e-cigarettes other forms of tobacco harm reduction are not needed in Australia (Berridge et al., 2021).

5 US

The history of public health in the US in nineteenth century is not dissimilar from that of the UK. As in the UK, public health began to focus narrowly on the promise of bacteriology and the conquest of germs after 1900. Curing diseases in individuals, not broad social, occupational or environmental reform, would be, in the minds of a new breed of public health professionals, both cheaper and more effective (Fairchild et al., 2010). After World War II, biomedical research took on the promise of population protection (Scheffler, 2019) in a context in which consumer culture took on increased importance in American notions of democracy and freedom (Cohen, 2003).

At a moment in which cigarettes dominated consumer culture, the American public health saga regarding tobacco began with the 1964 Surgeon General’s report linking cigarettes and lung cancer. No understanding of the contours of the political, scientific and public health dimensions of the bitter controversy regarding the promise and peril of e-cigarettes in the US is possible without an appreciation of the social context that had been created by a six-decade-long campaign, sometimes halting, against combustible cigarettes. It was a context marked by a legacy of deceit and manipulation by the tobacco industry one within which a challenge to smoking as a broadly accepted social behaviour had to confront the uniquely important role of anti-paternalism in American social discourse, a role that would, for years, necessitate the shaping of anti-tobacco policy in terms of the protection of the medical and social interests of non-smokers and of children.

But it was also a context marked by an increasing focus on individuals, their choices and their “treatment.” Understanding the relationship between smoking, disease and death was central to the rise of “risk factor” thinking in epidemiology in the US in the 1950s and 1960s. Risk factor thinking is important because it focused attention on individuals and their behaviour and made it harder, in a context in which talking about race and class in the US was fraught, to focus attention or action on the social determinants of health (Oppenheimer). Most forcefully making the linkage between risk factor thinking and not just individual behaviour but rather individual responsibly for disease was John Knowles, a widely known physician and President of the Rockefeller Foundation. In a classic piece, Knowles captured American thinking on the role that public health had to play in combatting disease: “Over 99 percent of us are born healthy and suffer premature death or disability only as a result of personal misbehavior….” He can either “change his personal bad habits or stop complaining. … Beneficent Government cannot—indeed, should not—do it for him” (Knowles, 1977).

Within this landscape, the Office of the Surgeon General, the US Centers for Disease Control and Prevention (CDC), the Food and Drug Administration(FDA), national health-related NGOs (e.g. American Cancer Society, American Lung Association Campaign for Tobacco Free Kids Action on Smoking and Health, Foundation for Non-Smokers Rights) and researchers who played a major role in confronting the tobacco industry were the key stakeholders shaping the interpretation of evidence, appropriate policy targets and acceptable policy options.

It was only when the prevalence of smoking had dramatically declined and the social class composition of smoking became characterised by a steep social gradient that public policy would take on an explicitly neo-prohibitionist dimension, one in which the goal of protecting smokers from their own behaviours was paramount. It was at that moment that e-cigarettes entered the market.

Considering this context, it is not surprising that even as his 1964 report spurred the American anti-tobacco movement, the Surgeon General described research into new, less threatening cigarettes as “a promising avenue for further development”. In the early 1970s, the government spent $6 million a year to try to develop safer tobacco products. Even former US Secretary of Health, Education, and Welfare Joseph A. Califano Jr., who called smoking “Public Enemy No. 1,” saw a place for “research aimed at creating a less hazardous cigarette” (Califano, 1978). As late as 1981, the Surgeon General advised smokers who could not or would not quit to switch to low-tar and low-nicotine brands. The American Cancer Society although worried that the development of less hazardous cigarettes might derail efforts to deter people from smoking or getting them to quit—supported “frank scientific discussion about the possibilities of developing cigarettes that will be less harmful and still satisfying to smokers” (Fairchild & Colgrove, 2004).

The AIDS epidemic in the 1980s compelled the US to confront its prohibitionist policy on injecting drug use. The evidence was clear that sharing injection equipment was an efficient means of HIV transmission. The Netherlands was the first to report that providing drug users with sterile equipment could reduce the incidence of infection. HIV activists in the US became strong proponents of such an approach even as heroin possession and use remained criminal. Advocates framed harm reduction as a pragmatic tactic for reducing but not eliminating all risks. The animating idea was that there were some who could not or would not stop drug use, regardless of whether it was legal or illicit. Harm reduction approaches, then, fell short of blanket prohibitions on behaviour or bans on products that carried any degree of risk needles and syringes we are condemning large numbers of addicts to death from AIDS”.

Needle exchange was utterly unacceptable to those who saw addiction, in and of itself, as a threat to be confronted, not facilitated. For many in African American communities, this was especially true. It sent “the wrong message” to society that drug use is acceptable. It thereby risked undermining other messages that would reduce harm to a greater extent. As a corollary, critics charged that harm reduction activities encouraged the initiation or continuation of potentially risky behaviours. It thereby perpetuated rather than attenuated harm. While individual harms might be reduced by efforts to make use safer, this reduction could be accompanied and even outweighed by an aggregate rise in harm (Fairchild & Colgrove, 2004). In the UK, the absence of a racial element to the debate was one factor which helped the adoption of a harm reduction approach (Berridge, 1993).

But even as the case for harm reduction in the case of injecting drug users was gaining wide scientific support, American optimism over tobacco harm reduction came to a halt in the 1980s. Stunning revelations from high-profile court cases demonstrated that the tobacco industry had, for decades, lied about the dangers of smoking and manipulated the levels of nicotine in its products to ensure that smokers stayed addicted. Opposition to anything less than total cessation became the new orthodoxy. It was reinforced by clinical guidelines describing smoking as a chronic disease, the availability of over-the-counter nicotine replacement therapies and a new focus on the protection of bystanders from second-hand smoke and children from tobacco advertising. As the head of the American Heart Association put it in 2000: “There is no such thing as a safer cigarette” (Fairchild & Colgrove, 2004). A solid “‘zero tolerance’ philosophy” regarding harm reduction involving safer cigarettes took hold (Warner, 1997).

It is against this backdrop that we can turn to the nearly six-decade effort on the part of anti-tobacco activists and public health officials to address the burdens of combustible cigarettes. To avoid the spectre of the nanny state, those who shaped anti-tobacco policy in the first decades after the Surgeon Generals 1964 Report made protection of non-smokers and children central while pursuing three broad strategies, namely the protection of youth and “innocent” bystanders (non-smokers unwillingly exposed to second-hand smoke), the denormalisation of smoking and taxation. In the course of pursuing these strategies over half a century, the CDC (Communicable Disease Center, now the Centers for Disease Control and Prevention) assumed a critically important federal role.

The protection of youth took on a new force in the late 1980s into the 1990s. The introduction of Joe Camel ads—clearly designed to appeal to the young—in 1988 drew widespread condemnation (Fairchild & Colgrove, 2004). Food and Drug Administration Commissioner David Kessler’s sought to reframe smoking as a “paediatric disease.” The 1994 Surgeon General’s Report, Preventing Tobacco Use Among Young People, exemplified this stance in its claim that “When young people no longer want to smoke the epidemic itself will die” (Department of Health and Human Services USA, 1994).

Ultimately, an anti-tobacco movement in the US determined that it had to challenge the normative culture that made smoking acceptable, even desirable. An analysis from the early 1990s vividly captured the underlying goal: “Increasing restrictions on smoking in public places to protect non-smokers from toxins in [environmental tobacco smoke] undermines the social acceptability of smoking. Decreasing the social acceptability and mandating restrictions on where and when one can smoke in turn discourages children from starting to smoke and facilitates adults’ decisions to cut down or stop smoking. While generating significant health benefits for smokers and nonsmokers, this drop in cigarette consumption translates into fewer sales and lower profits for the tobacco industry” (Bayer & Feldman, 2004). California’s campaign to denormalise tobacco consumption, which began in the early 1990s, sought to push tobacco out of “the charmed circle of the normal, desirable.” Lauding these efforts, anti-tobacco activists wrote, “In a society where smoking is not viewed as an acceptable activity, fewer people will smoke, and as fewer people smoke, smoking will become ever more marginalized” (Gilpin et al., 2004).

Those committed to the reduction of tobacco-related mortality and morbidity came to explicitly endorse a strategy of marginalisation and stigmatisation, as apparent in a 2006 report in the American Journal of Public Health titled, “Effect of Increased Social Unacceptability of Cigarette Smoking on Reduction in Cigarette Consumption” (Alamar & Glantz, 2006). After noting that bans on smoking in restaurants, bars and homes were as effective as taxes in reducing tobacco consumption, the authors concluded, “Our results indicate that increasing the social unacceptability of smoking is a highly effective policy tool in reducing consumption. Tobacco control programmes should stress the dangers of environmental tobacco smoke and reinforce the nonsmoking norm” (Bayer, 2008).

The complex politics of tobacco policy was underscored by the ultimate failure of an FDA effort to impose graphic warnings on cigarette packages. Reflecting the unique American conception of the constitutional protection of advertising as a form of speech, federal courts held that requiring graphic messaging represented “compelled speech,” violating the First Amendment to the US Constitution protecting freedom of speech.

Six decades of anti-tobacco efforts produced a radical transformation. In 1963, more than half of men and a third of women in the US smoked. By 2019, only 14% of adults smoked. The gap between men and women had substantially closed: 15.3% of men and 12.7% of women smoked. Despite this progress, a sharp social gradient in tobacco use emerged, with people of low-income and less formal education the most likely to smoke (Feldman & Bayer, 2011). By 2016, 35.3% of those with a high school equivalence degree smoked in contrast to only 6.9% of college graduates and 4.0% of those with graduate degrees (CDC, n.d.).

The policy trajectory that produced this epidemiological tobacco transition would ultimately have a profound influence on the response to e-cigarettes.

6 Conclusion

Although all three countries had a similar history of hostility to tobacco as a central plank of public health policy, our summaries of the pre-history of e-cigarette policy underscore differences between them. Note for example: the US unwillingness to control advertising because of the right to freedom of speech and focus on individual smoker treatment; the Australian belief in the superiority of “cold turkey” for smoking cessation rather than treatment; and the important British tradition of harm reduction using nicotine.

Each of the three countries had, by the twenty-first century, embraced increasingly restrictive measures to limit the toll of tobacco cigarette smoking. Each in its own way moved in the direction of neo-prohibitionist policies that would have been unthinkable decades earlier. In each, years of confrontation with the tobacco industry transformed a formerly vibrant industry into a social pariah. In each nation, there was a dramatic decline in prevalence of smoking so that smoking which had been normative behaviour in the 1950s had become increasingly marginalised. For some, the policy question at hand was how the “tobacco end game” would be played out.

The ensuing policy battles over e-cigarettes in each country can only be understood with an appreciation of this public health context. What is striking, and what motivated us to write this volume, was the fact that each of these countries pursued differing public health policies while appealing to the same bodies of evidence. In the case of England and Australia, in particular, the difference in approach was dramatic. Yet, as influential as each was in the global debate, all three nations came to understand the promise and risk of e-cigarettes in radically different ways. Each came to interpret the available evidence differently; each addressed the evidence from the perspectives of harm reduction and the precautionary principle in utterly divergent manners.

The national narratives to which we will now turn make it abundantly clear that it is inadequate to understand sound public health policy making as a matter of “implementation science.” Only a direct recognition of the role that history and politics played in shaping public health policy can permit us to fully understand how and why very different policy determinations were made. Amassing scientific evidence on the public health effects of e-cigarettes is not the end of the story; it is just the beginning.