Who Really Benefits from Vaping? New Evidence on Inequality and Tobacco Harm Reduction

I have just published an open-access critical review in Current Addiction Reports examining socioeconomic disparities in e-cigarette use. The central question is straightforward but consequential. Are e-cigarettes helping to reduce smoking-related inequalities, or could current patterns of use and regulation end up widening them? (doi:10.1007/s40429-026-00716-4).

My starting point is simple. Nicotine use is not evenly distributed across society. Smoking remains heavily patterned by deprivation. If we are serious about health equity, then tobacco harm reduction cannot be designed around the “average” smoker. It must work for the communities that bear the greatest burden of tobacco-related harm.

The SES gradient is shifting

One of the most important insights from the review is that the socioeconomic gradient in vaping is not static. In the earlier phases of modern e-cigarette markets, uptake was more common among higher socioeconomic groups who smoked. This pattern was often linked to higher health literacy, better access to products, and stronger engagement with cessation efforts.

More recent evidence, however, points to increasing uptake among lower socioeconomic groups in several high-income settings. Affordability, particularly through lower-cost device categories, plays a role. Retail and marketing exposure also matters. Critically, limited access to conventional cessation services means many disadvantaged smokers are seeking alternatives on their own.

From a tobacco harm reduction perspective, this shift should be viewed as an opportunity.

If smokers in disadvantaged communities are willing to try less harmful nicotine alternatives, policy and public health systems should support full switching away from combustible tobacco. Without that support, there is a risk of partial substitution rather than meaningful harm reduction.

The equity red flag: dual use

A consistent concern across the literature is the higher prevalence of dual use among lower socioeconomic populations. Using cigarettes and e-cigarettes concurrently can represent a transitional phase. However, where dual use becomes sustained, it may signal structural barriers rather than individual indecision.

Cost pressures, chronic stress, limited access to tailored cessation advice, and weaker behavioural support systems all shape switching trajectories. Dual use in this context reflects an inequity in conversion from smoking to exclusive vaping. It is not simply a matter of personal choice. If tobacco harm reduction is to reduce inequalities, the pathway to complete switching must be easier for disadvantaged smokers.

Youth protection and policy trade-offs

The review also addresses youth vaping trends, particularly in disadvantaged environments where exposure to pro-vaping cues may be higher. Youth protection is essential and proportionate regulation is justified.

At the same time, policy design must account for trade-offs. Blanket restrictions, especially where cessation infrastructure is weak, risk sustaining combustible tobacco use among low-income adults who smoke. Policies that reduce the appeal, accessibility, or affordability of lower-risk alternatives without strengthening cessation support may inadvertently entrench inequalities.

The equity challenge is therefore twofold. Protect young people while ensuring harm reduction remains accessible to adults who would benefit most.

What needs to happen next

The evidence base remains incomplete. Longitudinal studies are limited, and socioeconomic analyses from low- and middle-income countries are particularly scarce. Strengthening this evidence is critical for equity-informed regulation.

My conclusion is clear. Tobacco harm reduction has the potential to reduce smoking-related inequalities. That outcome is not automatic. It depends on policies and services that enable disadvantaged smokers to switch completely. Affordability, accurate risk communication, and accessible cessation support must sit at the centre of harm reduction strategies.

Yusuff Adebayo Adebisi

Pharmacist and epidemiologist advancing equity-driven, policy-relevant public health research. PhD Researcher at the University of Glasgow. Director of Research at Global Health Focus.

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