Statement from Fresh on electronic cigarettes, also known
as nicotine vaporisers (updated Sept 2016)
Tobacco vs nicotine - re-evaluating the harms
One in two long term tobacco smokers who don't quit will die from a smoking related disease with an average of 10 years of life lost, with half of those deaths happening during middle age[i].
Recent research from Australia suggests for heavier smokers who started as children, this figure may be more like 2 in 3[ii].
This presents an appalling and unacceptable loss of life in the North East and in England, where around 80,000 people a year die from smoking. Most smokers who die from tobacco, or who lose years of quality life and mobility as a result, will have probably tried to quit smoking several times and probably regret ever starting.
In 1976 Prof Michael Russell wrote that 'smokers smoke for the nicotine but die from the tar[iii].
When we urge people to stop smoking, we explicitly mean to quit smoking tobacco. The harm from smoking is caused primarily through the toxins produced by the burning of tobacco.
By contrast, non-tobacco, non-smoked nicotine products, are considerably less harmful. Electronic cigarettes represent a safer alternative to cigarettes for smokers who are unable or unwilling to stop using nicotine.
One concern is that some smokers hold incorrect beliefs about the harm from electronic cigarettes and nicotine - believing that part or most of the health risks from smoking are from nicotine. This may be putting some off switching to a safer alternative which replicates some of the behavioural aspects of smoking.
Perceptions of harm from electronic cigarettes have grown with only 15% of the public accurately believing in 2016 that electronic cigarettes are a lot less harmful than smoking. This is the lowest level than at any time in the history of the Smokefree Britain survey undertaken by ASH.
This is an updated version of the statement first published in March 2015 which backs a harm reduction approach to helping smokers to quit, and aims to encapsulate some of the key current evidence to both members of the public and to colleagues working in public health and the NHS
Safer for users and those around them
i/ To the vaper
Although not completely without risk, most experts agree that electronic cigarettes are much less harmful to health than tobacco smoking[iv], and that it is never better for a smoker or those around them to smoke rather than vape. An expert review of the evidence in 2015 by Public Health England concluded that e-cigarettes are around 95% safer than smoked tobacco and they can help smokers to quit.
Although some of the toxins that are present in tobacco have also been identified in a number of studies into electronic cigarettes and vapourisers, these have been at much lower levels than in tobacco and below levels which would usually cause significant concern[v].
Concern has been raised about studies which have found high levels of aldehyde chemicals in electronic cigarettes – suggesting these have overheated devices in a way that would be unpalatable to vapers. Nicotine is an addictive drug which stimulates the nervous system, increasing the heart rate and blood pressure[vi].
However, most of the harm from smoking comes from inhaling tobacco smoke rather than the nicotine.
There is some evidence to suggest using electronic cigarettes and vapourisers rather than smoking tobacco can improve lung function and respiratory symptoms.[vii]
ii/ To people around the vaper
Second-hand tobacco smoke contains over 5000 chemicals and Cancer Research UK estimates it kills 12,000 people in the UK every year from lung cancer, heart disease, stroke and Chronic Obstructive Pulmonary Disease (COPD)[viii]. By contrast there is no current evidence that electronic cigarettes and vapourisers pose any significant risk of secondhand harm to bystanders and the level of nicotine is around a tenth of that generated by tobacco cigarettes[ix].
A recent report for PHE recognised that the health risks of passive exposure to electronic cigarette vapour "are likely to be extremely low"[x].
On the current evidence, Fresh does not currently support any calls for electronic cigarettes and vapourisers to be included within current smokefree legislation, though we recognise there may be circumstances in which use is not encouraged. The Chartered Institute for Environmental Health also does not support calls for them to be prohibited under the smokefree legislation.
ASH has a useful 'five questions before you decide' document to help with the development of workplace policies depending on the objectives[xi]
Public Health England has also published guidance on the use of e-cigarettes in public places and workplaces[xii].
Whilst this guidance does not recommend specific policies, it sets out five principles which should be used to guide the development of evidence-based policies that maximise the potential for e-cigarettes to improve public health while managing the risks.
Popularity and effectiveness
An estimated 2.8 million adults in Great Britain currently use electronic cigarettes (vape) up from only 700,000 in 2012, the first year ASH collected figures through the annual Smokefree Britain survey.
Users are fairly evenly divided between current smokers (1.4million) and ex-smokers (1.3 million). What is encouraging is that the proportion of ex-smokers who now use electronic cigarettes has increased since 2014, when two thirds of current vapers were smokers and one third ex-smokers. The main reason for use given by ex-smokers who vape is to help them stop smoking, while for current smokers the main reason is to reduce the amount of tobacco they smoke.
Electronic cigarettes have now replaced other forms of NRT as the most popular quitting aid in England.[xiii] http://www.smokinginengland.info/latest-statistics/
An estimated 9% of adults in the North East have tried electronic cigarettes and / or vapourisers and around 6% have tried and still use them[xiv].
Most people who have tried them in the NE have done so to try to stop smoking completely, to reduce their tobacco consumption but not quit completely, or to protect others from secondhand tobacco smoke intake. In terms of effectiveness:
- A Cochrane Review found electronic cigarettes and vapourisers could help smokers stop or reduce their tobacco consumption, with no evidence of serious adverse effects.[xv]
- A 'real world' study has shown electronic cigarettes and vapourisers to be more effective in helping smokers than NRT bought over the counter or using no aid[xvi].
- There is also some evidence to suggest electronic cigarette use leads to abstinence among some smokers who had not intended to quit tobacco[xvii].
Date from English Stop Smoking Services shows that electronic cigarettes, when used alone or in combination with other stop smoking products, achieve short-term abstinence rates that are comparable to the most effective products (i.e. Varenicline) and consistently higher than success rates achieved by clients using traditional Nicotine Replacement Therapy (NRT).
If used regularly, tank models (which allow higher nicotine levels and more rapid delivery) get much better success rates amongst those trying to quit.
Even smokers who want to quit can find it hard to break the addiction and stay quit, resulting in tobacco being our biggest avoidable killer. NICE says that while the best way to reduce illness and death is stopping smoking in one step, there are other ways of reducing the harm of smoking including ongoing use of nicotine, especially for more heavily addicted smokers[xviii].
Although NICE recognises that electronic cigarettes and other unlicensed nicotine containing products are currently unregulated as medicinal devices by the MHRA, NICE does state that they are expected to be less harmful than tobacco.
We back an evidence based harm reduction approach which is also supported in the National Tobacco Control Plan for England and also by the Royal College of Physicians. We believe this approach could reduce death on a huge scale and bring long term health benefits from people swapping en masse to a less harmful form of nicotine, even if this means long term use, especially among smokers who have smoked since childhood and are more addicted.
The RCP's May 2016 'Nicotine without smoke: tobacco harm reduction' report examines the science, public policy, regulation and ethics surrounding e-cigarettes and other non-tobacco sources of nicotine. The RCP's recommendation was that "in the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK"
It also found that:
- e-cigarettes are not a gateway to smoking but can act as a gateway out of smoking
- e-cigarettes do not result in normalisation of smoking
- the possibility of some harm from long-term e-cigarette use cannot be dismissed due to inhalation of the ingredients other than nicotine, but is likely to be very small,
and substantially smaller than that arising from tobacco smoking
The report also recommends that regulation of e-cigarettes should be proportionate and should not be allowed significantly to inhibit the development and use of harm-reduction products.
It is preferable not to inhale products containing nicotine or small levels of chemicals at all – especially so for non-smokers and children. However, the aim of public health should be about saving lives and reducing the harm caused by tobacco. We believe it is important the potential benefits of these products should be maximised for the wellbeing of smokers, while minimising any risks to users, and ensuring they do not become a gateway product to tobacco for children and non-smokers.
Fresh is uniting partners around a long term vision of reducing tobacco smoking tobacco down to 5% in the North East. We believe more widespread adoption and promotion of evidence based harm reduction approaches could result in significant health gain across North East communities. This could be particularly effective in reducing the health burden amongst groups such as people with a mental health problem, who have higher smoking rates and a much lower life expectancy, smokers who are more addicted, and people with long term conditions such as chronic obstructive pulmonary disease.
Stop Smoking Services
Evidence suggests the most effective way for an individual to successfully quit smoking is to use behavioural support through a specialist stop smoking service, in combination with a NICE approved stop smoking product.
This is up to four times more effective than going it alone. Although the NHS cannot prescribe products not licenced as quitting aids by the MHRA (Medicines and Healthcare Products Regulatory Agency), the Department of Health has stated any smoker choosing to use an electronic cigarette and/ or vapourisers in a quit attempt should still receive behavioural support from Stop Smoking Services, as this will improve their chances of quitting successfully[xix].
According to official Stop Smoking Service monitoring data, Stop Smoking Service users who try to quit using unlicensed nicotine along with behavioural support achieve some of the highest success rates.
The latest 2014 Stop Smoking Services – Service and Monitoring Guidance states: "To date there remains limited evidence about the use of nicotine vapourisers for smoking cessation. However, expert opinion cited in the MHRA announcement and the NICE tobacco harm reduction guidance makes it clear that the use of nicotine vapourisers is likely to be considerably less hazardous than tobacco smoking. On this basis, services should, as part of the commissioning arrangement, still be able to provide behavioural support to clients who wish to use unlicensed, self-purchased products, whether this use is in combination with or instead of a licensed product". [xx]
Despite electronic cigarettes being the most popular product amongst smokers trying to quit in England[xxi], with approximately 30% of those using a product to help them quit opting for electronic cigarettes, this is not reflected in the number of people using Stop Smoking Services.
In 2015/26, only 2.5% of all quit attempts supported by SSS staff involved the use of electronic cigarettes or unlicensed nicotine containing products[xxii].
Fresh has worked with stop smoking services to communicate with smokers that they are offering support to people using their own ecigs to quit. Services are also advised to make it explicit through their own external communications that smokers will be offered support with their quit attempt if they are using electronic cigarettes or vapourisers.
If at some point a product is licensed as a medicine, localities will have to consider how they can be incorporated into current prescribing guidelines in order to fully harness the popularity of such products within the Stop Smoking Service.
A useful briefing is available for Stop Smoking Services from the National Centre for Smoking Cessation Training with some practical advice on how services can become more 'electronic cigarette friendly' [xxiii]
Monitoring any long term potential risks
The main objections to electronic cigarettes expressed have been around the promotion of electronic cigarettes and vapourisers to children and the risk they could act as a gateway product to children to start smoking.
However, to date, there is currently no evidence that electronic cigarettes and vapourisers are introducing a new cohort of young people to nicotine addiction. The number of children and young people regularly using electronic cigarettes remains very low[xxiv] and their use is overwhelmingly amongst those who are current or ex-smokers.
Concerns have been expressed about electronic cigarette advertising promoting these products as fashion accessories for the young. The Committee of Advertising Practice has imposed rules on the advertising of electronic cigarettes to ensure advertising does not make these products enticing to children. There are also unanswered questions whether the involvement of the tobacco industry in the electronic cigarette market will be used as an opportunity to promote pro-smoking messages, or promote dual use to smokers rather than quitting tobacco. There has been recent criticism in the US that some tobacco-owned electronic cigarette brands contain longer warnings than their more harmful tobacco products[xxv].
We need to be able to monitor the long term safety of these fast emerging products, and be responsive to the emerging evidence. The revised European Tobacco Products Directive came into force in May 2016[xxvi] bringing restrictions on tobacco as well as further clarity on the labelling of electronic cigarettes including ingredients and toxicity, ensuring quality and safety is the responsibility of manufacturers and importers, and prohibiting cross border advertising.
Concerns have also been expressed that ecigs maykeep smokers smoking tobacco rather than quitting altogether, but there has been criticism of the methodology of these studies that the sample only includes people who still smoke and do not include successful quitters. [xxvii]
Our hope is that where regulation is applied, itwill mean users can benefit from increased clarity and consistency for products which match their own requirements. In some cases, that will involve electronic cigarette/vaporiser products which meet MHRA standards as medicinal aids to stop smoking, which can then be recommended by health professionals and prescribed.
This is a rapidly evolving area of tobacco control and Fresh is committed to monitoring emerging evidence and research and will update this position statement as appropriate.
[i] "The Doctors Study" (Doll R, Peto
R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years
observations on male British doctors. British Medical Journal 1994; 309:901-911).
[ii] University of Melbourne and Sax Institute's 45 and Up Study, published in
the journal BMC Medicine
Prof Michael Russell, British Medical Journal, 1976
[iv] Estimating the Harms of
Nicotine-Containing Products Using the MCDA Approach, Nutt et al, 2014
Siegel M. Metals in ECVapor are Below USP Standards for Metals in Inhalation
Medications. 2013 / Burstyn I.
Peering through the mist: systematic review of what the chemistry of
contaminants in electronic
cigarettes tells us about health risks. BMC Public Health
2014;14(1) / Cahn Z, Siegel
M. Electronic cigarettes as a harm reduction strategy for tobacco control: a
step forward or a repeat of past mistakes? J Public Health Policy 2011;32(1):16–31.
[vi] Nicotine addiction in Britain. A report of
the Tobacco Advisory Group of the Royal College of Physicians.
London, RCP, 2000
[vii] Prof Riccardo
Polosa, Director, Institute of Internal Medicine and
University of Catania, "Clinical trials of
E-cigarettes: potential for harm reversal and risk reduction" – the E-Cigarette
Summit, London, November 2015. http://www.e-cigarette-summit.com/
[ix] Czogala, J., Goniewicz, M.
L., Fidelus, B., Zielinska-Danch, W., Travers, M. J., & Sobczak, A. (2013).
Secondhand exposure to
vapors from electronic cigarettes. Nicotine & Tobacco Research, ntt203.
[x]Britton J, Bogdanovica I. (2014) Electronic
cigarettes, A report commissioned by Public Health England.
[xii] Smoking in England toolkit. Survey
published 3.8.16 "Electronic cigarettes in England – latest trends". In Quarter 2 of 2016 37.5% of smokers that have used a product to try and
quit in last year have used an e-cigarette. s://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534586/PHE-advice-on-use-of-e-cigarettes-in-public-places-and-workplaces.PDF
Smokefree GB 2016 survey
Brown J, Beard E, Kotz D, Michie S & West R. Real-world effectiveness of
e-cigarettes when used to aid
smoking cessation: a cross-sectional population study.
Published online 20 May 2014
Polosa R, Caponnetto P, Morjaria JB. et al. Effect of electronic nicotine
delivery device (e-cigarette) on
smoking reduction and cessation: a prospective 6-month
pilot study. BMC Public Health 2011; 11: 786.
[xviii] PH45, Tobacco: harm-reduction approaches to smoking,
National Institute for Clinical Excellence https://www.nice.org.uk/guidance/ph45
[xxiv] ASH Fact Sheet: Use of electronic cigarettes
among adults in Great Britain
ASH Fact Sheet: Use of electronic cigarettes among
children in Great Britain
Briefing: The impact of the EU Tobacco Products Directive on e-cigarette
regulation in the UK