In the June issue of Practice Nursing, Graham Cope (2019) made a series of claims that go to the heart of the debate on e-cigarettes. His argument, one that will be familiar to many readers, was that nicotine contained in e-cigarettes may be harmful, that nicotine replacement therapy should be attempted before e-cigarettes, that the House of Commons Select Committee on Science and Technology had concluded that the vapour from them is ‘harmless’ and that the ‘increasing use’ of vaping by young people is a worrying trend. While each was stated as a fact, here at Public Health England (PHE) we would like to put forward our advice on e-cigarette use.
In England, where smoking has fallen to just one adult in seven, smoking attributable deaths remain at 78 000 every year
How safe is safe?
Context is crucial when discussing the role of nicotine and its place in starting, and potentially ending, smoking. In England, smoking in adults has declined to 14.7% in 2019, but smoking still causes 489 000 hospital admissions and 77 800 deaths per year, with 10% of mothers still smoking at the time of delivery (NHS Digital, 2019). As for nicotine, nothing is completely free from risk, but there can be few medicines safer and better tolerated than nicotine replacement therapy (NRT). Any risks from e-cigarettes come largely from the flavourings, the carrying fluid and the devices themselves – all of which are regulated by the Medicines and Healthcare Regulatory Agency. E-cigarettes function by electronically heating this liquid, which contains nicotine
Smoking remains the largest cause of preventable death in England (McNeill et al, 2019; NHS Digital, 2019), and the harm from smoking is caused principally by the burning of tobacco and the tar and carbon monoxide that this process produces.
The public health priority must be to help smokers, pregnant smokers most of all, to stop smoking tobacco for good. While it would be preferable for people to neither smoke tobacco or use nicotine replacements, abstinence from smoking can be difficult. Only 40% of women who smoke quit during pregnancy, with more than half relapsing within 6 months, and up to 90% relapsing within 1 year. The evidence shows that quitting abruptly with no NRT or support is far more likely to lead to early relapse.
Recent UK studies (Beard, 2019; Hajek, 2019) have found e-cigarettes to be around twice as effective as other NRT. Those who use e-cigarettes have often had multiple previous unsuccessful quit attempts. For whom is it safe, PHE tell smokers that they have to fail with NRT one more time before they try with a vaping device.
What if the harms of nicotine were outweighed by the harms from the warnings?
Every e-cigarette sold in the UK carries a warning on the packaging. Many commentators have emphasised the potential harms of nicotine and especially vaping, but this warning may be harmful itself.
‘The public health priority must be to help smokers, pregnant smokers most of all, to stop smoking tobacco for good. While it would be preferable for people to neither smoke tobacco or use nicotine replacements, abstinence from smoking can be difficult. Only 40% of women who smoke quit during pregnancy, with more than half relapsing within 6 months, and up to 90% relapsing within 1 year. The evidence shows that quitting abruptly with no NRT or support is far more likely to lead to early relapse’
Although authorities such as the Royal College of Physicians (RCP), Cancer Research UK, PHE and the US National Academy of Sciences (NASEM) recognise that e-cigarette use is likely to be ‘far less harmful’ than smoking – 28% of smokers not using e-cigarettes believe them to be more or equally harmful as smoking, and almost as many overestimate the relative harm of NRT compared to smoking tobacco (Brose, 2015; Action on Smoking and Health (ASH), 2018; Rigotti, 2018; Wilson, 2019). This false belief correlates with smokers being less likely to try e-cigarettes and much less likely to switch completely to e-cigarettes (Brose, 2015). It is a tragedy that when we inflate fears about nicotine, we risk scaring smokers out of quitting.
We all know the importance of telling a strong story to cut through all the noise and misinformation. The RCP, NASEM, PHE and Science and Technology Select Committee came to the conclusion that, in the words of the Committee, e-cigarettes are ‘substantially less harmful than conventional cigarettes’, and that the risks from second hand e-cigarette vapour are almost impossible to measure ‘because any potentially harmful compounds released into the surrounding area are so negligible’ (HoCSTC 2018).
As a personal strategy, ‘abstinence only’ has a lot to be said for. In other healthcare matters, it is the only way to eliminate alcohol-related harm and sexually transmitted infections. It protects the individual and those around them from the consequences of potentially unhealthy behaviours.
As a population strategy, this is more problematic. How much should we warn about the risks of condoms and what is their appropriate age of sale? Does their promotion only act as a gateway to riskier practices?
Only time will tell
PHE note that smoking prevalence in England is falling rapidly – by approximately one quarter in the past 5 years (Office for National Statistics (ONS), 2019). The latest University College London Smoking Toolkit Study found that smoking among 16–17-year-olds fell by almost half (to 12%) in the 8 years (from 2006–2014) and again (to 6.2%) in just 4 years to 2019 (Smoking in England, 2019). In the UK, regular use of e-cigarettes in adults and young people is largely static and confined almost entirely to those who have previously smoked tobacco (ONS, 2019). Among 11–18-year-olds, regular use remains low, at just 1.7%, and only 0.2% among those who have never smoked (McNeill et al, 2019).
There is a global experiment being undertaken in tobacco control. The UK, Canada, the US, New Zealand and Australia all have similar approaches to comprehensive tobacco control. Australia added the prohibition of e-cigarettes, the US permitted them but has little regulation and warns against their use, and the UK regulates them tightly but advises smokers to switch. The data so far is encouraging for supporters of the UK approach, and both Canada and New Zealand have abandoned failed attempts at prohibition in favour of approaches much more closely aligned with the UK.
The expert consensus in the UK is that the use of e-cigarettes is less harmful than smoking tobacco. Smokers should always be encouraged to quit smoking and the evidence is strong that e-cigarettes may help them to do so more easily than they would expect.