E-cigarettes — a potential game-changer in getting people to stop smoking
A recent report from Public Health England claims vaping is 95% less harmful than smoking, and that e-cigarettes can be useful in helping patients to quit: so what should practice nurses advise their patients?
Despite the decline in smoking prevalence observed over the last few decades, there remain over 8 million smokers in England. People who continue to smoke regularly will have a one in two chance of dying prematurely, by an average of 10 years, as a direct result of their smoking.1
Smoking is therefore the largest single contributor to health inequalities as well as remaining the largest single cause of preventable mortality and morbidity in England.1
In 2014-15, the number of people using NHS Stop Smoking Services showed a decline for the third consecutive year. Anecdotal evidence suggests this may be due to an increase in people using e-cigarettes to help them stop smoking rather than making use of these services.2
Until recently, health professionals have held mixed views on these products, ranging from fears that they could encourage non-smokers – especially children – to smoke; that they will normalise smoking again following its stigmatisation resulting from the ban on smoking in public places; and that e-cigarette use is at worst, dangerous and at best, its real risks are as yet unkown.
However, the expert independent review conducted on behalf of Public Health England has concluded that e-cigarettes are around 95% less harmful than smoking – and that there is no evidence that vaping is acting as route into smoking for children or non-smokers.1
Emerging evidence suggests some of the highest successful quit rates are now seen among smokers who use an e-cigarette and also receive additional support from their local stop smoking services.
Almost all of the 2.6 million adult users of e-cigarettes are current or ex-smokers, most of whom are using e-cigarettes to help them quit smoking or starting to smoke again after stopping.1
According to the ASH Smokefree GB adult survey, 2015, the most common reasons for using e-cigarettes are to help stop smoking completely (30%) or to help reduce the amount of tobacco smoked but not to stop completely (29%).3
Professor Ann McNeill, King’s College London and independent author of the review, said: ‘There is no evidence that e-cigarettes are undermining England’s falling smoking rates. Instead the evidence consistently finds that e-cigarettes are another tool for stopping smoking and in my view smokers should try vaping, and vapers should stop smoking entirely.
‘E-cigarettes could be a game changer in public health in particular by reducing the enormous health inequalities caused by smoking.’
Professor Kevin Fenton, Director of Health and Wellbeing at Public Health England said: ‘Smoking remains England’s number one killer and the best thing a smoker can do is to quit completely, now and forever.
‘E-cigarettes are not completely risk free but when compared to smoking, evidence shows they carry just a fraction of the harm. The problem is people increasingly think they are at least as harmful and this may be keeping millions of smokers from quitting. Local stop smoking services should look to support e-cigarette users in their journey to quitting completely.’
PHE has concluded that e-cigarettes could be used as a wide-reach, low-cost intervention to tackle smoking in the most deprived groups where smoking levels are at their highest. They could also be used to help tackle high smoking rates in people with mental health problems.
Most of the 8 million current smokers are from manual and more disadvantaged groups in society, including those with mental health problems, on low income, the unemployed and offenders. In some such population groups, the proportion that smokes is over two or three times higher than that in the general population.
A recent Cochrane Review confirmed that e-cigarettes can both help people to quit smoking and reduce their cigarette consumption.2 There is also evidence that e-cigarettes can encourage quitting or cigarette consumption reduction even among those not intending to quit or rejecting other support.1
AID TO STOP SMOKING
E-cigarettes have become the most common aid that smokers in England use to help them stop smoking (Figure 1), despite the fact that no licensed e-cigarette product is available. Although the most effective way for stopping smoking, currently supported by the research literature, is a combination of behavioural support (NHS in Figure 1) and medication (NRT on prescription or varenicline [Champix]),4,5 the problem is that fewer smokers are accessing these services, limiting their impact on population health.
According to the latest report on NHS Stop Smoking services, 450,582 people set a quit date through the NHS Stop Smoking Services in 2014-15, down 23% on 2013-14 and for the first time since NHS Stop Smoking Services (previously Smoking Cessation Services) were set up in 2000-01, this number has fallen for the third consecutive year.6 It is now lower than the number of people setting a quit data 10 years ago, in 2004-05, when it was 529,567. There has also been a fall in the number of pregnant women who set a quit date with NHS Stop Smoking Services, 18,887 compared with 19,833 in 2013-14 but 15,060 in 2004-05. This represents a reduction of 5% on 2013-14 but an increase of 25% on 2004-05. Just over half (51%) of those who set a stop date successfully quit (by 28 days), and this figure is also down by 23% on the previous year.6
The report showed that, of all pharmacotherapies used to help people quit smoking, ‘Combination of licensed nicotine containing products (NCPs) concurrently’ had the highest number setting a quit date (135,719) and the second highest number of successful quitters (65,061). ‘Varenicline (Champix) only’ had the highest number of successful quitters (68,296) and ‘Unlicensed NCP’ – such as e-cigarettes – had the highest quit rate (66%).6
These data cannot be used to determine comparative efficacy, as they are based only on the experience of people using NHS Stop Smoking services, so it is not known whether current e-cigarette products are more or less effective than licensed stop-smoking medications. However, they are much more popular, thereby providing an opportunity to expand the number of smokers stopping successfully. Some English Stop Smoking services and practitioners support the use of e-cigarettes in quit attempts and provide behavioural support for e-cigarette users trying to quit smoking; self-reported quit rates are at least comparable to other treatments.1
However, one thing that clinicians cannot do at present is to prescribe e-cigarettes. Given their potential benefits as quitting aids, PHE says it looks forward to the arrival on the market of a choice of medicinally regulated products that can be made available to smokers by the NHS on prescription. This will provide assurance on the safety, quality and effectiveness to consumers who want to use these products as quitting aids.
The best thing smokers can do for their health is to quit smoking completely and to quit for good. E-cigarettes can help, PHE says, so it is important that all health professionals providing accurate advice on the relative risks of smoking and e-cigarette use, and refer patients to stop smoking services, which provide smokers the best chance of quitting successfully.
FAQS
QUESTION. What’s the evidence for the ‘95% less harmful’ claim?
ANSWER. The estimate that e-cigarette use is around 95% safer than smoking is based on the facts that:
- The constituents of cigarette smoke that harm health – including carcinogens – are either absent in e-cigarette vapour or, if present, they are mostly at levels much below 5% of smoking doses (mostly below 1% and far below safety limits for occupational exposure)
- The main chemicals present only in e-cigarettes and not in tobacco have not been associated with any serious risk
- Some flavourings and constituents in e-cigarettes may pose risks over the long term. PHE considers the 5% residual risk to be a cautious estimate to allow for this uncertainty.1
Q. But I have read that e-cigarettes can cause lung inflammation, lung infection, and even lung cancer.
A. A worldwide media scare was prompted by misinterpretation of research findings from a study in mice exposed to extremely high concentrations of vapour from e-cigarettes.7 However, the accelerated weight loss, reduced immunity and early death reported in the experimental animals were more likely to be caused by stress and nicotine poisoning than exposure to the free radicals implicated by the scientists, and no human study corroborates any of the findings of this study.
Q. What about reports that e-cigarettes contain 10 times the carcinogens of regular tobacco?
A. Under certain conditions, e-cigarettes may release high levels of aldehydes. Aldehydes, including formaldehyde, acrolein and acetaldehyde, are released in tobacco smoke and contribute to its toxicity. Aldehydes are also released with when propylene glycol and glycerol in e-liquids are heated, but at much lower concentrations than in cigarette smoke (approximately 1/50). Formaldehyde may be released when e-liquids are overheated, when the e-liquid is low or the power setting of the e-cigarette is too high. Vapers call this a ‘dry puff’ – instantly detected by a distinctive harsh and acrid taste – that poses no danger to vapers because it is aversive. Normal vaping generates negligible aldehyde levels.8
The PHE report’s authors said: ‘We concluded that these new studies do not in fact demonstrate substantial new risks and that the previous estimate by an international expert panel,9 endorsed in an expert review,10 that e-cigarette use is around 95% safer than smoking, remains valid as the current best estimate based on the peer-reviewed literature.
Q. It was a long time before we realised the full extent of the harms of smoking. What’s to say it won’t be the same for e-cigarettes?
A. Ongoing monitoring is needed to ensure that if any new risks emerge, recommendations to smokers and regulatory requirements are revised accordingly.
Q. I’ve heard that you can’t be sure exactly what is in e-cigarettes – is this true?
A. The accuracy of labelling of nicotine content currently raises no major concerns. Poorly labelled e-liquid and e-cartridges mostly contained less nicotine than declared.
Q. How toxic is the nicotine in e-cigarettes?
A. Nicotine in the form of tobacco and more recently NRT has been available to thousands of millions of people and large numbers of them, including small children, have ingested considerable doses of nicotine. Fatal nicotine poisoning, however, is extremely rare. This strongly contradicts the often-repeated claim that an ingestion of 30-60mg of nicotine is fatal.1
There has been an increase in calls to poison centres following accidental exposures to ‘e-liquid’ but none has resulted in serious harm. Serious poisoning seems normally to be prevented by the fact that relatively low doses of nicotine induce nausea and vomiting, which stops users from further intake.1
To prevent accidental ingestion by children, the report recommends that e-liquids should be in childproof packaging.
Used as intended, e-cigarettes pose no risk of nicotine poisoning to users.
Q. How does vaping compare with conventional smoking?
A. Speed of nicotine delivery seems important for smokers’ satisfaction. Cigarettes deliver nicotine very fast via the lungs. It is likely that to out-compete cigarettes, e-cigarettes will need to provide nicotine via the lungs as well. Although some products may already provide a degree of lung absorption, most nicotine is probably delivered via a much slower route through buccal mucosa and upper airways, in a way that is closer to the delivery from nicotine replacement medications than to the delivery from cigarettes.
Use of a cigalike e-cigarette can increase blood nicotine levels by around 5 ng/ml within five minutes of use. This is comparable to delivery from oral NRT. Experienced EC users using the tank e-cigarette can achieve much higher blood nicotine levels over a longer duration, similar to those associated with smoking. The speed of nicotine absorption is generally slower than from cigarettes but faster than from NRT.1
Q. But surely e-cigarette use can lead to or prolong nicotine dependence?
A. Vapers feel they are less dependent on e-cigarettes than they were on cigarettes,11 and non-smokers experimenting with e-cigarettes do not find them attractive and almost none progresses to daily vaping.12 This contrasts with the fact that about half of adolescents who experiment with cigarettes progress to daily smoking.13
The rates of ever having tried an EC in the ASH GB Smokefree adult survey are more than three times those of current use;3 in the ASH GB Smokefree youth survey,14 about five times as many respondents had tried e-cigarettes than were currently using them, indicating that most of those who try them do not progress to current use.
Q. What about the dangers of passive vaping?
A. Across the middle range of nicotine levels, in machine tests using a standard puffing schedule, nicotine content of e-liquid is related to nicotine content in vapour only weakly. E-cigarette use releases negligible levels of nicotine into ambient air with no identified health risks to bystanders.
At an e-cigarette conference last year, Harrison and McFiggans reported on particles present in EC vapour. Their presentation was reported in the BMJ under the title ‘E-cigarette vapour could damage health of non-smokers’.15 McFiggans and Harrison requested a retraction of the piece because their findings did not concern any health risks.
Q. Can I prescribe e-cigarettes to my patients who want to stop smoking?
A. No. Before e-cigarettes and other similar nicotine containing products can be made available on an NHS prescription, they would need to be licensed by the Medicines and Health products Regulatory Authority (MHRA). It is five years since the MHRA introduced licensing for e-cigarettes but still no product has been licensed, probably because it isn’t commercially attractive – it costs between £252K and £390K per product, with ongoing annual fees of £65-249K.
REFERENCES
1. McNeill A, Brose LS, Calder R, et al. E-cigarettes: an evidence update. A report commissioned by Public Health England, 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf
2. McRobbie H, et al. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev, 2014.12:CD010216
3. Action on Smoking and Health (ASH). Use of electronic cigarettes (vapourisers) among adults in Great Britain 2015. http://www.ash.org.uk/files/documents/ASH_891.pdf
4. Stead LF, Lancaster T. Behavioural interventions as adjuncts to pharmacotherapy for smoking cessation. The Cochrane Library, 2012.
5. Kotz D, Brown J, West R. Prospective cohort study of the effectiveness of smoking cessation treatments used in the “real world”. Mayo Clin Proc 2014;89(10):1360-67
6. Health and Social Care Information Centre. Statistics on NHS Stop Smoking Services in England – April 2014 to March 2015. 19 August 2015. http://www.hscic.gov.uk/catalogue/PUB18002
7. Sussan TE, et al. Exposure to electronic cigarettes impairs pulmonsary anti-bacterial and anti-viral defences in a mouse model. PLoS One 2015:10(2);e0116861
8. McRobbie H, et al. Effects of the use of electronic cigarettes with and without concurrent smoking. Cancer Prevention Research 2015;8(9): 873-878.
9. Nutt DJ, Phillips LD, Balfour D, et al. Estimating the harms of nicotine-containing products using the MSDA (multi-critera decision analysis) approach. Eur Addict Res 2014;20:218-225 http://www.karger.com/article/FullText/360220
10. West R, McNeill A, Brown J, et al. Electronic cigarettes: what we know so far. Report to the UK All-Party Parliamentary Group on Smoking and Health, 1 July 2015.
11. Farsalinos KE, et al. Evaluating nicotine levels selection and patterns of electronic cigarette use in a group of ‘vapers’ who had achieved complete substitution of smoking. Substance Abuse: Research and Treatment 2013;7:139
12. Douptcheva N, et al. Use of electronic cigarettes among young Swiss men. J Epidemiol Comm Health 2013:p. jech-2013-203152
13. Johnston LD, et al. Monitoring the future: National survey results on drug use, 1975-2010 in Vol 1: Secondary School Students, Institute for Social Research, 2011
14. Action on Smoking and Health (ASH) Use of electronic cigarettes among children in Great Britain, 2015 http://ash.org.uk/files/documents/ASH_959.pdf
15. Torjeson I. E-cigarette vapour could damage health of non-smokers. BMJ 2014:349:6882
