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Using e-cigarettes is much less risky than smoking cigarettes. They have helped and are helping many thousands of people stop smoking. Smokers need to know that e-cigarettes are a healthier alternative to cigarettes. However, many people may be confused by media reports on e-cigarettes. Here, NNA summarises the evidence and sets out its position on key issues.

Vaping is safer than smoking

Vaping is at least 95% less risky than smoking.

The scientific consensus is that vaping (using e-cigarettes) is substantially less harmful than smoking. No credible expert would disagree with that opinion. This is because the harm from smoking tobacco arises from the process of combustion of tobacco producing some 4,000 chemicals, many of which are carcinogenic.

E-cigarettes heat a mixture of three major ingredients – propylene glycol and/or vegetable glycerine, nicotine, plus flavourings. When heated, these form an aerosol that is inhaled by the user. There is no combustion involved. A recent landmark report relying on 185 studies and produced by Public Health England concluded that vaping is 95% less risky than smoking tobacco.

References

  1. Britton, J. and Bogdanovica, I. (2014). Electronic cigarettes: A report commissioned by Public Health England. London: Public Health England.
  2. Farsalinos, K.E. and Polosa, R. (2014). Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Therapeutic Advances in Drug Safety, 5(2), 67-86.
  3. McNeill, A., Brose, L., Calder, R., et al. (2015) E-cigarettes: An Evidence Update. Report Commissioned by Public Health England 2015 available at: Public Health England, E-Cigarettes: an Evidence Update

Why do people use e-cigarettes?

Vapers prefer vaping to smoking

The vast majority of people use e-cigarettes as a way of stopping smoking or reducing smoking. Vaping is seen by vapers as a safer alternative to smoking. There are a variety of reasons why people continue to vape, including that they find vaping pleasurable, there's a variety of flavours, that it does not cause harm to bystanders, it does not smell of burnt tobacco and they like the feel of holding and using an e-cigarette.

References

  1. Action on Smoking and Health (ASH). (2014) Fact Sheet: Use of electronic cigarettes in Great Britain. [Online]. Available at: https://www.ash.org.uk/files/documents/ASH_891.pdf
  2. Berg, C.J., et al. (2015). Cigarette users' interest in using or switching to electronic nicotine delivery systems for smokeless tobacco for harm reduction, cessation, or novelty: A cross-sectional survey of US adults. Nicotine and Tobacco Research, 17(2): 245-255.
  3. Biener, L. and Hargraves, J.L. (2015). A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit. Nicotine and Tobacco Research, 17(2): 127-133.
  4. Farsalinos, K.E., et al. (2014). Characteristics, perceived side effects and benefits of electronic cigarette use: a worldwide survey of more than 19,000 consumers. International Journal of Environmental Research and Public Health, 11(4): 4356-4373.
  5. Hummel, K., et al. (2014). Prevalence and reasons for use of electronic cigarettes among smokers: Findings from the International Tobacco Control (ITC) Netherlands Survey. International Journal of Drug Policy, 26(6): 601-608.
  6. Kong, G., et al. (2014). Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine & Tobacco Research, 17(7): 847-854.
  7. Pepper, J.K., et al. (2014). Reasons for starting and stopping electronic cigarette use. International Journal of Environmental Research and Public Health, 11(10): 10345-10361.
  8. Richardson, A., et al. (2014). Prevalence, harm perceptions, and reasons for using noncombustible tobacco products among current and former smokers. American Journal of Public Health, 104(8): 1437-1444.
  9. Rutten, L.J., et al. (2015). Use of e-cigarettes among current smokers: Associations among reasons for use, quit intentions, and current tobacco use . Nicotine and Tobacco Research, 17(10): 1228-1234.
  10. Schmidt, L., et al. (2014). Prevalence and reasons for initiating use of electronic cigarettes among adults in Montana, 2013. Preventing Chronic Disease, 11: E204.

What is good about vaping?

Vaping has many benefits – it is a healthier, pleasurable alternative to smoking.

Many people choose vaping over smoking because it is more pleasurable, and the wide choice of devices and liquids means that they can tailor their vaping to suit their individual needs and wishes. Vaping, without the burden of a heavy sin tax,  is also much cheaper than smoking and is estimated to be 95% less harmful. E-cigarette aerosol dissipates quickly and has little lingering smell. There are no known or anticipated harms to bystanders from second hand vapour. There is a strong community spirit among vapers that is very important to many.

 

Purpose of flavours

Flavours appeal to adults and create a disassociation between smoking and vaping.

Most vapers start on tobacco flavours and move on to others. Fruit, sweet and bakery flavours are appealing to adults, and for many people are preferable to tobacco. There is no comparison between, for example, the taste of 'juicy peach' and the taste of cigarette smoke, and this distances vapers from their previous smoking habit.

References

  1. Action on Smoking and Health (ASH). (2014) Fact Sheet: Use of electronic cigarettes in Great Britain. [Online]. Available at: https://www.ash.org.uk/files/documents/ASH_891.pdf
  2. Farsalinos, K.E., et al. (2014). Characteristics, perceived side effects and benefits of electronic cigarette use: a worldwide survey of more than 19,000 consumers. International Journal of Environmental Research and Public Health, 11(4): 4356-4373.

Nicotine does not lead to cancer

There is no evidence that nicotine is carcinogenic.

There is little doubt that smoking causes cancer, however nicotine is not the culprit. It is the products of combustion which cause cancer in smokers and these are either absent in e-cigarette aerosol, or present in amounts far below levels which are known to cause harm to humans. Nicotine replacement is in common use as a tool to stop smoking through the use of nicotine patches and gums which are widely used and prescribed to children as young as twelve.

References

  1. Farsalinos, K.E. and Polosa, R. (2014). Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Therapeutic Advances in Drug Safety, 5(2), 67-86.
  2. Hajek, P., et al. (2014). Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction, 109(11): 1801-1810.
  3. Hecht, S.S. et al. (2014). Evaluation of toxicant and carcinogen metabolites in the urine of e-cigarette users versus cigarette smokers. Nicotine & Tobacco Research, 17(6): 704-709.

Nicotine addiction

Using nicotine is no worse than drinking coffee, says Professor John Britton - NNA agrees

Nicotine itself is not a particularly hazardous drug. The nicotine in e-cigarettes poses no more danger than drinking a few coffees on a daily basis, and no-one would seek to ban, or limit, adults' enjoyment of their coffee.

References

  1. BBC News Electronic cigarettes - miracle or menace? 11 February 2013 https://www.bbc.co.uk/news/uk-21406540
  2. Action on Smoking and Health (ASH) (2014). Nicotine and addiction. Available from: https://www.ash.org.uk/files/documents/ASH_114.pdf
  3. Royal Society of Public Health (2015). Nicotine “no more harmful than coffee”. Available at: Royal Society for Public Health: "Nicotine - no more harmful than caffeine"
  4. Yan, X.S. and D’Ruiz, C. (2015). Effects of using electronic cigarettes on nicotine delivery and cardiovascular function in comparison with regular cigarettes. Regulatory Toxicology and Pharmacology, 71(1): 24-34.

Is addiction to nicotine in the absence of harm a problem?


In the absence of physical harm to either the user or to others, the issue of whether nicotine addiction is a problem is more of a moral or psychological issue.


Some smokers looking to quit smoking want to be free of all dependence on nicotine, whilst others enjoy the use and benefits of nicotine but wish to avoid the harms of smoking. It is possible that long-term use of safer nicotine products protects ex-smokers against relapse to smoking. This is a personal choice and should be respected.

References

  1.  Action on Smoking and Health (ASH) (2014). Nicotine and addiction. Available from: https://www.ash.org.uk/files/documents/ASH_114.pdf

Dual use – smoking and vaping

Dual use reduces exposure to the harms caused by smoking and is a natural step towards complete switching.

Whilst many e-cigarette users report that they were able to switch immediately from smoking to vaping exclusively, others take more time and, for a period, combine smoking and vaping. Factors that influence the length of time it takes to switch from smoking to vaping include: the level of the person’s dependence on smoking, their enjoyment of smoking, their ability to develop an efficient vaping technique, finding a combination of products they enjoy, and their level of stress. Research has also shown that those who perceive e-cigarettes to have a higher risk are more likely to use e-cigarettes less frequently and to combine their use with smoking.

References

  1. Farsalinos, E., Romagna, G., Voudris, V. (2015). Factors associated with dual use of tobacco and electronic cigarettes: A case control study. International Journal of Drug Policy, 26 (6): 595-600.

E-cigarettes and an end to smoking


E-cigarettes are an attractive alternative to smoking and could replace smoking cigarettes as a means of using nicotine.

In 2016, there were an estimated 2.9 million people in Great Britain using an e-cigarette, of whom 1.3 million (52%) had switched completely away from smoking to vaping. Some commentators have argued that tobacco should cease to be available at all which is probably unrealistic. A more achievable goal is to try to ensure that there is widespread access to safer alternative means of consuming nicotine for those who wish to continue to use it. There are likely to be substantial benefits to individual and population-level public health by successfully encouraging more smokers to switch to using e-cigarettes.

References

  1. Office for National Statistics (2015). Adult smoking habits in Great Britain, 2014. Office for National Statistics; London, U.K. Available from: Office of National Statistics: Adult Smoking habits in Great Britain 2014
  2. Britton, J. and Bogdanovica, I. (2014). Electronic cigarettes: A report commissioned by Public Health England. London: Public Health England.
  3. McNeill A, Brose LS, Calder R, et al. E-cigarettes: an evidence update. A report commissioned by Public Health England. 2015. Public Health England, E-Cigarettes: An Evidence Update.

Youth and ‘gateways’ into smoking

There is no evidence that e-cigarettes are a so-called ‘gateway’ into smoking for young people.

In countries where e-cigarette use is common, smoking prevalence among young people continues to decline, in some cases at record rates. This might be because vaping is increasingly being seen by young people as an attractive alternative to smoking. E-cigarette use is confined almost entirely to those who have smoked. There is a huge amount of evidence of smokers switching to e-cigarettes as a safer alternative. Far from acting as a gateway into smoking, electronic cigarettes might actually be acting as a road away from smoking.

References

  1. Action on Smoking and Health (ASH). (2015) Fact Sheet: Use of electronic cigarettes in Great Britain. [Online]. Available at: https://www.ash.org.uk/files/documents/ASH_891.pdf
  2. Office for National Statistics (2015). Adult smoking habits in Great Britain, 2014. Office for National Statistics; London, U.K. Available from: Office of National Statistics, Adult Smoking Habits in Great Britain 2014
  3. National Institute of Drug Abuse (2015). Monitoring the Future Survey 2015: Teens and E-Cigarettes. National Institute of Drug Abuse. Available from: https://www.drugabuse.gov/related-topics/trends-statistics/infographics/teens-e-cigarettes

Vaping bans in public places

We do not support the statutory prohibition of e-cigarette use in public spaces, enclosed or outdoors.

E-cigarettes do not emit smoke. There are no known or anticipated harms to bystanders from second hand vapour. Therefore, there is no scientific basis on which to ban vaping in public places. Bans send the wrong message to the public, including smokers, vapers and potential vapers,  that e-cigarettes are as harmful as smoking. This discourages smokers from trying e-cigarettes or from making a full switch to the substantially safer product, and may also lead to vapers relapsing to smoking.

References

  1. Farsalinos, K.E. and Polosa, R. (2014). Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Therapeutic Advances in Drug Safety, 5(2), 67-86.
  2. Hajek, P., et al. (2014). Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction, 109(11): 1801-1810.

Content of products

The content of e-cigarette liquids should be disclosed on the packaging

Studies show that e-cigarette vapour typically contains chemicals at levels that are much lower than are found in cigarette smoke, and well below the levels that would pose any risk to human health.

E-cigarettes should be produced to proper standards, as set out in the British Standards Institute Publicly Available Specification for e-cigarettes. Nevertheless, vapers should be able to make informed choices about the products they use.

References

1. British Standards Institute (2015). Publicly available specification 54115: Manufacture, importation, testing, and labelling of vaping products, including electronic cigarettes, e-shisha and directly-related products – Code of practice . British Standards Institute; London. Available at:

https://shop.bsigroup.com/ProductDetail/?pid=000000000030303130

Renormalisation of smoking


There is no evidence that vaping ‘re-normalises’ smoking, in fact it is more likely to normalise not smoking.

Non-smokers, including young people, are well able to tell the difference between smoking and vaping, even more so now that the most common devices look nothing at all like a cigarette. Some experimentation with e-cigarettes is to be expected, especially among young people, however those surveys which asked the question indicate that the majority try nicotine-free products.

There is no evidence that these experimenters move on to regular use of nicotine containing products, or to smoking. Professor Robert West, one of the world’s leading tobacco researchers, has stated that the use of e-cigarettes by children and non-smokers is basically nil at the moment. Fear of normalisation, he said, should not stop us transforming the health of smokers.  We agree with this assessment.  

References

 

1. Action on Smoking and Health (ASH). (2014) Fact Sheet: Use of electronic cigarettes in Great Britain. [Online]. Available at: https://www.ash.org.uk/files/documents/ASH_891.pdf

2. Britton, J. and Bogdanovica, I. (2014). Electronic cigarettes: A report commissioned by Public Health England. London: Public Health England.Hickman, L. (2013). E-cigarettes: health revolution or a fresh pack of trouble? The Guardian. Available from: https://www.theguardian.com/society/2013/jun/04/e-cigarettes-health-revolution-smokers

Initiation and nicotine addiction among youth

We would prefer that young people neither smoke nor use e-cigarettes.

Population studies show that many young people experiment with e-cigarettes, but very few move on to use them regularly or go on to smoke regular cigarettes. Evidence is scarce, but it is likely that e-cigarettes carry a much lower risk of initiation to addiction than smoking because there are other elements within cigarette smoke that enhance the addictive properties of nicotine. E-cigarettes may protect those young people who are predisposed to take up smoking by diverting them from this course to a much safer alternative.

References

1. Action on Smoking and Health (ASH). (2014) Fact Sheet: Use of electronic cigarettes in Great Britain. [Online]. Available at: https://www.ash.org.uk/files/documents/ASH_891.pdf

2. Kong, G., et al. (2014). Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine & Tobacco Research, 17(7): 847-854.

Tobacco industry involvement in e cigarettes – a ploy to keep people smoking? 

The tobacco industry should be encouraged to develop products which promote switching to the safer alternative nicotine products


Despite the rightful criticism that has been directed at tobacco companies for the harm caused by smoking, these companies have both the finances and the reach to deliver very much safer products, such as e-cigarettes, to their core customers, , existing smokers - and they should be encouraged to do so. While some tobacco companies seem content to simply keep a foot in the door by buying up independent companies that are producing a range of e-cigarettes, others are investing heavily to develop new products that will help smokers switch completely away from smoking. Where this is occurring, it is to be encouraged.

Snus and other nicotine delivery systems

A wide range of reduced harm nicotine products should be available as options for smokers to help switch from cigarettes.

There is no 'one size fits all' solution to the harms to health caused by smoking tobacco. Just as e-cigarettes vary in terms of strength, flavour and design so that consumers can choose something which suits them, e-cigarettes are themselves not the ideal choice for everyone. Other reduced harm products such as snus and heat-not-burn products may better suit some smokers, and there is no justification for denying them this choice.

Accidental quitting

Accidental quitters are ex-smokers who had no intention of giving up smoking, but who are now fully switched to vaping, and have no intention of relapsing to smoking

Many consumers found they had stopped smoking after having tried an e-cigarettes and found the experience pleasant and satisfying. Spontaneous quitting of this type should be encouraged by making it easy for smokers to try and use e-cigarettes.

E-cigarettes on the NHS

NHS prescription of e-cigarettes may work for some smokers, but currently anticipated options are not good enough.


We believe that a major factor in the success of e-cigarettes in attracting smokers to the safer alternative is the very fact that they are not medicines. However, we accept that for some smokers the confidence that a medicinally licensed product may offer could be an important consideration. On that basis we would welcome some limited provision of devices via the NHS. NHS provision is also important for people such as those in hospital, whose access to electronic cigarettes may be limited or non-existent.

Advertising e-cigarettes

Advertising is crucial because smokers need to know about e-cigarettes and that they are a healthier alternative to cigarettes

Smokers need to know that e-cigarettes are a healthier alternative to cigarettes. Since the introduction of the Tobacco and Related Products Regulation 2016 (TRPR) all major advertising of e-cigarettes has been banned.  In our view this is highly counterproductive, because smokers need to know that safer alternatives to smoking are available. 

NNA believes that the provisions of the TRPR which restrict the advertising of e-cigarettes should be repealed, and will be campaigning to that end. 

The Pleasure Principle

A vital part of the successful transition from smoking to vaping is finding a combination of products and technique that suits the individual - that brings them pleasure

There are thousands of different individual vaping products, and uncounted millions of potential combinations. Few people will use the same combination of power unit (mod), atomizer, wattage, flavour and nicotine strength. This needs to be recognised as one of the greatest strengths of vaping as an alternative to smoking, and not as a threat. The larger the available choice for smokers, the higher the chance that they will find a combination that they enjoy, and allows them to switch fully and successfully.

Artificially limiting this choice through legislation has the converse effect of reducing the amount of smokers who will successfully make the transition.

Vaping in hospitals, including grounds

NNA does not support blanket bans of vaping in hospitals, including in the grounds

Smoking is covered by smokefree law and so is banned inside hospitals. Few people would disagree that this should generally be the case. However, many NHS smokefree policies now include vaping, often in site-wide policies, and despite the fact that the NHS now promotes vaping as a method of smoking cessation. The inclusion of vaping within smokefree policies sends the wrong message to the public and makes it more difficult for smokers to switch to the very much safer products.

NHS policies should never include vaping outside, and, where possible, indoor areas should be provided where people can vape in comfort.

Mental Health Units

NNA supports the provision of e-cigarettes to in-patients in mental health units

Smoking prevalence is very high among patients with mental health problems. However, mental health units present greater challenges in terms of patient safety when it comes to implementing a policy of allowing the use of e-cigarettes as substitutes for smoking. Personal choice is an important factor in the ability of a person to substitute vaping for smoking, and so where possible, patients should be allowed to use their own e-cigarette. Where this is not possible other options should be considered such as tamper proof, disposable e-cigarettes.

Tobacco Law Reform 
NNA considers that current UK legislation places obstacles to the adoption of tobacco harm reduction by limiting consumer awareness and choice of safer nicotine products.
We call for a lifting of the restrictions on the advertising of e-cigarettes including the limitation on media outlets and the ban on the making of health claims; and a lifting of the restrictions on devices including the sizes of tanks and refill containers and limits on strengths of nicotine liquids. 
In the context of the UK’s exit from the EU we call on the government to urgently review the impact of the Tobacco and Related Products Regulations 2016. 
We welcome the statement in the Tobacco Control Plan (Towards a Smokefree Generation) that the government will identify de-regulatory measures (p27) that further health objectives – which we urge should include facilitation of access to safer nicotine products.  
Longer term we would like to see fundamental tobacco law reform which should be based on a distinction between harmful combustible products and safer non-combustible products.

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