E-cigarettes and non-combustible inhaled tobacco products

Smoking tobacco exposes the smoker to over 5000 chemicals, many of which are poisonous and more than 70 of which may cause cancer^4,5,6. The evidence so far shows that e-cigarettes have significantly reduced levels of key toxicants compared to cigarettes, with average levels of exposure falling well below the thresholds for concern⁷. While there is a long history of research on the long-term effects of smoking, there is little data available for the long-term effects of ECs. A recent study showed that long-term e-cigarette users (who had been using their product for 17 months on average) had significantly lower levels of key toxicants in their urine than those that still smoked – with levels in e-cigarette users similar to exclusive Nicotine Replacement Therapy (NRT) users. The researchers concluded that the full benefit of using e-cigarettes is from stopping smoking entirely, as opposed to dual use of e-cigarettes and tobacco, who had similar exposure levels to smokers⁸.

1. Entry into smoking: Use among children is rare, and in the small number who do use ECs, most currently smoke or are ex-smokers. In 2016, only 4% of “never smoker” children in Great Britain had tried ECs, and only a tiny proportion (less than 1%) were regular users⁹. New regulations around age of sale and restrictions on advertising are likely to make this even less of an issue¹⁰. Overall youth smoking has fallen in England from 13% in 1996 to 3%in 2014¹¹.
2. Safety: As mentioned above, although the long-term safety profile of EC use is still to be evaluated, it is accepted that based on the evidence to date, vaping is a far safer alternative to smoking tobacco¹². Public Health England and the Royal College of Physicians estimate that ECs are unlikely to exceed 5% of the harm from conventional smoking^13,14. Public perceptions do not match the evidence however, with only 44% of adults thinking ECs are safer than smoking¹⁵, and this level of misperception has been worsening.
3. Cessation aid: Since late 2013 ECs have become England’s most popular quitting aid¹⁶. There is now growing evidence to suggest that ECs are helping users to stop smoking¹⁷, with it being estimated that ECs contributed to an additional 18,000 long-term ex-smokers in England in 2015¹⁸.
4. Regulation: New regulations were implemented in May 2016 through the revised EU Tobacco Products Directive (TPD). The regulations require EC manufacturers to abide by certain product specifications, including health warning labels, nicotine strength restrictions, and restriction of misleading information. The regulations also prohibit many forms of advertisement including a restriction on health claims.
5. Passive vaping: There is no good evidence to suggest that passively breathing vapour from e-cigarettes is likely to be harmful^{12, 19, 20}
6. More research needed: Ongoing research into the safety of e-cigarettes and their use for smoking cessation is underway. However, the benefits of ECs in assisting cessation should not be ignored while waiting for the publication of this research.
7. The RCGP position is informed by recommendations from PHE¹³

1. Primary Care Clinicians (PCCs) should provide advice to smoking patients on the relative risks of smoking
2. Patients should be advised that behavioural support and prescription medication from local Stop Smoking Services (SSS) is the most effective quit method. PCCs should provide referral to SSS where these services exist, and the patient wishes to access this support
3. Using their clinical judgement on an individual patient basis, PCCs may wish to promote EC use as a means to stopping. Patients choosing to use an e-cigarette in a quit attempt should be advised that seeking behavioural support alongside e-cigarette use increases the chances of quit success further. Most SSS are EC friendly, and patients can be advised to bring one to their appointment if they would like to quit using their device
4. PCCs recognise ECs offer a wide reaching, low-cost opportunity to reduce smoking (especially in deprived groups in society and those with poor mental health, both having elevated rates of smoking). In the UK, though start-up costs can be higher, it is likely to be less expensive to use an EC over time than it is to smoke²¹

• CRUK e-cigarette evidence infographic
• CRUK policy brief
• NCSCT E-cigarette Guidance²²
• PHE report²³
• RCP report²⁴

1. Peto, Lopez, et al. MORTALITY FROM SMOKING IN DEVELOPED COUNTRIES 1950-2020 (updated September 2015).
2. Kotz, D; Brown, J; West, R; (2014) 'Real-world' effectiveness of smoking cessation treatments: a population study. Addiction, 109 (9) pp. 1531-15303 Use of electronic cigarettes (vapourisers) among adults in Great Britain – ASH 2017
3. ASH. (2017). Use of e-cigarettes (vapourisers) among adults in Great Britain
4. IARC. Personal Habits and Indoor Combustions: Tobacco Smoking. IARC Mono gr Eval Carcinogen Risks to Humans. 2012;100E(6).
5. IARC. Personal Habits and Indoor Combustions: Second-hand Tobacco Smoke. IARC Mono gr Eval Carcinogen Risks to Humans. 2012;100E(7).
6. IARC. Tobacco smoke and involuntary smoking. IARC Mono gr Eval Carcinogen Risks to Humans. 2004;83.
7. 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):18.
8. Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users A Cross-sectional Study. Ann Intern Med. 2017. DOI:10.7326/M16-1107.
9. ASH. (2016). Use of electronic cigarettes among children in Great Britain, (October), 1–
10. Medicines and Healthcare products Regulatory Agency Published. E-cigarettes: regulations for consumer products (2016)
11. Smoking drinking and drug use among young people in England 2014, HSCIC
12. Hajek P, Etter J-F, Benowitz N, Eissenberg T, McRobbie H. Electronic cigarettes: Review of use, content, safety, effects on smokers, and potential for harm and benefit. Addiction (Abingdon, England). 2014;109(11):1801-1810. DOI:10.1111/add.12659.
13. Public Health England. (2015). E-cigarettes: a new foundation for evidence-based policy and practice
14. Tobacco Advisory Group of The Royal College of Physicians. Nicotine without Smoke; 2016.
15. Use of electronic cigarettes (vapourisers) among adults in Great Britain – ASH 2017
16. Smoking Toolkit Study
17. 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. Addiction. May 2014. DOI:10.1111/add.12623.
18. Beard E, West R, Michie S, Brown J. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. DOI:10.1136/bmj.i4645.
19. Hess IMR, Lachireddy K, Capon A. A systematic review of the health risks from passive exposure to electronic cigarette vapour. Public Health Res Pract. 2016;26(2):e2621617
20. McAuley TR, Hopke PK, Zhao J, Babaian S. Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality. Inhalation toxicology. 2012;24(12):850–7. Accessed May 28, 2014.
21. Liber AC, Drope JM, Stoklosa M. Combustible cigarettes cost less to use than e-cigarettes: global evidence and tax policy implications. Tobacco Control 2017; 26: 158–163. February 2017.
22. National Centre for Smoking Cessation and Training. (2016). Electronic cigarettes: A briefing for stop smoking services.
23. McNeill, A., Brose, L., Calder, R., Hitchman, S., Hajek, P., & McRobbie, H. (2015). E-cigarettes: an evidence update. Commissioned by Public Health England.
24. Tobacco Advisory Group of The Royal College of Physicians. (2016). Nicotine without smoke.