This piece was written by one of our contributors; Ireland-trained medical doctor – Ciara Kelly.
E-cigarettes and vaping have been making headlines worldwide quite a bit this year. Many of you reading this may have seen e-cigarettes in use at work, at home, maybe at school or university, or in your local shopping centre! But while the vast majority of us have heard of e-cigarettes, I would guess that that same majority are perhaps a little bit confused about these devices. And that’s very understandable.
In the U.K., Public Health England has stated that based on their review of the evidence to date, vaping is around 95% safer than smoking (1), while in Ireland, the Health Service Executive does not recommend use of e-cigarettes as a smoking cessation intervention, citing the lack of long-term safety and efficacy data for these devices as the rationale for their position (2). In the USA, as many of you reading might have seen, the Centres for Disease Control and Prevention (CDC) are currently investigating a multi-state outbreak of severe lung disease associated with e-cigarette use, with (as of October 29th) 1888 cases identified to date including 37 deaths in 24 states (3).
So understandably, the 4/11 on e-cigarettes and vaping can seem about as a clear as mud. To make it easier for you to understand, in this article we’re going to break it down into two key questions on the topic.
- Does using e-cigarettes pose risks to our health?
- How do e-cigarettes measure up against existing smoking cessation interventions?
Before we dive into answering these questions, it’s important to say that no one is disputing how harmful tobacco cigarette use (i.e. traditional smoking of combustible cigarettes) is to the health of the smoker, and those in their environment. Tobacco is the leading cause of preventable illness and death in Ireland and the U.K. , and 1 in every 2 smokers will die of a tobacco-related disease (4,5). Public health policy on tobacco in Ireland and the UK aims to increase smoking cessation rates (therefore reducing the prevalence of smokers in society) and decrease smoking initiation rates (especially amongst children and young adults). The importance of these efforts is not up for dispute, and it is therefore crucial that any proposed new smoking cessation aids (such as e-cigarettes) are both safe and effective to use in the short and long-term. It is also crucial that these devices do not become a ‘gateway’ to smoking, particularly among those who have never smoked, and that is a real concern among public health authorities regarding e-cigarette use.
So, what exactly are e-cigarettes, and what is vaping?
Electronic cigarettes are battery powered devices that people use to heat liquid (the ‘e-liquid’, which is a chemical mixture) into a vapour that can be inhaled – i.e. ‘vaping’. The e-liquid usually consists of nicotine, propylene glycol & other chemicals (2) – but not tobacco, unlike combustible cigarettes. All e-cigarettes consist of a lithium battery, a cartridge containing the e-liquid, an atomizer which heats the e-liquid to create the aerosol, and a mouth piece – however, the design of e-cigarettes has changed quite a bit since they were first marketed in Europe in 2006 (6). E-cigarettes may or may not contain nicotine – but it’s important to note that in those that do, the nicotine content of the e-liquid may vary in strength (which is measured in milligrams).
There are MANY different e-cigarette brands now, some of which are owned (in full or in part) by the tobacco industry, and others which are not. For example, the very popular e-cigarette brand Juul which many of you may have heard of, has 72% of the e-cigarette market share in the USA, and the tobacco company Altria has a 35% financial stake in Juul(6)!
Okay, so now we know what e-cigarettes are…
What do we know about e-cigarette use and our health?
Good question. Many of you have by now probably have seen, and possibly been alarmed by, the news headlines about the multi-state outbreak of lung disease associated with e-cigarette use in the USA. Public Health England recently published an update on this outbreak on their blog which you can read here. First of all, the big take-home point on the question of e-cigarettes and our health is that the majority of public health bodies agree that while e-cigarettes are likely less harmful than traditional combustible (i.e. tobacco) cigarettes, we cannot say that they are risk-free. In addition, we do not have long-term data on the use of these devices to tell us what the health consequences might be – remember, they were first marketed in China as recently as 2004 (1)! Cigarettes were in the public domain for a LONG time before research in the 1950s demonstrated the link between cigarette smoking and lung cancer risk – and it took a LOT longer than that for smoking regulations (such as workplace smoking bans) to be introduced as landmark public health interventions.
In the USA, the specific chemical (s) potentially causing the ongoing vaping-associated lung disease outbreak mentioned above have not yet been identified, and the Centres for Disease Control and Prevention (CDC) have found that products containing THC (tetrahydrocannabinol, the main psychoactive component of cannabis) are associated with most patients with lung injury (7). These products were obtained informally by most of the patients, the majority of whom are young males. According to Public Health England, what that tells us is that the outbreak does not seem to be associated with long-term use of nicotine e-cigarettes (these came onto the market in the US in 2007) (7). In this context, it’s important to note the differences in regulation of e-cigarettes between the USA and the UK, which were highlighted by Public Health England in a recent update on their website, stating that (7):
‘The Medicines and Healthcare products Regulatory Agency (MHRA) is responsible for overseeing the tobacco regulations (in the U.K.). The main chemicals under suspicion in the US such as THC and Vitamin E acetate oil are not permitted in e-cigarettes in this country.’Public Health England
In Ireland, as regards to e-cigarette regulation, the Health Service Executive states (2):
‘E-cigarettes are not medical products or medical devices and are not regulated by the Health Products Regulatory Authority (HPRA). The EU Tobacco Products Directive regulates certain aspects of e-cigarettes, including setting safety and quality standards, making health warnings mandatory, introducing notification requirements for manufacturers and importers, imposing stricter rules on advertising and monitoring market developments. Under Regulation 26 of the 2016 Regulations, a manufacturer or importer of an e-cigarette or refill container must submit a notification to the Health Service Executive of any such products he or she intends to place on the Irish market.’Health Service Executive, Ireland
As regards to e-cigarettes and health, what we know at present is that e-cigarettes are likely less harmful than combustible cigarettes, but health risks remain, and their long-term effect on health is uncertain at present. A nice addition to that comes from the CDC in the USA, stating (8):
‘E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products. If you’ve never smoked or used other tobacco products or e-cigarettes, don’t start.’Centre for Disease Control and Prevention, United States
Now, let’s look at the second big question.
Do e-cigarettes help people quit smoking?
Public Health England estimates that in the U.K., approximately 60% of smokers want to quit, 10% of whom intend to do so within 3 months, and unfortunately, approximately half of all smokers in England try to quit smoking with no help at all, relying on willpower alone (5). We have a comprehensive evidence base for the clinical and cost-effectiveness of existing smoking cessation services and interventions not including e-cigarettes. According to the guidelines by the National Institute for Health and Care Excellence (NICE), all of the following should be offered to adults who smoke (9) (we’ll look at NICE’s position on e-cigarettes later on in this article):
- Behavioural support (individual and group)
- Nicotine replacement therapy (NRT) (short and long-term)
- Certain prescription medications licensed for smoking cessation (these are called Varenicline and Bupropion)
- Very brief advice
In Ireland, a 2017 Health Technology Assessment by the Health Information and Quality Authority (HIQA) concluded that the most effective smoking cessation intervention was the use of a combination of the prescription drug varenicline & NRT together, from a clinical and cost perspective. As regards e-cigarettes, HIQA stated (10):
‘Although the currently available results for e-cigarettes are promising, there is insufficient evidence at present to reliably demonstrate their effectiveness as an aid to smoking cessation. It would be appropriate to await the results of ongoing trials before deciding whether e-cigarettes should be recommended.’Health Information and Quality Authority
So, we know that our existing smoking cessation interventions work very well – in fact, it is estimated that if a person combines stop smoking aids with expert support from local stop smoking services, they are up to four times as likely to stop smoking successfully (5).
So where do e-cigarettes fit in?
Do we have any research comparing them to existing smoking cessation interventions?
The best evidence from the literature to help us answer this question comes from a large UK-based study published earlier this year – the so-called ‘TEC randomised controlled trial (RCT)’ (11). This was a trial which aimed to compare the efficacy of refillable e-cigarettes and NRT (and both were combined with the same behavioural support) among 886 adult smokers seeking help to quit smoking across three UK sites providing ‘stop smoking’ services. There were two groups in this study, randomised to either of the two interventions. In one group, 446 adults received NRT of their choice (single or combination) provided for up to 12 weeks. In the second group, 438 adults received an e-cigarette starter pack and were encouraged to buy additional e-liquids and e-cigarette products of their choice. Participants attended weekly sessions at their stop smoking service and provided outcome data at 4 weeks. They were then followed up by telephone at 6 and 12 months. Subjects who reported at least a 50% reduction in their cigarette consumption were invited to attend for validation of this claim using carbon monoxide (CO) testing, and the primary outcome of this study was CO-validated sustained abstinence rates at 52 weeks.
What were the results?
For those in the NRT group, the 1-year quit rate was approximately 10%, but 18% in the e-cigarette group – quite a bit higher, I know! Does that mean we can now say ‘Yep, e-cigarettes are more effective than NRT?’ Absolutely not. Science is just not that simple – but you all know that by now! First of all, it’s important to note than in the e-cigarette group, a massive 80% of subjects were still using their e-cigarette at 1 year, compared to 9% of the NRT group who were still using their NRT of choice. That’s of concern for two reasons – first, as we’ve seen, the long-term effects of e-cigarette use on our health are uncertain, and second, it may mean that majority of the e-cigarette group had not overcome their nicotine addiction (this is important, as not doing so raises the possibility that the person could more easily relapse and begin smoking again in the future).
Second, there are also some limitations to this study. The researchers and subjects of course could not be blinded to whether they were using NRT or e-cigarettes, meaning that the participant’s may have had their own expectations and bias regarding the likelihood of success of their allocated intervention, which may have affected the observed quit rates. Plus, the trial results may not be generalisable to other types of smokers or settings, or to cartridge-based e-cigarettes.
Finally, it’s just ONE study. Population level public health advice on smoking cessation intervention doesn’t change based on just one study – it’s the totality of evidence to date that matters.
So – what is your take-home on e-cigarettes and vaping?
I’ve summarised some bullet points from the UK NICE guidelines (9) and the US CDC (8) on this topic as they make very useful take-home messages, and I’ll finish with these below:
- Many people have found e-cigarettes helpful to quit smoking cigarettes
- People using e-cigarettes should stop smoking tobacco completely, because any smoking is harmful
- The evidence suggests that e-cigarettes are less harmful to health than smoking but are not risk free
- The evidence in this area is still developing, including evidence on the long-term health impact
- E-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.
- If you’ve never smoked or used other tobacco products or e-cigarettes, don’t start.
And of course, if you’re reading this and want to get help with quitting smoking, please speak to your GP and/or pharmacist about your local smoking cessation services and treatment options – getting the right help and support is absolutely crucial to maximise your chances of success.
(1) Public Health England (2015) ‘E-cigarettes: An evidence update.’ Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/733022/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf
(2) Health Service Executive (2019) ‘E-cigarettes.’ Available at: https://www.hse.ie/eng/about/who/tobaccocontrol/e-cigarettes/
(3) Centres for Disease Control and Prevention (2019) ‘Outbreak of lung injury associated with use of e-cigarette, or vaping, products.’ Available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
(4) Health Service Executive (2019) ‘Smoking – the Facts.’ Available at: https://www.hse.ie/eng/about/who/tobaccocontrol/kf/
(5) Public Health England (2018) ‘Health matters: Stopping smoking – what works?’ Available at: https://www.gov.uk/government/publications/health-matters-stopping-smoking-what-works/health-matters-stopping-smoking-what-works
(6) Irish Cancer Society (2019) ‘E-cigarettes and heated tobacco products: An evidence review by the Irish Cancer Society and the Irish Heart Foundation.’ Available at: https://www.cancer.ie/sites/default/files/content-attachments/position_paper_on_e-cigarettes_and_htp_ics_and_ihf.pdf
(7) Public Health England (2019) ‘Vaping and lung disease in the US: PHE’s advice.’ Available at: https://publichealthmatters.blog.gov.uk/2019/10/29/vaping-and-lung-disease-in-the-us-phes-advice/
(8) Centres for Disease Control and Prevention (2019) ‘E-cigarettes.’ Available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
(9) National Institute for Healthcare and Excellence (2018) ‘Stop smoking services and interventions.’ Available at : https://www.nice.org.uk/guidance/ng92/chapter/Recommendations#advice-on-ecigarettes
(10) Health Information and Quality Authority (2017) ‘Health technology assessment of smoking cessation interventions.’ Available at: https://www.hiqa.ie/sites/default/files/2017-04/Smoking%20Cessation%20HTA.pdf
(11) Hajek et al. (2019) ‘E-cigarettes compared with nicotine replacement therapy in the UK stop smoking services: the TEC RCT.’ Available at: https://www.ncbi.nlm.nih.gov/books/NBK545384/pdf/Bookshelf_NBK545384.pdf