Ask the expert: Electronic cigarettes

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1. What are e-cigarettes?

Electronic cigarettes (ECs) are an alternative to traditional tobacco-based cigarettes. They hold a battery that heats a solution containing nicotine to form a vapour that is inhaled. These vapours can be flavoured and contain varying quantities of nicotine, including some that are nicotine-free.

ECs are used in different forms:

Fully disposable, single-use ECs

ECs with replacement cartridges

‘Tank systems’ that contain a reservoir that the user fills with liquid

Variable power ECs or ‘mods’ - usually tank systems where the user can adjust the delivery of vapour

2. How much do they cost and where can they be purchased?

A single, disposable EC costs around £6, whereas a starter kit that also contains a charger, battery and replacement cartridges, can retail from between £15 and £90. These are widely available online, as well as on the UK high street in supermarkets, newsagents and some pharmacies. In comparison, smoking 20 cigarettes per day can cost the user around £250 per month. It is difficult to estimate the savings associated with switching to ECs, however, Professor Robert West, Director of Tobacco Studies at University College London, has estimated it to be around 20% (NHS Choices, 2015).

3. How common are they?

It was estimated in 2015 that 2 600 000 adults in the UK were using ECs. Of these, 1 100 000 were ex-smokers, and 1 400 000 were using ECs concurrently with tobacco products. Initially, there were concerns that ECs might encourage non-smokers to start using tobacco products. However, the available evidence has shown that the number of non-smokers regularly using ECs remained stable between 2013 and 2015, at 0.2% of the UK adult population (Action on Smoking and Health (ASH), 2015a).

Similarly, concerns that young people would be attracted to EC use have not been validated to date, with only 1% of 16–18 year old never-smokers using ECs regularly (ASH, 2015b). It is also becoming increasingly difficult for young people to access these devices: from October 2015, selling or supplying ECs in the UK to individuals less than 18 years in age was made illegal.

4. How do they differ from traditional cigarettes in terms of risk?

ECs generally contain the following ingredients in their solutions:

Propylene glycol/glycerine

Nicotine

Flavourings

Water

Notably, they do not contain tobacco, tar or the many additional carcinogenic substances found in traditional cigarettes. The exhaled air also contains the above ingredients, but importantly, the degree of nicotine released into the surrounding air poses no identifiable risk to passive bystanders (Public Health England (PHE), 2015a).

However, there are still risks associated with the use of ECs. Formaldehyde and acetaldehyde, formed from the reaction of propylene glycol with glycerine in the EC solution, are carcinogens. The quantity released is less than in tobacco products, but estimating the degree of risk in such a new product is difficult.

PHE has recently quoted that ECs are ‘95% less harmful’ than smoking (PHE, 2015a). This figure is controversial, as it was derived from a panel of experts estimating harm and not from collected data (Nutt et al., 2014). However, a collaboration between various public health bodies has recently released a statement to clarify the message and to convey to the public that they are significantly less harmful than smoking (PHE, 2015b), a message that has been reiterated this year by the Royal College of Physicians (Royal College of Physicians (RCP), 2016).

5. How are regulations changing?

Due to the varying strengths of the EC solution, different delivery systems and availability of unregulated products online, there is concern that the amount of nicotine being delivered to the user is variable and unknown. This issue has been addressed with increased legislation being enacted from May 2016; however, it is possible that users have created stockpiles in anticipation of this action. Nicotine-containing products, including ECs not already registered as medicines, will have to comply with the EU Tobacco Products Directive. Among other measures, products will have to list all ingredients; contain a maximum nicotine concentration of 20 mg/ml; provide a comprehensive information leaflet with safety profile; and clearly state the risk of addiction on the packet.

6. Do they have a role in smoking cessation?

A 2014 Cochrane systematic review assessed the available evidence as to whether ECs could be used as a smoking cessation tool, and whether they are safe for this purpose. They included two randomised controlled trials with over 600 patients and found that compared with a placebo EC, patients using nicotine-containing ECs were more likely to have abstained from smoking for 6 months. There is currently insufficient data to draw conclusions about how ECs compare with other smoking cessation methods; however, there is some evidence to suggest that ECs may help those unable to stop smoking to reduce their cigarette consumption, when compared with placebo ECs and nicotine patches (McRobbie, Bullen, Hartmann-Boyce, & Hajek, 2014). In contrast, a recent meta-analysis found that EC use was not associated with a reduction in the use of tobacco smoking (Kalkhoran & Glantz, 2016). However, the methods used in that study have been widely questioned.

In April 2016, the RCP released their report, ‘Nicotine without smoke: Tobacco harm reduction’. This report reviewed the above evidence and concluded, ‘… in the interests of public health it is important to promote the use of e-cigarettes … as widely as possible as a substitute for smoking’ (RCP, 2016).

7. What are the long-term risks?

ECs have not been used for enough time for the long-term safety profile to be analysed. However, their safety profile is likely to be better than tobacco smoking. Research on this topic is ongoing and an update of the 2014 Cochrane review should become available later this year.

8. What relevant audits could GPs do to improve care for patients using ECs?

There are plenty of opportunities to audit the uptake and success of smoking cessation in General Practice. Current National Institute for Health and Care Excellence (NICE) guidelines recommend that 5% of the smoking cohort be treated during any single year and that practices should aim for a minimum of 35% of these to have abstained from smoking at 4 weeks (NICE, 2008). If required, interventions could be made to improve the accessibility of smoking cessation advice, including information about ECs.

9. The bottom line: What advice should we be giving to patients?

ECs should be discussed in an open and positive manner, especially in those who have tried other methods of smoking cessation. Points to consider during the consultation include the following:

Currently no significant adverse events from short-term use observed in trials

No evidence is available to analyse the long-term safety profile of ECs, so there may be unknown harms

Current best evidence strongly suggests that ECs are safer than tobacco products

Guidance from PHE and RCP suggests ECs have a role in smoking cessation, in combination with behavioural support

Guidance and smoking cessation resources that are specifically aimed at primary care physicians are provided on the website of the Primary Care Respiratory Society: www.pcrs-uk.org/smoking-cessation.

10. Are there any useful resources for patients?

The NHS has an abundance of resources to support patients wishing to stop smoking. These can be accessed at www.nhs.uk/conditions/smoking-(quitting)/Pages/Treatment.aspx. This site outlines the role of supportive, psychological and pharmacological treatments, as well as a link dedicated to the most recent advice about ECs. A good summary leaflet to print at the end of a smoking cessation consultation, ‘Tips to help you stop smoking’, can be found on patient.co.uk (http://patient.info/health/tips-to-help-you-stop-smoking).