E Cigarettes Feb16
E Cigarettes Feb16
E Cigarettes Feb16
Electronic cigarettes
(also known as vapourisers)
This briefing provides answers to some of the most frequently asked questions about electronic
cigarettes and includes references to other sources of information.
Summary
Electronic cigarettes deliver nicotine in a vapour rather than in smoke
Compared to tobacco products, electronic cigarettes are significantly safer 8
In the UK, the devices are used primarily as an aid to cutting down or quitting smoking and
evidence suggests they compare favourably with other stop smoking aids 13 14 15
In the UK there is no evidence that use of electronic cigarettes leads to a take-up of smoking 8
Electronic cigarettes in the UK will be regulated by the EU Tobacco Products Directive from
20 May 2016 unless manufacturers opt for products to be licensed by the medicines regulator,
the MHRA
What are electronic cigarettes and how do they differ from tobacco
products?
Electronic cigarettes, also known as vapourisers or electronic nicotine delivery systems (ENDS),1 are
battery-powered devices that deliver nicotine by heating a solution of nicotine, flavouring, additives and
propylene glycol and/or vegetable glycerine (glycerol). The devices typically consist of a mouthpiece,
battery and cartridge or tank containing the nicotine solution.2
When a user sucks on the device, a sensor detects air flow which activates a heating element (the
atomiser) which heats the liquid in the cartridge so that it evaporates. The vapour delivers the nicotine
to the user. Electronic cigarettes were developed to mimic the action of smoking, including nicotine
delivery, without the toxic effect of tobacco smoke.3
When a person smokes a conventional tobacco cigarette, smoke is inhaled into the lungs and then
exhaled. Smoke is also emitted from the burning tip of the cigarette, releasing toxins into the air. By
contrast, as there is no combustion involved in the use of electronic cigarettes there is no smoke.
Vapour is released into the air only when the user exhales.
A review of the evidence commissioned by Public Health England (PHE) in 2014 found that the hazard
associated with electronic cigarette products currently on the market is likely to be extremely low,
and certainly much lower than smoking.5 Other reviews have drawn similar conclusions with one
putting the risks of vaping at less than 5% of the risks of smoking6 and another review concluding
that Electronic cigarette [EC] aerosol can contain some of the toxicants present in tobacco smoke but
at levels which are much lower. Long term health effects of EC use are unknown but compared with
cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders. 7
Following the publication of some reports suggesting that electronic cigarettes may pose more of a
risk than previously thought, PHE commissioned a further expert independent evidence review. This
review also concluded that electronic cigarettes, when used as intended, are significantly less harmful
than smoking.8 The review notes that most of the chemicals causing smoking-related disease are
absent in electronic cigarettes and the chemicals that are present pose little danger.
Alongside publication of the review, PHE issued a statement noting that while not risk free, electronic
cigarettes carry a fraction of the risk of smoking cigarettes and have the potential to help smokers quit
smoking.9
The 2015 PHE review also examined reported risks of e-liquid poisonings, fires and battery explosions
linked to electronic cigarette use. While there is a risk of fire from the electrical elements of electronic
cigarettes and a risk of poisoning from ingestion of e-liquids, these risks appear to be comparable
to similar electrical goods and potentially poisonous household substances. These risks can be
controlled through standard regulations such as childproof containers and instructions about correct
use of the charger which will come into effect through the Tobacco Products Directive. For further
information see: ASH Briefing: The impact of the introduction of the EU Tobacco Products Directive on
e-cigarette regulation in the UK
ASH Briefing: Electronic Cigarettes 2
Is there a risk to bystanders from electronic cigarette vapour?
Most second-hand smoke from cigarettes comes from the burning tip, known as sidestream smoke.
By contrast, electronic cigarettes do not generate any
sidestream vapour. What is emitted into the air is exhaled by the electronic cigarette user. This
comprises nicotine and some other particles, primarily consisting of flavours, aroma transporters,
glycerol and propylene glycol. 7
A recent review of the impact of electronic cigarettes noted that passive exposure to the aerosol can
expose non-users to nicotine but at concentrations that are unlikely to have any significant health
impact.7 The 2015 PHE review also reported that the amount of nicotine released into the ambient air
poses no identifiable risk to bystanders.8
While electronic cigarette vapour can contain some of the toxicants present in tobacco smoke these
are at much lower levels.7 One preliminary study found that the concentration of particles in electronic
cigarette vapour was about 100-fold lower than from tobacco smoke.10
The fact that some electronic cigarettes look similar to conventional cigarettes has been said to risk
confusion as to their use in enclosed public places, such as on public transport.11 However, given that
the most distinctive feature of cigarette smoking is the smell of the smoke, which travels rapidly, it is
not clear how any such confusion would be sustained in enclosed places. For further information see:
ASH briefing: Will you permit or prohibit electronic cigarette use on your premises?
The Smoking Toolkit Study, which provides information about smoking prevalence and behaviour in
England, found that electronic cigarettes have overtaken over-the-counter (OTC) nicotine replacement
therapy (NRT) as the first choice of stop smoking aid13 and are 60% more effective in helping
smokers quit than NRT bought OTC or quitting unaided.14 The effectiveness was broadly similar to
using a prescription medicine (including NRT) with limited professional support but less than using a
prescription medicine with specialist behavioural support. The Smoking Toolkit Study estimates that in
2014 electronic cigarettes resulted in 20,000 more people quitting smoking who otherwise would not
have done so.
A Cochrane review which combined the results from two randomised controlled trials involving over
600 people showed that using an electronic cigarette containing nicotine increased the chances of
stopping smoking long-term compared to using an electronic cigarette without nicotine. About 9%
of smokers using electronic cigarettes were able to stop smoking at up to one year compared with
around 4% of smokers who used nicotine-free electronic cigarettes.15 Using an electronic cigarette
with nicotine also helped more smokers reduce the amount they smoked by at least half compared to
using a device without nicotine. There was no evidence that using electronic cigarettes at the same
time as using tobacco cigarettes made people less likely to quit smoking. The electronic cigarettes
used in this study have since been superseded by more sophisticated technology which it is believed
delivers more nicotine to users.
The 2015 PHE evidence review concluded that recent studies support the Cochrane Review findings
that electronic cigarettes can help people to quit smoking and may in fact be contributing to the decline
in smoking. There is also some evidence to suggest that electronic cigarette use leads to abstinence
among some smokers who had not intended to quit.16
A US review sought to assess the association between electronic cigarette use and smoking cessation
irrespective of users motivation for using the devices.17 The review found that users of electronic
cigarettes were less likely to stop smoking than smokers not using them as an aid to quitting.
However, a number of experts have criticised the methodology of the review 18 with one commentator
Public Health England recommends that smokers who have tried other methods of quitting without
success be encouraged to try electronic cigarettes and that Stop Smoking Services should support
smokers using electronic cigarettes to quit by offering them behavioural support. This is supported by
recent data which shows that smokers using the English Stop Smoking Services who quit whilst using
electronic cigarettes have reported higher quit rates at 4-weeks than smokers using other quitting
aids.20
The National Centre for Smoking Cessation and Training (NCSCT) has produced an e-cigarette
briefing summarising the evidence to date, especially in relation to the role of the stop smoking
services and how stop smoking practitioners should respond to enquiries about e-cigarettes from
smokers.
In 2013, the National Institute for Health and Care Excellence (NICE) published guidance on a harm
reduction approach to smoking.21 NICEs recommendations aim to inform how best to reduce illness
and deaths attributable to smoking through a harm reduction approach. As part of this guidance,
NICE supports the use of licensed nicotine containing products (NCPs) to help smokers cut down, for
temporary abstinence and as a substitute for smoking, possibly indefinitely. The NICE guidance does
not recommend the use of unlicensed nicotine containing products. However, the guidance is clear
that using an electronic cigarette is safer than smoking.21
The Smoking Toolkit Study has found a difference in use of electronic cigarettes by social group.
Among adult smokers interviewed between 2013 and 2014 23.8% of smokers in social classes AB
reported using the devices compared to 16.7% in social class E.24
The advertising of electronic cigarettes is currently governed by rules drawn up by the Committee on
Advertising Practice which will cover the period until the TPD comes into effect.29 From May 2016
nearly all advertising will be prohibited.
With conventional tobacco sales in decline in established markets and electronic cigarette sales
growing, the tobacco industry has begun to launch its own products as well as taking over existing
manufacturers. To date, the following companies have launched their own electronic cigarettes or
acquired existing electronic cigarette companies: 30
Altria / Philip Morris USA launched its own version of electronic cigarettes in August 2013 with its
MarkTen brand. It also owns the Green Smoke brand.
BAT BAT established the start-up company, Nicovations (originally Nicoventures Ltd) in 2011, with
the focus of development and commercialisation of innovative regulatory approved nicotine products.
In September 2014 the company announced that its development partner Kind Consumer had been
granted a medicines licence for its nicotine inhaler, Voke. Since then it has also been granted a
medicines licence for e-Voke, an electronic cigarette.31 To date, neither product has yet been released
on the market.
BATs Vype brand of electronic cigarettes went on sale in the UK in late July 2013.
Japan Tobacco International has a stake in the US company Ploom. The JTI Ploom was recently
launched in the UK. JTI has also recently acquired the E-Lites brand.
Philip Morris International has acquired the UK firm Nicocigs which produces the Nicolites brand.
Reynolds American The second largest tobacco company in the United States, Reynolds American
entered the market in 2013 with its Vuse brand of electronic cigarettes.