The Truth about E-Cigarettes

Five years ago you’d probably never heard of electronic cigarettes, or e-cigarettes. Now it seems you can’t open a newspaper – or go into a newsagent, supermarket or pharmacist – without seeing them advertised or on sale.

For smokers concerned about the toxic cocktail ofcancer-causing substances in tobacco smoke, e-cigarettes – sometimes touted as a safer alternative to smoking – might initially sound like a Holy Grail.

But – and it’s a big ‘but’ – e-cigarettes are not regulated in the way that approved nicotine replacement therapies (NRT) such as patches and gum are. This means they haven’t undergone all the rigorous tests needed, so we don’t yet know enough about whether e-cigarettes are safe or effective.

And although they’re widely available in the UK, they’re banned in some other countries.

Let’s be clear – we’re not calling for a ban on e-cigarettes. But we do want to see ‘light touch’ regulation brought in, to ensure they are as safe as possible, and that consumers know what they’re buying.

And the increasing popularity of e-cigarettes makes it crucial to answer questions about their impact – not just on the health of smokers who use them, but on non-smokers, ex-smokers, children and society as a whole.

That’s why we commissioned researchers at the University of Stirling to identify the unanswered questions and concerns around e-cigarettes, and look at the broader issue of tobacco ‘harm reduction’ – measures to reduce illness and death caused by tobacco use.

We’ve just published their report (pdf), and a summary has been published in the journal Tobacco Control). In this post, we’ll look in more detail at the questions and issues it raises.

What Are E-Cigarettes?

E-cigarettes look like real cigarettes and usually consist of a battery, a cartridge containing nicotine (the addictive ingredient in tobacco), a solution of propylene glycol or glycerine mixed with water, and an atomiser (a device that turns the nicotine solution into a fine mist or vapour).

When someone inhales on the e-cigarette the nicotine solution is heated and evaporates.Research shows the e-cigarette user inhales a ‘hit’ of nicotine as they would when inhaling smoke from a cigarette (although other research has questioned how effective some e-cigarettes are at nicotine delivery).

Cartridges are available in different concentrations of nicotine, and in various flavours such as apple, chocolate, coffee and mint. Most e-cigarettes have an LED at the tip which lights up when someone inhales, in a similar way to the lit tip of a cigarette.

Are They Really ‘Safer than Cigarettes’?

Traditional tobacco cigarettes contain around 4000 different chemicals, including toxins like arsenic and radioactive polonium-210. Tobacco smoke has long been recognised as a carcinogen responsible for more than one in four UK cancer deaths, and the biggest single cause of cancer in the world.

The lack of tobacco in e-cigarettes means they are likely to be much safer than smoking cigarettes, but this isn’t difficult, since tobacco kills half of all long-term users.

Some manufacturers make much of the fact that e-cigarettes contain many fewer cancer-causing chemicals than cigarettes. But there are still some important – yet unanswered – questions about the safety of the chemicals that are in e-cigarettes, and the current lack of regulation means there’s no way of verifying what’s actually in them, especially with so many different companies now entering the market.

For example, we know very little about the safety of the propylene glycol in many e-cigarettes. And nicotine itself can be toxic in very high doses. So there are questions about the safety of leakage from cartridges and refill bottles.

Perhaps more worryingly, research has found that some e-cigarettes contain chemicals other than nicotine and propylene glycol or glycerin. Tests on some e-cigarettes have found small amounts of nitrosamines, formaldehyde (both cancer-causing chemicals), acetaldehyde and acrolein (toxins) in the vapour or liquid. These are all chemicals found in tobacco smoke, at far higher levels.

Given these questions about the contents of the vapour, it’s also not clear if people exposed to second hand e-cigarette vapour (passive ‘vaping’) are at any risk.

The answer to this is crucial since e-cigarettes are being used by some smokers in places where cigarettes are banned under smoke free laws.

Finally, given reports of malfunctions, we‘d like to see these products regulated to help ensure that the mechanical components in the device are safe and reliable, and deliver consistent doses of controlled chemical contents.

Who Uses E-Cigarettes and Why?

E-cigarette manufacturers aren’t yet allowed to market their products as quitting aids, as they haven’t been through the strict tests needed to see how effective they are.

Some research suggests that smokers are already using them to help give up and we want to see much more research to be sure if e-cigarettes could be useful in helping smokers quit (or cut down) smoking.

There are also big questions about how people use e-cigarettes, and why. For example:

• How many people are using them to cut down their cigarette consumption, or to try to quit entirely?
• Are people using e-cigarettes in combination with smoking, for example to ‘get round’ smoke free laws?
• If so, what impact does such ‘dual use’ mean for their future attempts to quit? Are they less likely?
• Are smokers who may have otherwise successfully conquered their nicotine addiction more likely to stay on e-cigarettes (and thus addicted to nicotine) long term, if they start using them?

More research to answer such questions is needed to understand the long-term impacts of using e-cigarettes.

Effects on Tobacco Smoking?

One of the effects of decades of legislation against tobacco is to make smoking less socially acceptable, as more people are aware of the health risks and it has become more difficult to smoke in public. But the UK’s smoke free legislation doesn’t cover e-cigarettes. So we also need to consider whether using e-cigarettes in places where tobacco smoking is now banned might make smoking more acceptable again.

Likewise, e-cigarettes aren’t covered by the UK’s ban on tobacco advertising. So e-cigarettes are marketed all over the place, and even promoted by celebrities and at celebrityevents – techniques barred to the tobacco industry since 2003. It’s important to look at whether e-cigarettes could serve as a ‘gateway’ to smoking traditional cigarettes – by ex-smokers, non-smokers and, most importantly, children.

More than 200,000 under 16s start smoking in the UK every year, so protecting children from the dangers of smoking is a top priority for us. We need to find out more about whether e-cigarettes are attractive to children (particularly given the appealing flavourings and heavy advertising involving celebrities), and whether this will affect the number of children who subsequently take up smoking.

Tobacco Industry Involvement

Over the last few years, the tobacco industry has become heavily involved in selling e-cigarettes – a move that is seen by some as an ‘insurance policy’ against future potential losses in cigarette sales. This raises many issues around conflicts of interest and the role, if any, of the tobacco industry in public health.

The World Health Organisation’s Framework Convention on Tobacco Control (FCTC) is a global public health treaty set up to provide a united response to the tobacco epidemic. Part of the FCTC aims to prevent tobacco industry interference and there are concerns this will be weakened by the industry’s entry into the e-cigarette market and that this may simply be another tactic to keep profits high.

Next Steps

Today’s report by Stirling University will help guide future research and ultimately answer questions about potential benefits and harms of e-cigarettes. A comprehensive report by the French Office for Smoking Prevention (OFT) has also just been published (pdf), which recommends a strict approach to marketing among other proposals.

In 2010, the Medicines and Healthcare Products Regulatory Agency (MHRA), which regulates all medicines and medical devices in the UK, asked for feedback on how to regulate new nicotine-containing products (including e-cigarettes).

We told them (response 1015 in this pdf) that we think such regulation will help address questions around the safety and effectiveness of e-cigarettes. The MHRA response to this consultation is expected any day now, along with results of the research they undertook to inform their decision.

Similarly, the National Institute for Health and Care Excellence (NICE) is due to publish new guidelines on tobacco harm reduction approaches to smoking, which may have implications for e-cigarettes.

We hope that the expected announcements by the MHRA and NICE will help answer some of the outstanding questions around e-cigarettes.

We’re determined to reduce the number of smoking-related cancers. If e-cigarettes can help reduce this toll, it’s crucial to public health that this avenue is properly explored to fully understand the benefits and risks of these devices.

Written by Claire Knight