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There's a bewildering array of products on the market, but we’re starting to understand them better

More than two million people in the UK now use e-cigarettes.

A lot’s changed since we last blogged about them. And over the last year we’ve been monitoring the growing evidence on e-cigarettes, learning more and more about why they’re used and how they will be regulated.

This is an important topic for smokers and vapers alike. And while we regularly hear of stories about how e-cigarettes are helping people quit, we also hear about how they’re creating new challenges.

Just this week, they’ve hit the headlines again. On Wednesday, the World Health Organisation recommended a ban on the use of e-cigarettes indoors (something we think is unnecessary).

It’s vital for any organisation like us, which is battling the huge death toll from tobacco, to gather a comprehensive overview of the evidence.

So let’s take another look at what’s happened since we last wrote about e-cigarettes, both in terms of the evidence of their effectiveness, and how they’re being regulated and marketed.

Although the picture still isn’t completely clear, overall we’re cautiously optimistic about their potential. There are still risks to be minimised, but we believe that e-cigarettes have significant potential to help smokers quit by delivering nicotine in a way that seems to be safer than smoking cigarettes.

Are they safer than smoking?

In short – almost certainly yes.  E-cigarettes don’t contain tobacco, but instead produce a vapour from nicotine dissolved in one of two chemical compounds – either propylene glycol or glycerine. What else they contain isn’t standardised across the different products.

In contrast, tobacco contains a dangerous cocktail of chemicals which, for half a century, have been known to cause cancer. And lab studies have shown that the levels of these toxins found in e-cigarette vapour are generally far lower than in cigarettes.

But e-cigarettes aren’t as risk-free as the bubblegum or chocolate flavours may suggest.  It’s important to remember that they still contain nicotine, which is highly addictive. And because they are relatively new products there still hasn’t been sufficient time to understand what the health impact will be for people who use them long-term.

But, overall, the balance of evidence at the moment suggests that e-cigarettes are much safer than smoking tobacco.

What about the new generation of e-cigarettes?

Many people start vaping with ‘cigalikes’

Many people start vaping with ‘cigalikes’

While there’s been a rapid increase in people using e-cigarettes there are some signs this growth is starting to slow.

There is now a bewildering array of products on the markets, but we’re starting to understand them better.

Many people start vaping with ‘cigalikes’ – products that look like normal tobacco cigarettes and carry a glowing LED tip at the end. But some vapers move onto the refillable ‘tank style’ second generation devices, or the third generation customisable models – which look very different. There is some evidence that users may be able to get a higher dose of nicotine from these high-tech products.

But we need more research on this new generation of products, particularly how they can be best used to help people quit – most of the research to date has focused on people using first generation ‘cigalikes’.

Are they helping smokers quit?

Smoking remains the single biggest preventable cause of cancer, responsible for 1 in 5 cases of cancer in the UK.  We encourage those who smoke to quit entirely. And the best way to quit is to use NHS Stop Smoking Services (alongside appropriate medication), which evidence shows more than trebles your chance of success compared to going it alone.

But in the past couple of years, there’s been a big rise in the number of smokers using e-cigarettes as part of their attempt to quit smoking.  Swapping regular cigarettes for e-cigarettes offers a less harmful option, which may help some smokers quit smoking for good.

So far there hasn’t been enough evidence to judge their effectiveness as a stand-alone quit aid, or how best they can be used to help smokers quit. But recent results from a study we funded analysed those trying to quit without professional support and found that e-cigarette users were more likely to succeed than those who used no aid or over-the-counter nicotine replacement therapy such as gum and patches.  But it’s important to point out that this study still showed that NHS Stop Smoking Services were much more effective in helping people to quit.

So that’s a quick look at the latest evidence of how e-cigarettes used and whether they’re effective. What about how their sale and marketing is regulated?

‘Light touch’ regulation

Unlike quit-aids like nicotine gum and patches, which are regulated as medical products, e-cigarettes are currently regulated as consumer products. This means that they don’t have to provide a list of ingredients, identify the nicotine content, ensure a constant delivery of nicotine, or even be child-proof. So there’s still more that can be done to make sure they are as safe as possible.

This will all change in 2016, when new EU rules will come into force that will improve e-cigarette safety and quality.

E-cigarettes that manufacturers want to continue to sell as consumer products will be regulated under the new Tobacco Products Directive (TPD).  This means they’ll come with warnings about the addictiveness of nicotine, restrictions on product design, nicotine content, and manufacturers won’t be allowed to advertise them on TV, radio and in print media.

But if manufacturers want to make claims that their products can help people quit smoking, their e-cigarettes will be regulated as a medicine (in the same way as nicotine gum and patches).  They will have to seek a medicines license from the Medicines and Healthcare products Regulatory Agency (MHRA). And if they’re granted a license, they won’t face the same restrictions on strength, design and advertising as those regulated as consumer products, and will still be widely available as over-the-counter medicines, and potentially available on the NHS.

We think these regulations are good news for consumers. We would like to see as many products as possible licensed to maximise the potential for supporting smokers to quit and minimise the potential risks.

And once in place, this should provide the ‘light-touch’ regulations needed to improve the quality and safety of these products, while ensuring that they’re still accessible to smokers and not marketed to non-smokers, including children. Which brings us to our next point.

What about children?

So far, in Great Britain, fewer than one in a hundred children say they’ve used e-cigarettes regularly. And as yet there’s no evidence that e-cigarettes act as a ‘gateway’ into smoking cigarettes. These are encouraging facts.

But as the market for e-cigarettes continues to grow, the situation may change. That’s why we’re pleased to see that the Government plans to ban under-18s from buying e-cigarettes. It will be crucial to track how children respond to these products, and if necessary back further controls on marketing and availability to prevent children using them.

How are they marketed now?

A report we commissioned from Stirling University, looked at e-cigarette marketing and advertising over a year in the UK. The study found a raft of marketing ploys including the use of celebrity endorsements, innovative designs, and sweet-tasting flavours, which might attract non-smokers, including children.

Some of these adverts have already been banned after being judged attractive to children while referring to smoking and for suggesting that they can help people quit without the evidence and licensing to back up these claims.

There are also concerns that some e-cigarette advertising may inadvertently ‘normalise’ tobacco smoking making it more acceptable, and perhaps undermining the tobacco control policies that have made a real impact on smoking rates.

The Committees of Advertising Practice recognise these concerns and is planning to introduce new marketing rules for e-cigarettes. We hope these rules will refine marketing regulations, to ensure e-cigarettes are targeted at those who can benefit – namely smokers and users of nicotine-containing products – and not to non-smokers.

Do they change what people think about smoking?

In recent years, smoking has become less socially acceptable, but as is clear from the ‘cigalike’ products, vaping can mimic smoking, which may start to make smoking acceptable again. Is there any evidence for this? Not yet, but like with other areas of e-cigarette research there just simply hasn’t been enough time to be sure either way.

In reaction to these concerns, the Welsh Government is exploring a ban on vaping in all enclosed public spaces, fearing that it may make smoking acceptable again. We don’t believe that there is currently sufficient evidence to justify this. But through our continued support of research, these answers will become clearer, allowing governments to make evidence-based decisions. In the short term, expert guidance is available to businesses to help them make informed decisions on whether to permit e-cigarette use within their premises.

What about the tobacco industry?

E-cigarettes aren’t just big news, they’re big business. And the tobacco industry’s growing interest in this business is a serious concern.

In the last year the tobacco industry has started launching their own products and buying more established e-cigarette companies. It’s not clear why they are interested in e-cigarettes – is it as an insurance policy from declining tobacco sales? Or another ploy to improve their reputation? Either way their involvement raises concerns due to serious conflicts of interest.

The World Health Organisation’s Framework Convention on Tobacco Control (FCTC) is a global public health treaty, signed by 178 nations, aimed at reducing the harm from smoking. All members are required to protect their health policy from the influence of the tobacco industry. As we’ve highlighted before, the tobacco industry isn’t to be trusted when it comes to trying to influence policy.

So we’ll be keeping a close eye on its involvement in e-cigarettes to ensure they can’t use their investment to influence public health policy again.

Maximising the potential

While it’s clear that e-cigarettes have enormous potential to cut smoking rates, it’s vital that all other potential consequences are taken into account. By building and acting on the evolving evidence base around e-cigarettes we believe their full potential can be realised, and the risks minimised.

The debate around e-cigarettes isn’t likely to be resolved any time soon, and we’ll likely continue to see headlines about their risks and benefits for some time to come.

For our part, we will continue to invest in e-cigarette research, presenting a clear assessment of the evidence for those who need it.

Chit Selvarajah is a senior policy advisor at Cancer Research UK

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Nicola Smith November 21, 2014

Thank you for your comment and congratulations for successfully quitting smoking! You raise an interesting point. From the available evidence we know that the Stop Smoking Services are the best way to try and quit smoking. The most recent data shows that half of people are still quit one month after using these services (e.g. for England: http://www.hscic.gov.uk/catalogue/PUB14610). Unfortunately it’s really difficult to follow everyone up for any longer than this and, for the majority of people, there’s no data on their smoking status a year on. For example data from Scotland (pdf) shows that of the people who were successfully tracked down a year later, around 20% reported that they were still quit – but overall, 70% of people could not be followed up.

As well as this, so far there’s no long-term data on e-cigarettes, and the only indication we have of how quit rates compare to the NHS Stop Smoking Services is from the study we funded mentioned above, along with other results from this study looking at behavioural support and prescription medication from the Stop Smoking Services – clearly suggesting an advantage with e-cigarettes over quitting with no aid, but showing much higher success rates with the Stop Smoking Services.

But of course we will be keeping an eye on the evidence, continuing to fund research to try and answer these questions, and will post again when we know more about the safety and effectiveness of these new products.

Thanks
Nikki
Cancer Research UK

Aldo Tanca November 20, 2014

I am glad cancer research came up with a balance article on the topic.
My personal experience is that, having smoked one pack per day from age 16 to 35, with not a single day cigarette free, the 23 of February 2012 I switched to e-cigarettes and never smoked a cigarette since then, or craved for it.
This has turned my life upside down and for the better.
It is just my experience, but, being the internet social as it is, over the last years I have been in touch with thousands of people in my situation, and I meet from time to time with many, I think no less than an hundred, that have stayed smoke-free for year.
From what I see and read, NHS methods might not be that successful on the long term. I would like to see statistics over 2 and 5 years, to have a clearer idea.
All I could find uses a 6 months time frame, it would be great if this article could be updated with links to long term statistics, if available for readers to form an opinion.

The thing is, quitting an habit is much harder than substitute it with a better one. In that sense, I have no intention to “pack the habit up”, to use the expression of another commenter. I want it to be safe, but if it is reasonably safe I am fine doing it for the rest of my life.
This is why I feel, like many other vaporizer users, that the term e-cigarette is in itself wrong. There is no smoke production, no chemical reactions, it is not a cigarette.
And ingredients should be regulated but the products should not be marketed as medicines, as this will push prices up and make people less able to pack up the bad habit: smoking.

Davee Hedges November 17, 2014

I quit smoking after 71 years using e-cigarettes, I changed gradually from a pipe to e-lookalike cigs then to cartomiser e-cigs. I have tried the odd pipe of baccy since but it really doesn’t cut the mustard so I’m continuing with the cartomiser vapes. I’d not had any negative symptoms of smoking until a full body scan showed a 7mm nodule in my left lung. This was monitored over 18 months and was shown to have grown to 18mm. I had the nodule removed by keyhole surgery and my lymph nodes biopsied in April 2013. (This was my 5th cancer since 2000!) After the op. I got my e-pipe out on the ward and vaped just like we could years ago. It appears I was the 1st person to do this in this hospital and they didn’t know what to do about it, but they let me carry on. I have to say that the annoying morning cough has disappeared and my lungs are looking good again. The only possible health problems I can see is the quality of the make up of the liquid (the ingredients) and the burning of the wick which happens after a while. Anything of a burnt nature is questionable to the good health of the body and when the wick gets charred, I doubt that inhaling this charred wick is good. It is fairly obvious when this happens as one gets a slight burning sensation in the mouth & throat which indicates that the wick needs moving on the heater coil or a new coil assembly is required. For me changing to vaping has been a complete success, It costs less, I don’t smell of smoke, I can breathe better, no crackling or bubbling in my lungs and at the moment I can vape almost anywhere without offending others.

GB Gallen November 13, 2014

There is ‘some’ evidence that E-cigarettes are “gateway devices” for smoking among young people.
(http://www.bmj.com/content/348/bmj.g2034)

Electric cigarettes October 31, 2014

I think today we have lots of doubt and cons and pros on E cigarette but thanks your post it’s really informative for us.

Janet manning October 9, 2014

My son has swapped to e cigarettes in an attempt to stop smoking. He now now smokes more as he thinks they are less harmful. Instead of them being an aid to help smokers they are replacing the cigarette in the long term.

Chris Lloyd October 7, 2014

Good article but doesn’t answer the question about smoking indoors fully. It only considers whether it has the potential to affect an increase in tobacco smoking, not the question about whether, and if so for how long and in what concentration, nicotine vapour which hasn’t been absorbed by the lungs remains in the air indoors.
That’s the main outstanding question for me.

Margaret Gartside October 6, 2014

I feel that people are changing to e cigs but are not giving up smoking. Because these cig don’t have the harmful chemicals in people think it’s safe to smoke them. I have a couple of friends who have changed to e cigs but I can’t see them packing up completely.

Maham October 6, 2014

It helped me quit!

Peter Keenan October 4, 2014

I was on over 30 a day and have C.O.P.D. in March 2013 I had a lung age of 83 years, in April of that hear I moved to E.Cigs. since then I have lost over 3 Stone in wheight,my lung age is now 57, I am te years and I ride an average 35 miles a day for 4 says a week and I am now a member of my Local rowing team,l’età just say I tell GREAT.

Kathy October 4, 2014

I have using e-cigarettes for the last two years ,I had smoked tobacco products for forty years prior to this, e-cigs make it so easy to give up tobacco.

alex October 3, 2014

I have given up cigarettes for nearly 3 years, all because of e-cigs. I now use the second generation devices and make my own e juice.
I have managed in that time to reduce the nicotine level down to 5 and an going to start integrating 0 nicotine over the coming months. Whilst I am still addicted to nicotine, I believe I have received ask the other benefits i would have received if i had given up proper! Breathing, taste, smell etc. Of course there will be individual cases where this may not be the case however I believe we have to be realistic and forward thinking and embrace e-cigs for what they are. The best tool out there to give up smoking.

misha October 3, 2014

10% nicotine * sorry