The promise and challenges of e-cigarettes – the story continues to unfold

There's a bewildering array of products on the market, but we’re starting to understand them better Image from Flickr https://www.flickr.com/photos/pixelblume/6956170154

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’

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

• E-cigarette image from Flickr