Reducing the harm of tobacco, could e-cigarettes be part of the solution?

Electronic cigarettes, which produce a nicotine vapour without tobacco, have become increasingly popular in the last decade, bringing with them a fair bit of controversy.

We’ve blogged before about the ongoing research into e-cigarettes – including some of the misleading headlines that have followed. And much of this has focused on debates around whether the devices themselves are safe, and whether they can successfully help people stop smoking.

Stop Smoking Services are still the most effective way to help people move away from tobacco. But with increasing pressure from government cuts, these vital services are under threat. So alongside a suitable funding solution, it’s important to fully understand other opportunities, like e-cigarettes.

And a new report, published today by the Royal College of Physicians, focuses on one area where e-cigarettes could make a real difference.

As with some of the recent headline-grabbing reports on e-cigarettes, it summarises all the available evidence on the devices. But this latest analysis switches the focus onto the potential e-cigarettes have for reducing the harm from tobacco by simply being an alternative source of nicotine for smokers.

The report is extensive, covering everything from the science of how our bodies absorb nicotine, through the different types of nicotine replacement therapies available to people, and the impact of tobacco control policies at a population level.

Crucially, it helps tackle a common misconception that e-cigarettes are as harmful as smoking. And as we’ll explore below, this could be an important opportunity for smokers who aren’t planning to stop smoking – or find it very difficult to stop – to switch to a far safer source of nicotine.

What is harm reduction?

The idea behind harm reduction approaches is to accept that people may be unwilling or unable to move away from a dangerous behaviour. The goal is then to find ways of minimising the harmful consequences of that behaviour. A couple of commonly used examples are clean needles for intravenous drug users, and seatbelts in cars.

And when it comes to smoking, attempts to reduce the harm of tobacco are largely aimed at substituting nicotine.

Smoking still kills more than 270 people in the UK every day. And while nicotine is the main addictive substance in cigarettes, there’s no evidence it can cause cancer.

So, as the new report states, finding safer alternatives to tobacco as a source of nicotine could have a big impact on public health:

The health and life expectancy of today’s smokers could be radically improved by encouraging as many as possible to switch to a smoke-free source of nicotine

The idea of replacing the source of nicotine isn’t new – especially when it comes to helping people stop smoking. But the rapid growth in the popularity of e-cigarettes suggests the way that nicotine is substituted could be worth reassessing.

Replacing nicotine

Nicotine replacement therapy (NRT) provides medical quality nicotine without the cocktail of toxic chemicals in tobacco, or the ones produced through combustion to make smoke. It has been shown to help people stop smoking by weaning them off the nicotine their brain has been trained to crave.

But NRT is also recommended by the National Institute for Health and Care Excellence (NICE) as a substitute for tobacco. Some people choose to use NRT longer term to stop them relapsing, and evidence from people who’ve used these products for years shows no increase in their risk of cancer or cardiovascular disease.

But the NRT medications available on the NHS and over-the-counter can’t deliver nicotine with the same hit as cigarettes. Nicotine patches are designed to slowly release nicotine over 16 or 24 hours, which is different to how nicotine levels peak following a cigarette. Nasal sprays, gum and inhalators can trigger a quicker rise in nicotine in the blood but, as this report highlights, the peak isn’t as high as from cigarettes, and it also takes much longer to reach.

Evidence shows that combining a patch with one of these fast-release products is an effective approach when looking to substitute the nicotine a person would usually get from tobacco. But people can be concerned that in using patches or quick-release products they may be exposed to too much nicotine, even though the evidence actually shows most people don’t normally use enough to be expected to benefit from it.

So NRT offers smokers a clean source of nicotine, and if you’re looking for something reliable you can get on the NHS, this is your safest bet. In combination with professional behavioural support, this gives smokers the best chance of stopping smoking altogether.

But the truth remains that the approved products aren’t as effective at delivering nicotine as a cigarette. And for many smokers, the main problem with NRT from a harm reduction perspective is that they just don’t appeal as much as cigarettes.

It’s here that many believe e-cigarettes could be the answer.

The e-cigarette opportunity

The evidence summarised in the new report points towards e-cigarettes as being a potentially powerful tool to reduce the harm of tobacco.

E-cigarettes, particularly the more advanced models, can deliver nicotine in a higher dose more quickly. When you inhale nicotine rather than get it through the skin like patches, it reaches the brain more quickly, and e-cigarettes may more closely match the way someone would smoke.

The vast range of products available aren’t medically approved, and vary greatly in quality, but the latest figures show that they are already more popular than NRT.

The next important question is one of safety. And in terms of the level of risk for using e-cigarettes compared to tobacco, the expert panel at the Royal College of Physicians concludes that:

Although it is not possible to precisely quantify the long-term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure

So whether this estimate turns out to be spot on or a fraction off the mark, it certainly seems there is a huge benefit to be had in smokers switching to an e-cigarette.

Professor Linda Bauld, an author of the Royal College of Physicians report and Cancer Research UK’s expert in cancer prevention based at the University of Stirling, agrees.

Smokers and the public should be reassured that e-cigarettes offer a viable route away from tobacco and are unlikely to have a negative impact on bystanders

– Professor Linda Bauld

“E-cigarettes are still a relatively new technology,” she says. “However, we already know a lot about these products, as today’s Royal College of Physicians report outlines. Smokers and the public should be reassured that e-cigarettes offer a viable route away from tobacco and are unlikely to have a negative impact on bystanders.”

According to Bauld, there’s an important balance to be had between what’s popular and what’s successful for those looking to stop smoking.

“There’s likely to be the most benefit where we can combine the most popular route to stopping – e-cigarettes – with the most successful – free local Stop Smoking Services,” she says.

And Bauld stresses that smokers can still make use of Stop Smoking Services and licensed Nicotine Replace Therapies alongside an e-cigarette if they choose to.

“The behavioural support that services provide can complement the e-cigarettes ability to replace the nicotine in tobacco,” she adds.

“The combined benefit of these approaches could really help prevent cancers caused by tobacco, and we need to seize this opportunity.”

But isn’t evidence on e-cigarettes conflicting?

E-cigarettes are being fiercely debated and, with mixed media reports and sometimes conflicting headlines, it’s not surprising that the picture may seem unclear. But the scientific and public health community in the UK agree that e-cigarettes are less harmful than tobacco – something that today’s report reinforces.

But this latest report isn’t the first of its kind. Public Health England released a summary of research on e-cigarettes last year, which had a different focus but reached much the same positive conclusion about the opportunity for these products in tobacco control.

And we, along with the British Lung Foundation, Royal Society for Public Health and many others have signed a consensus statement which says: “We all agree that e-cigarettes are significantly less harmful than smoking.”

Scientists will continue to explore all the potential impacts of these products, and we’re investing in studies to help answer some of the remaining questions. But because there hasn’t yet been the time to gather long-term data on e-cigarettes, it’s still not possible to say for certain what the long-term impact of these products will be.

But as this important new report makes clear, smokers who want to continue using nicotine, or feel they can’t manage without it, can consider e-cigarettes a valid, safer alternative to tobacco.

Nikki Smith is a senior health information officer at Cancer Research UK