Electronic cigarettes (e-cigarettes) were first created by Chinese medical practitioner Hon Lik in 2003 and patented in 2004. They have since evolved and gained popularity.
Using an e-cigarette is known as ‘vaping’ and ASH England estimates that there are currently 2.8 million e-cigarette users in Great Britain, an increase from 700,000 in 20101. 6% of Welsh residents currently use an e-cigarette, equating to 141,000 of the country's population (Welsh Health Survey 2015).
The advent of e-cigarettes has caused much debate in the public health community. Some take a cautionary approach, and others see e-cigarettes in a more positive light.
Supporters consider them to be an effective smoking cessation device which is less harmful than tobacco cigarettes. E-cigarettes deliver nicotine without the vast majority of the other chemicals found in tobacco cigarettes that are responsible for smoking-related diseases. For this reason organisations such as the Medicines and Healthcare Products Regulatory Agency (MHRA)2 and the National Institute for Health and Care Excellence (NICE)3 have indicated that e-cigarettes are less harmful than tobacco.
Concerns around e-cigarettes involve product safety and the long-term health implications of use. With regards to young people in particular, arguments have been raised that e-cigarettes could act as a gateway to tobacco smoking, whereby young people who do not use tobacco cigarettes experiment with e-cigarettes and go on to try and then regularly use tobacco cigarettes. A further concern relates to whether the ever-increasing use of e-cigarettes, which are not covered by the smoke-free premises regulations, are leading to a perceived renormalisation of smoking as an activity. Although increasingly e-cigarettes are moving away from resembling tobacco cigarettes, initially many were very similar in appearance.
E-cigarettes in Wales
E-cigarettes are not currently covered by the smokefree laws in operation in the UK. In June 2015 the Welsh Government consulted on a proposal to restrict the use of nicotine inhaling devices (such as e-cigarettes) in enclosed public places. This regulation was set to be passed as part of the Public Health (Wales) Bill but due to a lack of support from a sufficient number of Welsh Assembly Members the Bill collapsed. In May 2016, the First Minister stated that the proposed ban would be dropped from the future Public Health Bill legislation.
Since October 2015 it has been illegal in Wales and England to sell e-cigarettes to children and young people under the age of 18.
Tobacco Products Directive (TPD)
In May 2016 the EU’s revised Tobacco Products Directive (TPD) came into force. This revision included many updates to regulations on tobacco products but also set out new regulations covering e-cigarettes. E-cigarettes containing up to 20 mg/ml of nicotine will be regulated by the TPD (levels of 18mg/ml have been reported on user websites as suitable for typical smokers). Above that level, or if manufacturers and importers decide to opt into medicines regulation, such products will require authorisation by the MHRA as over the counter medicines in the same way as nicotine replacement therapy (NRT).
The TPD is intended to introduce harmonised standards across the EU, improve the quality of products and reduce the risk of accidents, particularly in relation to children accidentally drinking liquids or products leaking. To achieve this it includes a number of standards which products must meet. The regulations include:
- Introducing a size limit for e-liquids of 10ml for dedicated refill containers and 2ml for disposable electronic cigarettes, cartridges and tanks
- Requiring products to be child and tamper proof
- Requiring the pack to include a health warning covering 30% of the surfaces of the unit packet and any outside packaging stating ‘This product contains nicotine which is a highly addictive substance'
- Requiring instructions for use, information on addictiveness and toxicity on the packaging and accompanying information leaflet
- Banning certain promotional and misleading descriptors on packaging
- Ensuring that all substances contained in the product and information on the product’s nicotine content are declared on the label
- Requiring manufacturers to inform Member States before placing new or modified products on the market and notify a range of product information concerning composition, emissions and sales/marketing data
- Introducing a registration scheme for businesses engaged in cross-border distance sales of electronic cigarette products.
A detailed briefing on the impact of the EU TPD on UK e-cigarette regulation can be found here.
Together with the above regulations the EU TPD introduced new rules in relation to the advertising of e-cigarettes. From now on the advertising or promotion, directly or indirectly, of e-cigarettes and re-fill containers on a number of media platforms, including on television, radio, newspapers and magazines is prohibited. Member States can decide to regulate domestic advertising (billboards, buses etc.) and Scotland is currently considering this. No adverts are allowed to make health claims re: helping to quit or comparisons between e-cigarettes.
Awareness and use of e-cigarettes and young people
Each year we run a survey looking into the awareness/use of e-cigarettes among young people in Wales. The 2016 ASH Wales e-cigarette report was released in May 2016. Responses from 838 young people aged 18 and under formed the basis of the results.
Findings showed that awareness of e-cigarettes was very high among the young people surveyed, with just over 90% of respondents reporting that they knew what an e-cigarette was prior to completing the survey. A variety of different sources informed this awareness, including, in particular, use by strangers/friends, shop advertisements, plus the media/social media and internet.
Use of e-cigarettes was far more prevalent among respondents who had previously smoked or currently smoke tobacco cigarettes. Of the 570 young people who had never smoked tobacco cigarettes just 11.1% (n = 63) had ever used an e-cigarette, with the majority of these individuals (n = 47) having tried an e-cigarette only once. Regular use of e-cigarettes (more than once a month) by never smokers was rare at 1.1% (n = 6). Respondents from the most deprived parts of Wales were far less likely to have never used an e-cigarette (48.6%) relative to respondents located in the least deprived areas of the country (75.4%). A number of reasons were provided for using e-cigarettes by survey participants, including an inquisitorial attitude to their taste and because friends were using them.
Of those respondents who reported using both e-cigarettes and tobacco cigarettes at some point (n = 175), 90% had first used tobacco cigarettes suggesting the absence of any gateway theory. The survey results, however, do suggest that e-cigarettes represent an effective smoking cessation device among respondents. For those study participants who had used both e-cigarettes and tobacco cigarettes, 25% (n = 43) smoked fewer tobacco cigarettes after first using an e-cigarette, with a further 34% of dual e-cigarette and tobacco users (n = 59) ceasing to smoke tobacco cigarettes altogether.
Summary of existing research findings
- Awareness/use among young people
Studies show that awareness of e-cigarettes among young people in Wales is high and a relatively substantial number of these have reported using e-cigarettes at least once, however the prevalence of regular e-cigarette use among this cohort is low.
- Gateway effect
Additional longitudinal research is required to determine whether e-cigarettes act as a gateway to tobacco smoking/nicotine addiction among young people. The majority of existing research suggests this is not the case, with e-cigarettes found to be almost exclusively used by smokers and ex-smokers.
- Smoking cessation
E-cigarettes are increasingly being used for smoking cessation purposes and preliminary evidence indicates that e-cigarettes facilitates reductions in cigarette consumption among smokers. More research is required however to determine the overall effectiveness of e-cigarettes as a smoking cessation aid.
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.
- Impact on health
E-cigarettes cannot be regarded as completely safe given research has found they do contain some carcinogens and toxicants. However, it is widely accepted that e-cigarettes are much less harmful to health than tobacco products. Further research is required to determine the long-term impact on health of e-cigarettes.
- Passive vaping
There is no evidence to suggest the passive vapour from e-cigarettes is harmful to the health of bystanders.
- E-cigarette market
The tobacco industry is increasingly involved in manufacturing and promoting e-cigarettes, while continuing to sell tobacco cigarettes. For this reason it is important to monitor the e-cigarette market and the role of the tobacco industry.
Most up-to-date research
Research into e-cigarettes is being undertaken at a rapid rate. In August 2015 a comprehensive review of the evidence was commissioned by Public Health England4. The review highlights the need for further research in areas where there is continued uncertainty but concludes that on the basis of what we know so far:
- E-cigarettes are much safer than smoked tobacco. Experts estimate at least 95% safer
- Smokers who’ve tried other methods of quitting could be encouraged to try e-cigarettes
- Encouraging smokers not ready to quit to switch could have positive public health benefits
- No current evidence that use is undermining decline in smoking among children or adults
- Evidence that e-cigarettes are effective in helping people to quit smoking
- There has been a shift towards inaccurate perceptions of harm from e-cigarettes
- Continued vigilance is needed to ensure new regulations maximise the public health opportunities
In April 2016 the Royal College of Physicians (RCP) released a report titled ‘Nicotine without smoke: tobacco harm reduction’5 in which they conclude that e-cigarettes are likely to be beneficial to UK public health. Based on this report they therefore suggest that smokers can be reassured and encouraged to use e-cigarettes, and the public can be reassured that e-cigarettes are much safer than smoking.
Based on the latest available evidence the RCP report concludes that:
- E-cigarettes are not a gateway to smoking
In the UK, use of e-cigarettes is limited almost entirely to those who are already using, or have used, tobacco.
- E-cigarettes do not result in normalisation of smoking
There is no evidence that either nicotine replacement therapy (NRT) or e-cigarette use has resulted in renormalisation of smoking. None of these products has to date attracted significant use among adult never-smokers, or demonstrated evidence of significant gateway progression into smoking among young people.
- E-cigarettes and quitting smoking
Among smokers, e-cigarette use is likely to lead to quit attempts that would not otherwise have happened, and in a proportion of these to successful cessation. In this way, e-cigarettes can act as a gateway from smoking.
- E-cigarettes and long-term harm
The possibility of some harm from long-term e-cigarette use cannot be dismissed due to inhalation of the ingredients other than nicotine, but is likely to be very small, and substantially smaller than that arising from tobacco smoking. With appropriate product standards to minimise exposure to the other ingredients, it should be possible to reduce risks of physical health still further. Although it is not possible to estimate the long-term health risks associated with e-cigarettes precisely, 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.
The report acknowledges the need for proportionate regulation, but suggests that regulation should not be allowed significantly to inhibit the development and use of harm-reduction products by smokers. A regulatory strategy should take a balanced approach in seeking to ensure product safety, enable and encourage smokers to use the product instead of tobacco, and detect and prevent effects that counter the overall goals of tobacco control policy.
E-cigarette use on your premises
Will you permit or prohibit e-cigarette use on your premises? ASH England have created a checklist of five questions to ask before you decide.
2MHRA (2013). Product-specific information and advice: Nicotine containing products. December 31
3NICE (2013). Tobacco: harm-reduction approaches to smoking. NICE public health guidance 45.
4McNeill A, Hajek P et al (2015). E-cigarettes: an evidence update – A report commissioned by Public Health England
5Royal College of Physicians (2016). Nicotine without smoke: Tobacco harm reduction. London: RCP