Electronic cigarettes

Electronic cigarettes, e-cigarettes and vapes are all terms used to describe a battery-powered device which allows its user to inhale nicotine through a vapour rather than smoke.

Position statement

Two thirds of all smokers would like to quit smoking and around 40% of smokers try to give up every year. Public Health England has declared e-cigarettes 95% less harmful than tobacco. Based on the most up-to-date evidence, ASH Wales would encourage anyone who smokes (and isn’t pregnant) to try switching to an e-cigarette.

ASH Wales believes those who want to quit smoking should be fully supported to do so with whichever method suits their needs best and this could be using an e-cigarette. Read more on quitting with e-cigarettes here. However, we view e-cigarettes solely as a smoking cessation aid and strongly discourage their use recreationally, particularly among young people and never smokers.

To date, our annual research on young people and e-cigarette usage has shown that non-smokers are not using electronic cigarettes (see below for detailed analysis).

Smokers are up to 4 times more likely to succeed at quitting if they use Nicotine Replacement Therapy (NRT) and/or other stop smoking medications combined with behavioural support through stop smoking services such as Help Me Quit.

E-cigarettes are popular among smokers who want to give up and are the most commonly used smoking cessation tool in the UK. E-cigarettes, along with behavioural support, could assist the remaining 19% of the Welsh smoking population quit this deadly habit.

How do e-cigarettes work?

E-cigarettes work by heating a mixed liquid of nicotine, flavourings and propylene glycol and/or vegetable glycerine (both commonly used in food production). Unlike traditional cigarettes these devices do not burn tobacco, meaning the most harmful aspects of smoking – tar and carbon monoxide – are not created.

First created in 2004 by a Chinese pharmacist who was looking for an alternative to cigarettes after his father’s death to smoking, e-cigarettes are now used by an estimated 2.9 million adults across the UK. In Wales, around 7% of the population use an e-cigarette, equating to 169,000 people.

e-cig, vape, healthy, unhealhy

E-cigarettes Debate

E-cigarettes have caused much debate among the public health community, with some taking a cautionary approach whereas others see e-cigarettes as an innovation which is supporting hardened smokers to quit.

for

  • Effective smoking cessation device, helping long-term and hardened smokers to quit
  • ‘95% less harmful’ than cigarettes, says Public Health England
  • Deliver nicotine without the majority of the chemicals found in tobacco cigarettes
  • Do not create poisonous CO (smoke) or tar
  • Large health-focussed organisations such as the Public Health England, MHRA and NICE agree e-cigarettes are less harmful than tobacco

Against

  • Concerns mainly centre around the long-term health implications, particularly the effect of vapour on the lungs
  • Risks around product safety and user-awareness especially around charging devices, where incompatible chargers have led to minor explosions
  • Worries that e-cigarettes could act as a gateway to tobacco smoking, whereby young people who do not use tobacco cigarettes may experiment with e-cigarettes and then go on to try tobacco cigarettes
  • Perceived ‘renormalistion’ of smoking due to the fact e-cigarettes can be used in enclosed public spaces (although most establishments have their own rules in place)

Tobacco Products Directive (TPD)

In 2016, the European Union’s revised Tobacco Products Directive (TPD) came into force across the UK. This revision included updated regulations for tobacco products, but it also set out new regulations covering e-cigarettes.

E-liquid containing up to 20 mg/ml of nicotine is regulated by the TPD. However, anything 20mg/ml and above, or if manufacturers decide to go for medicinal regulation, products require authorisation by the MHRA to be sold as over-the-counter medicines similarly to 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 faulty/leaking products.

The regulations, which are not law, include:

Size limit for e-liquids of 10ml for dedicated refill containers and 2ml for disposable electronic cigarettes, cartridges and tanks

Child and tamper-proof bottles

Health warnings cover 30% of the packaging, stating: “This product contains nicotine which is a highly addictive substance”

Manufacturers must inform Member States before putting new or modified products on the market

Products must have instructions for use, information on addictiveness and toxicity

Promotional and misleading descriptors are banned

All substances contained in the product and information on the product’s nicotine content declared on the label

Registration scheme for businesses engaged in cross-border distance sales of electronic cigarette products

E-cigarette use in Wales

E-cigarettes do not fall under the smokefree regulations currently in place across the UK. Since autumn 2015, it has been illegal to sell e-cigarettes to children and young people under the age of 18 in Wales and England.

In 2015 the Welsh Government proposed to restrict the use of nicotine inhaling devices (such as e-cigarettes) in enclosed public places under 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 declared that the planned ban would be dropped from the renewed Public Health Bill legislation – it successfully passed in 2017.

Young people and e-cigarette use in Wales

Over the past 3 years we have run an annual survey looking into the awareness/use of e-cigarettes among young people in Wales.

The latest survey showed awareness of e-cigarettes was very high with over 90% reporting they knew what an e-cigarette was. A variety of different sources informed this awareness, particularly including: use by strangers/friends, shop advertisements, the media/social media and the internet.

Use of e-cigarettes was far more prevalent among respondents who had previously smoked or currently smoke tobacco cigarettes. Of ‘never smokers’ just 11% had ever used an e-cigarette and 75% of those had only ever tried an e-cigarette once. Regular use of e-cigarettes by never smokers was rare at 1%.

Of those young people who reported using both e-cigarettes and tobacco cigarettes at some point, 90% had first used tobacco cigarettes – suggesting the absence of any gateway theory. The survey results do however suggest that e-cigarettes represent an effective smoking cessation device among respondents. For those who had used both e-cigarettes and tobacco cigarettes, 25% smoked fewer tobacco cigarettes after first using an e-cigarette, with a further 34% of dual users stopping smoking altogether.

Young people and e-cigarette use – UK vs US

A large UK study1 looked at evidence from five surveys and also found little indication that use of e-cigarettes by young people leads to smoking. Involving over 60,000 11 to 16-year olds, the findings showed a consistent pattern: most e-cigarette experimentation does not lead to regular use and levels of regular e-cigarette use in young people who have never smoked remain very low. Usage among young people who have never smoked was negligible – between 0.1% and 0.5% across the five surveys.

Evidence from the US2 however shows different trends compared to the UK, where there is some evidence of e-cigarette use among young people acting as a gateway to tobacco cigarette smoking. Nevertheless, it is difficult to know whether these results are indicative of a causal relationship as it is hard to verify whether these young e-cigarette users would have later smoked tobacco cigarettes as they were more susceptible to smoking in the first place.

Harms of nicotine in e-cigs and young people

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Some research has found that the nicotine found in e-cigarettes can be harmful to young people, by making them more susceptible to future substance abuse and induces risks to brain development. More information is available on our Smoking and Young People webpage.

Passive vaping

The possibility of some harm from long-term vapour exposure cannot be dismissed, however the level of harm is likely to be very small and substantially smaller than that arising from second-hand tobacco smoke3.

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 or passive vaping, the available data suggests they are unlikely to exceed 5% of those associated with smoked tobacco products and may well be substantially lower than this figure, especially for second-hand exposure.

Advertising

The Tobacco Products Directive introduced a raft of advertising rules in relation to e-cigarettes. From now on the advertising or promotion – directly or indirectly – of e-cigarettes and re-fill containers on media platforms, including on television, radio, newspapers and magazines, is prohibited. EU Member States can decide to regulate domestic advertising (billboards, buses etc.) and no adverts can make health claims.

Tobacco industry involvement

The tobacco industry is increasingly involved in the e-cigarette market with all the big tobacco industry companies now producing their own e-cigarette brands, whilst continuing to buy-up smaller companies.

Industry-funded research is also an emerging issue; as seen previously with cigarettes, any industry-funded research can produce outcomes which suit the industry’s objectives.

Vaping in the work place

Working with the CIEH, ASH England have created guidance for work places around deciding whether to allow vaping in their premises:

Download the guide

Further Reading

[1] Bauld L et al. Young People’s Use of E-Cigarettes across the United Kingdom: Findings from Five Surveys 2015-2017. International Journal of Environmental Research and Public Health (2017).  http://www.mdpi.com/1660-4601/14/9/973/pdf

[2] National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes. Washington, DC. (2018). https://doi.org/10.17226/24952

[3] Royal College of Physicians (2015). Nicotine without smoke: Tobacco harm reduction