E-cigarette FAQs

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Since 2012, the number of people using e-cigarettes has risen from 700,000 to 2.9 million. E-cigarettes are the most popular smoking cessation aid in the UK, so it’s likely you will encounter patients who have questions about them. Here are the answers to ten frequently asked questions.

Electronic cigarettes (e-cigarettes) are battery-powered devices which heat a solution that typically contains nicotine and propylene glycol or glycerine, producing an inhalable vapour. Unlike tobacco cigarettes, e-cigarettes do not contain cancer-causing tobacco or involve combustion. So there is no smoke, tar or carbon monoxide.

E-cigarettes are almost certainly far safer than smoking, as they don’t contain tobacco - the single biggest preventable cause of death worldwide. They do contain nicotine, which is addictive, but isn’t responsible for the major health harms from smoking.

Studies show that people who switch completely from tobacco to e-cigarettes show reduced exposure to the harmful chemicals in tobacco smoke.[1,2,3] There remain some questions around long-term safety of these products due to the lack of long-term health studies. Some traces of toxic chemicals have been found in some products, although generally in much lower levels than tobacco cigarettes.[4,5]

The evidence so far points towards them being a much safer alternative to tobacco.

 

References

[1] Hecht SS, Carmella SG, Kotandeniya D, et al. Evaluation of toxicant and carcinogen metabolites in the urine of e-cigarette users versus cigarette smokers. Nicotine Tob Res 2015;17(6):704-9.

[2] Wagener TL, Floyd EL, Stepanov I, et al.  Have combustible cigarettes met their match? The nicotine delivery profiles and harmful constituent exposures of second-generation and third-generation electronic cigarette users.  Tobacco Control 2016;26:e23-e28.

[3] Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, carcinogen, and toxin exposure in long-term e-cigarette and nicotine replacement therapy users: a cross-sectional study. Ann Intern Med 2017;166(6):390-400.

[4] Williams M, Villarreal A, Bozhilov K, et al. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One 2013;8(3):e57987.

[5] Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014;23:133-139.

There is emerging evidence to show that e-cigarettes can help people cut down or stop smoking.[1] A study suggested that e-cigarettes may have contributed to an additional 18,000 long-term ex-smokers in England in 2015.[2] This compares to the number of successful quits (albeit short term, self-reported) through NHS England Stop Smoking Services of almost 200,000 between April 2015 and March 2016.[3]

A study in 2014 demonstrated that those who made quit attempts with e-cigarettes and no other support were around 60% more successful than those who used no aid.[4] In contrast, the same study found that those who use over the counter NRT with no support are no more likely to quit than those who go cold turkey. This is likely due to people not using their chosen product enough to satisfy their cravings.[5]

Swapping tobacco cigarettes for e-cigarettes may help increase the likelihood of quitting entirely. Evidence from NHS Stop Smoking Services suggests e-cigarettes may be particularly effective when combined with behavioural support.[3] The National Centre for Smoking Cessation and Training (NCSCT) has advised Stop Smoking Services to be open to those wishing to use an e-cigarette as an aid to stop smoking, especially those who have tried and failed to quit using licensed stop-smoking medicines.[6]

 

References

[1] Beard E, West R, Michie S, et al. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ 2016;354:i4645.

[2] NHS Digital. Statistics on NHS Stop Smoking Services: England, April 2015 to March 2016. NHS Digital; 2016.

[3] Brown J, Beard E, Kotz D, et al. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction 2014;109(9)1531-1540.

[4] E. Beard, Bruguera C, McNeill A, et al. Association of amount and duration of NRT use in smokers with cigarette consumption and motivation to stop smoking: a national survey of smokers in England. Addict Behav 2015;40:33-38.

[5] National Centre for Smoking Cessation and Training (NCSCT). Electronic cigarettes: a briefing for stop smoking services. London: NCSCT; 2016.

[6] Bauld L, MacKintosh AM, Eastwood B, et al. Young people's use of e-cigarettes across the United Kingdom: findings from five surveys 2015-2017. Int J Environ Res Public Health 2017;14(9):973.

There are some concerns that e-cigarettes could act as a gateway to young people taking up smoking cigarettes, but so far the evidence does not support this view in the UK. Experimentation with e-cigarettes in ‘never smokers’ remains low and coincides with the continuing decline in youth smoking.

Public Health England commissioned an independent review which was endorsed by the Royal College of Physicians (RCP). They noted that “there is insufficient evidence that e-cigarettes renormalise smoking or act as a gateway to smoking”.

A new study by the UK Centre for Tobacco and Alcohol Studies, PHE, ASH and DECIPHer Centre at the University of Cardiff found that levels of regular vaping in young people who have never smoked remain very low, showing that the majority of young people who experiment with e-cigarettes don’t go on to use them regularly. The highest rate of regular use of e-cigarettes in young people who had never smoked was 0.5%.[1]

 

References

[1] Bauld L, MacKintosh AM, Eastwood B, et al. Young people's use of e-cigarettes across the United Kingdom: findings from five surveys 2015-2017. Int J Environ Res Public Health 2017;14(9):973.

There are many different types of e-cigarettes, often referred to as first, second or third generation. First-generation e-cigarettes (also known as ‘cigalikes’) look like a cigarette and generally use cartomisers (refills).[1] Second-generation e-cigarettes tend to be larger and have a more powerful battery with adjustable power settings. The battery is linked to an atomiser (heating element) and a ‘tank’ which users can fill with their choice of e-liquid.[1] Third-generation e-cigarettes are normally even larger and allow users to adjust the air flow, voltage or wattage applied to the atomiser.

Research suggests that the newer devices may be better at delivering nicotine, but users should use the device that suits them best. Patients should visit their local Stop Smoking Services or specialist e-cigarette retailers for further advice.

 

References

[1] National Centre for Smoking Cessation and Training (NCSCT). Electronic cigarettes: a briefing for stop smoking services. London: NCSCT; 2016.

Many people can save hundreds of pounds over the course of a year after making the switch from cigarettes to e-cigarettes. Each person will use their e-cigarette differently, and across a wide range of devices and liquids, so prices can vary. A starter kit for third generation devices typically ranges from £20 to £70 and users will occasionally need to replace the atomiser, which costs a couple of pounds, and purchase e-liquid. But after purchasing a starter kit, e-cigarettes will often work out cheaper over time than smoking.

Patients can safely use an e-cigarette and NRT in conjunction. They don’t need to have stopped using the e-cigarette before they start NRT. When people are trying to stop smoking, it is important that they can get enough nicotine to manage cravings.

The ‘e-Voke’, manufactured by British American Tobacco, is currently the only e-cigarette licensed as a medicine. However, although granted a licence, e-Voke is not commercially available in the UK market.

E-cigarettes are currently not available on prescription in the UK, and there are no e-cigarettes licensed as a medicine commercially available in the UK. However, most Stop Smoking Services will let patients bring along their own e-cigarette. It is unlikely there will be a medically licensed product that will be available for prescription in the near future.

The UK has introduced a ban on under-18s purchasing e-cigarettes.

The revised EU Tobacco Product Directive (TPD) came into force in May 2017, and created a dual-track approach for regulating e-cigarettes. For smoking cessation claims to be made about an e-cigarette they must be licensed as medicines by the Medicines and Healthcare products Regulatory Agency (MHRA). All other e-cigarettes are regulated as consumer products and must adhere to the regulations set out by the TPD.

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