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.

Since 2012, the number of people using e-cigarettes has risen from 700,000 to 3.2 million[1]. 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.

See the evidence behind this information 

Reference

[1] Action on Smoking and Health (ASH). Use of e-cigarettes among adults in Great Britain, 2018

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 different to ‘heated tobacco products’ or ‘heat not burn’ products. Heated tobacco products are electronic devices that, unlike e-cigarettes, still contain tobacco leaf and heat it to a high temperature, without setting it alight.

All the information and research discussed on this hub refers only to e-cigarettes, not heated tobacco.

E-cigarettes are almost certainly far less harmful 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] Some traces of toxic chemicals have been found in some products, although generally in much lower levels than tobacco cigarettes.[4,5] There remain some questions around long-term safety of these products due to the lack of long-term health studies, which is why e-cigarettes are only recommend as a tool for quitting smoking, rather than for non-smokers. 

However overall, the evidence so far points towards them being a far less harmful 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 growing evidence to show that e-cigarettes can help people cut down or stop smoking. A study suggested that e-cigarettes may have contributed to an additional 18,000 long-term ex-smokers in England in 2015.[1] This compares to the number of successful quits (albeit short term, self-reported) through NHS England Stop Smoking Services of almost 156,000 between April 2016 and March 2017.[2]

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.[3] 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.[4]

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. A recent high-quality randomised controlled trial part-funded by CRUK showed e-cigarettes to be nearly twice as effective as NRT, when both aids were combined with behavioural support.[5] 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.[4] In 2018, new National Institute for Health and Care Excellence (NICE) guidance recommended that health and social care workers offer advice on e-cigarettes to people interested in using an e-cigarette to quit smoking.[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 2016 to March 2017. NHS Digital. 2017.

[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.NCSCT

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

[5] Hajek P, Phillips-Waller A, Przulj D et al. A randomised trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of medicine. 2019.

[6] NICE, Clinical guideline 92: Stop smoking interventions and services. 2018.

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. Regular use of e-cigarettes remains largely confined to current or ex-smokers. 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 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. [1] UK data from 2019 found that while 5.5% of young people aged 11-18 who have never smoked have ever tried an e-cigarettes, only 0.8% are current vapers, and only 0.1% vape more than once a week. 

Reference

[1] Action on smoking and health (ASH). Use of e-cigarettes among adults in Great Britain, 2018. 2018.

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.

Reference

[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.

Smoking is the combustion of tobacco. You can smoke a cigarette but not an e-cigarette because there is no tobacco or combustion. Instead e-cigarettes heat a liquid containing nicotine, which produces a vapour that is inhaled. Therefore, you vape an e-cigarette.

Coding e-cigarette users:

  1. If a patient uses an e-cigarette (vapes) but doesn’t smoke tobacco at all, then code as a non-smoker
  2. If a patient uses an e-cigarette (vapes) but also smokes tobacco, then code as a smoker

Unlike tobacco smoke, there’s not good evidence to suggest that second-hand e-cigarette vapour is dangerous to others.[1]

Reference

[1] McNeill A, Brose LS, Calder R, et al. Evidence review of e-cigarettes and heated tobacco products. London: Public Health England; 2018.

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