In January 2020, the World Health Organization (WHO) issued a strong warning about e-cigarettes through a Q&A on its website and a series of tweets, claiming the use of e-cigarettes – also known as vaping – is harmful to the health of both users and non-users and that there is little evidence that vaping helps smokers to quit.
Meanwhile, in the UK, e-cigarettes are considered to be a viable tool in smoking cessation, as recommended by Public Health England (PHE), the National Institute for Health and Care Excellence (NICE), Action on Smoking and Health (ASH) and various other organisations and charities. The Royal Pharmaceutical Society (RPS), which is currently updating its e-cigarettes policy, due to be published in Spring 2020, recognises that vaping has a “potential role to play in helping smokers reduce and stop smoking in the short-term or as a pathway to other nicotine replacement therapies (NRTs)”.
With this conflicting advice, it is not surprising that many people are unsure about the safety and benefits of vaping, especially in the long-term. In February 2019, a survey of 844 smokers and 1,156 ex-smokers by Yorkshire Cancer Research found that a quarter of smokers would not try vaping, with many believing it is just as bad for people as cigarettes. The researchers found tobacco users are suspicious of e-cigarettes and have no desire to give e-cigarettes a go, despite some healthcare professionals urging them to do so.
In the UK, e-cigarettes are tightly regulated for safety and quality. But what are the pros and cons of using them, and should the pharmacy team be recommending them as part of a smoking cessation strategy?
According to the NHS, an e-cigarette is defined as a “device that allows a person to inhale nicotine in a vapour rather than smoke”. It works by heating a liquid that typically contains nicotine, propylene glycol and/or vegetable glycerine and flavourings. There are many different types of e-cigarettes available, in various forms and containing varying amounts of nicotine to suit people’s needs.
The NHS website recommends that “a rechargeable e-cigarette with a refillable tank delivers nicotine more effectively and quickly than a disposable model and is likely to give people a better chance of quitting smoking”. Some refillable e-cigarettes have tanks that need to be filled with an e-liquid, while others use a cartridge or pod system that works with e-liquid capsules.
None of the e-cigarette products on the market in the UK are licensed as medicines. However, they are regulated by the Tobacco and Related Products Regulations 2016. The nicotine content varies from 1mg/ml up to 20mg/ml, which is the legal limit. In 2019, ASH found that 64 per cent of current vapers using nicotine were using e-liquids under 12mg/ml, and a further 24 per cent were using 13 to 20mg/ml.
A Mintel report in February 2019 on smoking cessation and e-cigarettes revealed that the smoking cessation market, including NRT products, such as patches, is in decline while the e-cigarette market continues to grow.
According to research by ASH in September 2019, an estimated 7.1 per cent of the adult population, which is around 3.6 million people in the UK are current vapers. Over half of current vapers are ex-smokers, and the proportion has grown year on year, while the proportion of vapers who also smoke (dual users) declined to 39.8 per cent in 2019. Most ex-smokers use e-cigarettes to help them quit or to prevent relapse, while 21 per cent of current smokers use e-cigarettes to cut down. Only 0.8 per cent of never-smokers are current vapers.
In August 2018, the House of Commons’ Science and Technology Committee issued a statement that e-cigarettes are substantially less harmful – by around 95 per cent – than conventional cigarettes. While nicotine is the addictive substance in e-cigarettes, it is relatively harmless. “The main harm from smoking comes not from nicotine, but from the thousands of other chemicals in tobacco smoke,” according to a PHE spokesperson. “E-cigarettes don’t contain tobacco and don’t produce tar or carbon monoxide – two of the most harmful constituents in tobacco smoke.”
A UK clinical trial published in the New England Journal of Medicine in January 2019 found that, when combined with expert face-to-face support, people who used e-cigarettes to quit smoking were twice as likely to succeed as people who used other NRT products, such as patches or gum. Participants in the study were offered weekly support with local clinicians, who also monitored the carbon monoxide levels in their breath, which is a measure of smoking, for the first four weeks of the trial.
In April 2019, research commissioned by the UK Vaping Industry Association (UKVIA) revealed that smokers who have switched to vaping save on average £346.32 a year after kicking the habit. The survey of 1,790 Brits, found that the financial implications of buying packets of cigarettes is one of the main considerations for those who now vape instead. Other reasons for vaping rather than smoking included smelling better, having better teeth, breathing more easily and no longer having smoker’s cough.
An estimated 7.1 per cent of the adult population are current vapers
According to the March 2018 NICE guideline Stop smoking interventions and services, e-cigarettes are “substantially less harmful to health than smoking but are not risk free” and more research is needed, especially into their long-term impact. Some of the components of e-liquids can create toxic chemicals if they are overheated, and some flavourings could pose a risk to health if they are not regulated. According to ASH and PHE, the risk on other people’s health from passively inhaling e-cigarette vapour is very low.
There have been concerns about the effects of vaping on heart health. However, a two-year research trial named VESUVIUS at Dundee University, funded by the British Heart Foundation and published in November 2019, found that smokers, especially women, who switched to e-cigarettes had significant improvements in their vascular health within four weeks.
“Importantly, these improvements were seen regardless of whether people were vaping e-cigarettes with nicotine or e-cigarettes without nicotine,” says Jamie Hartmann-Boyce, senior researcher in health behaviours at the Nuffield Department of Primary Care Health Sciences, University of Oxford. “Though recently we’ve seen many stories about e-cigarettes and nicotine might worsen heart health, those studies focus on very short-term data, and many of them are not conducted in people. This study should provide reassurance as it has studied more people and followed them up for longer than many of the recently reported studies.”
The liquid in e-cigarettes can burn the skin and cause nicotine poisoning if it’s swallowed. Some devices have leaked and caused serious injuries in fires. Anyone using rechargeable e-cigarette devices should use the correct charger and not leave the devices charging unattended or overnight. Jamie stresses that people using e-cigarettes should “buy them from a reputable retailer and shouldn’t tamper with the devices themselves”.
Smokers who have switched to vaping save on average £346.32 a year
There has also been concern by WHO about e-cigarette use in teenagers, and whether young people who vape are more likely to use conventional cigarettes, cigars or hookah (also known as shisha). But according to ASH in June 2019, in its YouGov Smokefree GB Youth Survey, while some young people, particularly those who have tried smoking, experiment with e-cigarettes, regular use remains low. In addition, research published online in the journal Tobacco Control in April 2019 found little evidence that the rise in e-cigarette usage has renormalised teenage smoking.
According to the NHS, there’s been little research into the safety of e-cigarettes in pregnancy, but these are likely to be much less harmful to a pregnant woman and her baby than cigarettes. Licensed NRT products, such as patches and gum, are still the first-line recommended option to help pregnant woman quit smoking, but some women may prefer to use e-cigarettes instead.
There have been media reports in the US linking e-cigarette usage with severe lung disease. According to World Health Organization data, by 10 December 2019 the USA reported more than 2,409 hospitalised cases of lung damage and 52 confirmed deaths linked to e-cigarettes. These cases have been predominantly among young men and were narrowed down to products containing tetrahydrocannabinol (THC) – the main psychoactive compound in cannabis.
“The acute illnesses observed in the US this past year largely relate to unregulated products,” says Jamie Hartmann-Boyce, senior researcher in health behaviours at the Nuffield Department of Primary Care Health Sciences, University of Oxford. “These have also been attributed to a constituent called vitamin E acetate, which is banned from e-cigarettes in the UK, and may explain why we haven’t see a similar spate of illnesses here.”
Americans have been advised not to vape products containing THC, or use vaping products from informal sources, with doctors calling for an immediate ban. Here, Public Health England continues to monitor the situation, and healthcare professionals and members of the public can report any safety issues through the MHRA’s Yellow Card Scheme.
Giving up smoking is a personal experience, and pharmacy customers need to choose an approach that is right for them. PHE’s report, Vaping in England: an evidence update, published in February 2019, states that smokers should be advised to stop smoking as soon as possible and explore all available options for support, including from the pharmacy team.
Jamie says that NRT products and other smoking cessation therapies (e.g. varenicline) should be recommended as the first-line approach, alongside behavioural support. However, pharmacy teams and other healthcare professionals should be able to advise on e-cigarettes if these are preferred by smokers trying to quit. “If people have tried to use these pharmacotherapies before and have been unsuccessful, or if they don’t want to try them, then switching to e-cigarettes is likely to bring substantial health benefits,” he says. “Of note, many people who use NRT are not necessarily given the right instructions. To maximise chances of quitting, people should use a patch as well as a short-acting form, such as gum, lozenges or inhalator”.
Robbie Turner, director of pharmacy and member experience at the RPS, says that both NRT and e-cigarettes can be used to help people quit smoking for good. “Pharmacists and their teams should be trained to provide the support required to help people overcome their nicotine addiction and reduce the long-term use of cigarettes,” he says. “We still recommend that pharmacists advise smokers to use licensed NRT products rather than e-cigarettes, whilst recognising that e-cigarettes may be the preference for some people and they should be supported in this.”
Many people struggle to quit smoking on their own. Dr Rachel Orritt, Cancer Research UK’s health information manager, says that support from a free local stop smoking service is still the most effective way for people to stop in the long-term. “Community pharmacists are ideally placed to encourage people to consider this option and provide details of their nearest service,” she says.
Nicotine is highly addictive, and at some point vapers may wish to stop using e-cigarettes completely, but healthcare professionals stress that this should not be advised too soon. “Many vapers express a desire to quit eventually,” says Hazel Cheeseman, director of policy at ASH. “Pharmacists could support people to gradually reduce the nicotine in their e-cigarettes or combine vaping with a licensed NRT product. E-cigarette users shouldn’t be encouraged to quit vaping if there is a risk it could lead them to start smoking again. If vapers are looking to cut down on vaping, switching to NRT with behavioural support could be a good option.”
Even if a pharmacy does not have a smoking cessation service in place, pharmacy teams can still provide valuable product advice and support to customers who want to quit smoking.
According to ASH, the health benefits of stopping smoking start within hours of putting out the last cigarette, and it’s never to late to quit and this should be relayed to customers. Some health improvements are seen over the course of a number of years, depending on how long a person has smoked. However, the body begins to recover in as little as 20 minutes when a person quits smoking.