E-cigarettes present an opportunity to significantly accelerate already declining smoking rates, and thereby tackle one of the largest causes of death in the UK today. They are substantially less harmful—by around 95%—than conventional cigarettes. They lack the tar and carbon monoxide of conventional cigarettes—the most dangerous components. It has also proven challenging to measure the risks from ‘second-hand’ e-cigarette vapour because it is negligible and substantially less than that of conventional cigarettes.
There are uncertainties, nevertheless, especially about any long-term health effects, because the products have not yet had a history of long use. Ultimately, however, any judgement of risks has to take account of the risk of not adopting e-cigarettes—that is, continuing to smoke conventional cigarettes, which are substantially more harmful. Existing smokers should be encouraged to give up, but if that is not possible they should switch to e-cigarettes as a considerably less harmful alternative.
To help fill remaining gaps in the evidence on the relative risks of e-cigarettes and heat-not-burn products, the Government should maintain its planned annual ‘evidence review’ on e-cigarettes, and extend it to also cover ‘heat-not-burn’ products—a more recently introduced product which heats rather than combusts tobacco—and support a long-term research programme to be overseen by Public Health England and the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment. The Government should report each year on the state of research in its Tobacco Control Plan, and establish an online hub for making the detailed evidence readily available to the public and to health professionals.
An estimated 2.9 million people in the UK are using e-cigarettes to stop smoking, and tens of thousands are using them to successfully quit smoking each year. Concerns about the risk of e-cigarettes potentially providing a ‘gateway’ into conventional smoking, or that the variety and type of flavours could attract young non-smokers in significant numbers, have not materialised.
A medically licensed e-cigarette could assist smoking cessation efforts by making it easier for medical professionals to discuss and recommend them as a stop smoking treatment with patients. The Government should review with the e-cigarette industry how its systems for approving stop smoking therapies could be streamlined to be able to respond appropriately should e-cigarette manufacturers put forward a product for licensing.
People with mental health issues smoke significantly more than the rest of the population, and could therefore benefit significantly by using e-cigarettes to stop smoking. By encouraging patients in mental health units who are smokers to switch to e-cigarettes as a way out of their cigarette addiction, they could continue to engage in treatment sessions within the facilities, without the interruption of smoking breaks. Some NHS mental health units are allowing unrestricted use of e-cigarettes but it is unacceptable that a third of the 50 English NHS trusts who responded to the Committee’s survey ban them. Three-quarters of NHS trusts were mistakenly concerned about ‘second-hand’ e-cigarette vapour, despite the negligible health risk. NHS England should set a policy of mental health facilities allowing e-cigarette use by patients unless trusts can demonstrate evidence-based reasons for not doing so.
Many businesses, public transport providers and other public places do not allow e-cigarettes in the same way that they prohibit conventional smoking. But, there is no public health (or indeed fire safety) rationale for treating use of the two products the same. There is now a need for a wider debate on how e-cigarettes are to be dealt with in our public places, to help arrive at a solution which at least starts from the evidence rather than misconceptions about their health impacts.
Some aspects of the regulatory system for e-cigarettes appear to be holding back their use as a stop smoking measure. The limit on the strength of refills makes some users have to puff harder to get the nicotine they seek and may put some heavy smokers off persisting with them. The restriction on tank size does not appear to be founded on scientific evidence, and should therefore urgently be reviewed. A prohibition on making claims for the relative health benefits of switching to e-cigarettes means that some who might switch are not getting that message. A ban on advertising ‘tobacco’ products has prevented manufacturers putting information in ‘pack inserts’. The Government should review these regulatory barriers to identify scope for change post-Brexit, including an evidence-based assessment of the case for discontinuing the ban on ‘snus’ oral tobacco.
There should be a shift to a more risk-proportionate regulatory environment; where regulations, advertising rules and tax duties reflect the evidence of the relative harms of the various e-cigarette and tobacco products available. While an evidence-based approach is important in its own right, it also would help bring forward the behaviours that we want as a society—less smoking, and greater use and acceptance of e-cigarettes and novel tobacco products if that serves to reduce smoking rates.
Published: 17 August 2018