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The Chinese company Ruyan is credited with first introducing e-cigarettes to the market in 2004. Typically, e-cigarettes consist of a plastic or metal tube, a glowing light-emitting diode tip, and the emission of vapor and commonly resemble cigarettes in size and appearance, although models that do not resemble cigarettes also exist.
According to data from the Smoking Toolkit Study, the proportion of smokers in England who have used an e-cigarette in the past three months increased from around 2% in May 2011 to more than 15% in November 2013 – equivalent to around 1.3 million smokers in the UK. Use does not seem to vary by sex or socioeconomic status. Use among non-smokers in the UK, and particularly among young non-smokers, is rare. Although data for prevalence suggest that growth stalled in late 2013, some people have forecast that use of these products will soon overtake that of cigarettes. Most smokers who use e-cigarettes do so to help them to cut down or stop smoking, though some report use predominantly to replace cigarettes at times when smoking is not allowed or accepted. Smokers smoke for nicotine, but are killed by the carcinogens, carbon monoxide and many other toxins that accompany nicotine in tobacco smoke. Because e-cigarettes deliver nicotine in vapor rather than smoke, their emissions are limited to those contained in, or generated from, the nicotine solution used in the device.
E-cigarettes are marketed in the UK as consumer products, and are thus exempt from medicines and tobacco regulations. Although electronic cigarettes are not licensed as smoking cessation products, there is evidence that they are being used in an analogous way to NRT. Suppliers have no obligation to provide data for the performance of the products they sell, and few do. In 2013 the Medicines and Healthcare Products Regulatory Agency announced their intention to regulate e-cigarettes as medicines from 2016, using a streamlined light touch approach to apply medicines standards of purity and delivery, and pre-screen advertising to prevent marketing abuse.
Although medicines licensing increases manufacturing costs, licensed products in the UK qualify for 5% rather than 20% sales tax, will be available on prescription through health services as well as on general sale, and can be advertised as cessation or harm reduction products. It is therefore likely that while some suppliers will opt for regulation as a tobacco product, others will opt for medicines regulation. In either case, these forms of regulation will resolve many of the concerns outlined above.
Despite the controversies, it is clear that e-cigarettes are far less hazardous than is tobacco. With more than a million UK smokers using them to help to cut down or quit smoking, they are proving to be valuable harm reduction and cessation products and could make a substantial contribution to reducing the burden of death, disability and poverty currently caused by tobacco smoking. Health professionals should embrace this potential by encouraging smokers, particularly those disinclined to use licensed nicotine replacement therapies, to try them, and, when possible, to do so in conjunction with existing NHS smoking cessation and harm reduction support. E-cigarettes will save lives, and we should support their use.
Given the likely low hazard of inhaled nicotine, potential risks to health from the product arise almost entirely from the other constituents of vapour. The main component is propylene glycol, which is thought to be safe, although adverse lung effects from sustained long-term inhalation cannot be ruled out. Similar concerns apply to other constituents, but again the risks are probably slight. Thus, even in the absence of regulation to ensure product standards, the direct hazard to users – irrespective of smoking status – and others, from e-cigarettes is low. However, the introduction of product standards to avoid or minimise contamination could further reduce any ill effects. The greater potential risks, and much of the controversy, arise from the relationship between e-cigarette use and tobacco smoking. There are concerns about sustained dual use in smokers who might otherwise have quit completely and also that continued use of e-cigarettes might make relapse to smoking more likely among those who have quit tobacco completely. Although it is too early to tell whether smokers who quit smoking with e-cigarettes are more likely to relapse than are those who use other methods, no evidence as yet shows that dual use results in reduced quit rates.
