To vape or not to vape? The RCGP position on e-cigarettes
Dr Richard Roope, RCGP and Cancer Research UK Clinical Champion for Cancer
Smoking tobacco is the single largest cause of preventable illness and premature death, being responsible for around 100,000 deaths a year in the UK1 . Smoking accounts for 27% of all cancer deaths, 35% of all respiratory deaths and 13% of all circulatory disease deaths. It is in this context that smoking cessation is one of the most effective health interventions. Up until recent years the main tools to support those trying to give up smoking have been nicotine replacement therapy, and oral bupropion or varenicline. Research shows that professional support alongside medication has been the most effective approach. (8% success rates at one year, compared with 3% in those who attempt to quit unaided).2
ENDS are battery-powered devices that allow the inhalation, or “vaping” of an aerosol containing nicotine, with the option of flavouring. They became available in 2004, following their invention in China in 2003, and global use has increased year on year. By May 2016 2.8 million adults in Great Britain were using ENDS. Of these, approximately 47% were ex-smokers and 51% were using both cigarettes and ENDS.3
Smoking tobacco exposes the smoker to over 7,000 chemicals4 , of which approximately 70 are carcinogenic5. To date 42 chemicals have been detected in ENDS aerosol6 – though with the ENDS market being unregulated there is significant variation between devices and brands. While there is a long history of research on the long-term effects of smoking, there is clearly no such data available for the long-term effects of ENDS.
1. Entry into smoking: Use among children is rare, and in the small number who do use ENDSs, most who currently smoke are ex-smokers. Only 4% of “never smoker” children in Great Britain had tried ENDS, and regular use was only confined to those who smoked7. New regulations around age of sale and restrictions on advertising are likely to reduce what is already an issue of low concern. Overall youth smoking has fallen from 13% in 1996 to 3% in 20148.
2. Safety: As mentioned above, although the long-term safety profile of EC use is still to be evaluated, it is accepted that vaping is an order of magnitude safer than conventional tobacco9. PHE and the Royal College of Physicians estimate that ENDSs are 95% safer than conventional smoking1011. However, only 46% of the public think ENDS are safer than smoking12.
3. Cessation aid: Since late 2013 ENDSs have become the England’s most popular quitting aid13.
4. Passive vaping: There are no identified hazards to bystanders14.
5. More research needed: Ongoing research is underway. However, the benefits of ENDS in assisting cessation should not be deferred while waiting for the publication of this research.
The RCGP, in line with recommendations from PHE , recommends that:
1. GPs provide advice on the relative risks of smoking and e-cigarette use, and provide effective referral routes into stop smoking services.
2. GPs engage actively with smokers who want to quit with the help of e-cigarettes.
3. Where a patient wants to quit smoking, and has not succeeded with other options, GPs should recommend and support the use of ENDS.
4. GPs recognise ENDS offer a wide reaching, low-cost intervention to reduce smoking (especially deprived groups in society and those with poor mental health, both having elevated rates of smoking).
5. All GPs encourage smokers who want to use e-cigarettes as an aid to quit smoking to seek the support of local stop smoking services.
For further reading about Electronic Cigarettes, please see Cancer Research UK's briefing, and Q&A sheet, and a handy infographic regarding successful ways of stopping smoking.
If you are interested in reading more, please take some time to explore the Primary Care Cancer toolkit.
1Estimated premature deaths for each jurisdiction are as follows: England – 78,200; Scotland – 13,000; Wales – 5,500; N. Ireland – 2,300. Sources: Statistics on Smoking: England, 2015. ScotPHO Smoking Ready Reckoner - 2011 Edition Welsh Government - Health Improvement NIdirect - smoking
2Dobbie F, Hiscock R, Leonardi-Bee J, et al. Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study. Southampton (UK): NIHR Journals Library; 2015 Nov. (Health Technology Assessment, No. 19.95.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK327140/ doi: 10.3310/hta19950
5Smoking drinking and drug use among young people in England 2014, HSCIC, www.hscic.gov.uk/pubs/sdd14
6McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD010216.
8Smoking drinking and drug use among young people in England 2014, HSCIC, www.hscic.gov.uk/pubs/sdd14
9Hajek P, Etter J-F, Benowitz N, Eissenberg T, McRobbie H. Electronic cigarettes: Review of use, content, safety, effects on smokers, and potential for harm and benefit. Addiction (Abingdon, England). 2014;109(11):1801-1810. doi:10.1111/add.12659.
11Tobacco Advisory Group of The Royal College of Physicians. Nicotine without Smoke.; 2016.
13Smoking Toolkit Study www.smokinginengland.info
14Hess IMR, Lachireddy K, Capon A. A systematic review of the health risks from passive exposure to electronic cigarette vapour. Public Health Res Pract. 2016;26(2):e2621617