E-cigarettes and non-combustible inhaled tobacco products

September 2017

Using their clinical judgement on an individual patient basis, primary care clinicians may wish to promote e-cigarettes use as a means to stopping. Patients choosing to use an e-cigarette in a quit attempt should be advised that seeking behavioural support alongside e-cigarette use increases the chances of quit success further.


Smoking tobacco is the single largest cause of preventable illness and premature death, being responsible for around 122,000 deaths a year in the UK1. Smoking accounts for 27% of all cancer deaths, 40% of all respiratory deaths and 20% 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 behavioural support, nicotine replacement therapy, and oral bupropion or varenicline. Research shows that professional support alongside medication (as offered by local Stop Smoking Services) is the most effective approach, and is around three times more effective than going ’cold turkey’2.

Electronic cigarettes (ECs) are battery-powered devices that allow the inhalation, or “vaping” of an aerosol containing nicotine, that has the option of being flavoured. They became more widely available around 2007, following their invention in China in 2003, and global use has increased year on year. As of 2017, there are now 2.9 million adults in Great Britain using ECs. There are now more ex-smokers (52%) in Great Britain using ECs than dual users of both cigarettes and ECs (45%)3.

This updated guidance seeks to give clinicians the current understanding about where ECs may help with smoking cessation and the current understanding in regards to their safety.

Smoking tobacco exposes the smoker to over 5000 chemicals, many of which are poisonous and more than 70 of which may cause cancer4,5,6. The evidence so far shows that e-cigarettes have significantly reduced levels of key toxicants compared to cigarettes, with average levels of exposure falling well below the thresholds for concern7. While there is a long history of research on the long-term effects of smoking, there is little data available for the long-term effects of ECs. A recent study showed that long-term e-cigarette users (who had been using their product for 17 months on average) had significantly lower levels of key toxicants in their urine than those that still smoked – with levels in e-cigarette users similar to exclusive Nicotine Replacement Therapy (NRT) users. The researchers concluded that the full benefit of using e-cigarettes is from stopping smoking entirely, as opposed to dual use of e-cigarettes and tobacco, who had similar exposure levels to smokers8.

  1. Entry into smoking: Use among children is rare, and in the small number who do use ECs, most currently smoke or are ex-smokers. In 2016, only 4% of “never smoker” children in Great Britain had tried ECs, and only a tiny proportion (less than 1%) were regular users9. New regulations around age of sale and restrictions on advertising are likely to make this even less of an issue10. Overall youth smoking has fallen in England from 13% in 1996 to 3%in 201411.
  2. Safety: As mentioned above, although the long-term safety profile of EC use is still to be evaluated, it is accepted that based on the evidence to date, vaping is a far safer alternative to smoking tobacco12. Public Health England and the Royal College of Physicians estimate that ECs are unlikely to exceed 5% of the harm from conventional smoking13,14. Public perceptions do not match the evidence however, with only 44% of adults thinking ECs are safer than smoking15, and this level of misperception has been worsening.
  3. Cessation aid: Since late 2013 ECs have become England’s most popular quitting aid16. There is now growing evidence to suggest that ECs are helping users to stop smoking17, with it being estimated that ECs contributed to an additional 18,000 long-term ex-smokers in England in 201518.
  4. Regulation: New regulations were implemented in May 2016 through the revised EU Tobacco Products Directive (TPD). The regulations require EC manufacturers to abide by certain product specifications, including health warning labels, nicotine strength restrictions, and restriction of misleading information. The regulations also prohibit many forms of advertisement including a restriction on health claims.
  5. Passive vaping: There is no good evidence to suggest that passively breathing vapour from e-cigarettes is likely to be harmful12, 19, 20
  6. More research needed: Ongoing research into the safety of e-cigarettes and their use for smoking cessation is underway. However, the benefits of ECs in assisting cessation should not be ignored while waiting for the publication of this research.
  7. The RCGP position is informed by recommendations from PHE13

  1. Primary Care Clinicians (PCCs) should provide advice to smoking patients on the relative risks of smoking
  2. Patients should be advised that behavioural support and prescription medication from local Stop Smoking Services (SSS) is the most effective quit method. PCCs should provide referral to SSS where these services exist, and the patient wishes to access this support
  3. Using their clinical judgement on an individual patient basis, PCCs may wish to promote EC use as a means to stopping. Patients choosing to use an e-cigarette in a quit attempt should be advised that seeking behavioural support alongside e-cigarette use increases the chances of quit success further. Most SSS are EC friendly, and patients can be advised to bring one to their appointment if they would like to quit using their device
  4. PCCs recognise ECs offer a wide reaching, low-cost opportunity to reduce smoking (especially in deprived groups in society and those with poor mental health, both having elevated rates of smoking). In the UK, though start-up costs can be higher, it is likely to be less expensive to use an EC over time than it is to smoke21

  1. Peto, Lopez, et al. MORTALITY FROM SMOKING IN DEVELOPED COUNTRIES 1950-2020 (updated September 2015).
  2. Kotz, D; Brown, J; West, R; (2014) 'Real-world' effectiveness of smoking cessation treatments: a population study. Addiction, 109 (9) pp. 1531-15303 Use of electronic cigarettes (vapourisers) among adults in Great Britain – ASH 2017
  3. ASH. (2017). Use of e-cigarettes (vapourisers) among adults in Great Britain
  4. IARC. Personal Habits and Indoor Combustions: Tobacco Smoking. IARC Mono gr Eval Carcinogen Risks to Humans. 2012;100E(6).
  5. IARC. Personal Habits and Indoor Combustions: Second-hand Tobacco Smoke. IARC Mono gr Eval Carcinogen Risks to Humans. 2012;100E(7).
  6. IARC. Tobacco smoke and involuntary smoking. IARC Mono gr Eval Carcinogen Risks to Humans. 2004;83.
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  8. 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. DOI:10.7326/M16-1107.
  9. ASH. (2016). Use of electronic cigarettes among children in Great Britain, (October), 1–
  10. Medicines and Healthcare products Regulatory Agency Published. E-cigarettes: regulations for consumer products (2016)
  11. Smoking drinking and drug use among young people in England 2014, HSCIC
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  13. Public Health England. (2015). E-cigarettes: a new foundation for evidence-based policy and practice
  14. Tobacco Advisory Group of The Royal College of Physicians. Nicotine without Smoke; 2016.
  15. Use of electronic cigarettes (vapourisers) among adults in Great Britain – ASH 2017
  16. Smoking Toolkit Study
  17. Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction. May 2014. DOI:10.1111/add.12623.
  18. Beard E, West R, Michie S, Brown J. 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. DOI:10.1136/bmj.i4645.
  19. Hess 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
  20. McAuley TR, Hopke PK, Zhao J, Babaian S. Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality. Inhalation toxicology. 2012;24(12):850–7. Accessed May 28, 2014.
  21. Liber AC, Drope JM, Stoklosa M. Combustible cigarettes cost less to use than e-cigarettes: global evidence and tax policy implications. Tobacco Control 2017; 26: 158–163. February 2017.
  22. National Centre for Smoking Cessation and Training. (2016). Electronic cigarettes: A briefing for stop smoking services.
  23. McNeill, A., Brose, L., Calder, R., Hitchman, S., Hajek, P., & McRobbie, H. (2015). E-cigarettes: an evidence update. Commissioned by Public Health England.
  24. Tobacco Advisory Group of The Royal College of Physicians. (2016). Nicotine without smoke.