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E-cigarettes: an evidence update: A report commissioned by Public Health England

August 1, 2015
By McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, and McRobbie H

An expert review of the latest evidence concludes that e-cigarettes are around 95% safer than smoked tobacco and they can help smokers to quit.

Key messages
1. Smokers who have tried other methods of quitting without success could be encouraged to try e-cigarettes (EC) to stop smoking and stop smoking services should support smokers using EC to quit by offering them behavioural support.

2. Encouraging smokers who cannot or do not want to stop smoking to switch to EC could help reduce smoking related disease, death and health inequalities.

3. There is no evidence that EC are undermining the long-term decline in cigarette smoking among adults and youth, and may in fact be contributing to it. Despite some experimentation with EC among never smokers, EC are attracting very few people who have never smoked into regular EC use.

4. Recent studies support the Cochrane Review findings that EC can help people to quit smoking and reduce their cigarette consumption. There is also evidence that EC can encourage quitting or cigarette consumption reduction even among those not intending to quit or rejecting other support. More research is needed in this area.

5. When used as intended, EC pose no risk of nicotine poisoning to users, but e-liquids should be in ‘childproof' packaging. The accuracy of nicotine content labelling currently raises no major concerns.

6. There has been an overall shift towards the inaccurate perception of EC being as harmful as cigarettes over the last year in contrast to the current expert estimate that using EC is around 95% safer than smoking.

7. Whilst protecting non-smoking children and ensuring the products on the market are as safe and effective as possible are clearly important goals, new regulations currently planned should also maximise the public health opportunities of EC.

8. Continued vigilance and research in this area are needed.

Executive summary
Following two previous reports produced for Public Health England (PHE) on e-cigarettes (EC) in 2014, this report updates and expands on the evidence of the implications of EC for public health. It covers the EC policy framework, the prevalence of EC use, knowledge and attitudes towards EC, impact of EC use on smoking behaviour, as well as examining recent safety issues and nicotine content, emissions and delivery. Two literature reviews were carried out to update the evidence base since the 2014 reports and recent survey data from England were assessed.

EC use battery power to heat an element to disperse a solution of propylene glycol or glycerine, water, flavouring and usually nicotine, resulting in an aerosol that can be inhaled by the user (commonly termed vapour). EC do not contain tobacco, do not create smoke and do not rely on combustion. There is substantial heterogeneity between different types of EC on the market (such as cigalikes and tank models). Acknowledging that the evidence base on overall and relative risks of EC in comparison with smoking was still developing, experts recently identified them as having around 4% of the relative harm of cigarettes overall (including social harm) and 5% of the harm to users.

In England, EC first appeared on the market within the last 10 years and around 5% of the population report currently using them, the vast majority of these smokers or recent ex-smokers. Whilst there is some experimentation among never smokers, regular use among never smokers is rare. Cigarette smoking among youth and adults has continued to decline and there is no current evidence in England that EC are renormalising smoking or increasing smoking uptake. Instead, the evidence reviewed in this report point in the direction of an association between greater uptake of EC and reduced smoking, with emerging evidence that EC can be effective cessation and reduction aids.

Regulations have changed little in England since the previous PHE reports with EC being currently governed by general product safety regulations which do not require products to be tested before being put on the market. However, advertising of EC is now governed by a voluntary agreement and measures are being introduced to protect children from accessing EC from retailers. Manufacturers can apply for a medicinal licence through the Medicines and Healthcare products Regulatory Agency (MHRA) and from 2016, any EC not licensed by the MHRA will be governed by the revised European Union Tobacco Products Directive (TPD).