Electronic cigarettes, smoking and population health
Tobacco smoking is addictive and causes more death and disability in the UK, and contributes more to social inequality in health, than any other avoidable cause. One in five adults in the UK, or about 10 million people, still smoke, and half of these will die prematurely as a consequence of their smoking. However, experience of this burden of disease is becoming rare among those in higher managerial and professional occupations, of whom only one-in-ten smoke.1 In contrast, one in three people in routine and manual occupations are smokers,1 as are more than half of the unemployed, over 40% of people with longstanding mental health problems,2 and more than 70% of people who are homeless or imprisoned.2 Consequently, death and disability from smoking is now the domain of the most disadvantaged, dispossessed, marginalised and mentally ill in society. It is Britain's silent, biggest and increasingly unseen killer.
Millions of these deaths can be prevented by motivating smokers to try to quit through population measures such as tobacco price increases, media campaigns and smoke-free policies, and encouraging those who attempt to quit to maximise their chance of success by using medical services offering nicotine or other pharmacotherapy in conjunction with behavioural support.3,4 However, less than 10% of smokers who try to quit actually use these services, as most try without any help at all; these people are around three times less likely to succeed as a consequence.5 A complementary approach, promoted by the Royal College of Physicians (RCP) in 2007, is to encourage smokers who are not otherwise ready or able to quit smoking to substitute cigarettes with alternative, but safer, forms of nicotine, available as a simple consumer choice at the point of sale.6 At the time of the 2007 report the available product options comprised of smokeless tobacco, the least hazardous forms of which are illegal in the UK,6 and conventional nicotine replacement therapy (NRT) products, which have limited appeal to many smokers.6 Electronic cigarettes (e-cigarettes), which appeared in the UK at around the time the 2007 report was published, have transformed this market, and are now providing clear proof of the concept that, if offered attractive, socially acceptable and affordable alternatives to tobacco, large numbers of smokers will use them. By the end of May 2014 over 15% of smokers in England had tried electronic cigarettes, and one in ten, or about 1 million people in the UK, were using them daily.7 There are now more smokers who want to quit using e-cigarettes than conventional NRT, and they tend to use e-cigarettes as a partial, and in some cases then a complete, substitute for tobacco.7 While it is not clear how high the prevalence of electronic cigarette use will rise, this transformation in the way that nicotine is used in UK society offers vast potential to improve public health. Almost inevitably, that potential health benefit is accompanied by potential threats.
Several other countries have also seen rapid growth of electronic cigarette use, including the USA where the market has recently been estimated to be worth $1.85 billion per year.8 The first e-cigarettes were produced in China, to largely unknown standards of purity and delivery, and probably delivered nicotine with a pharmacokinetic profile similar to a conventional NRT inhalator.9 However, their distinguishing characteristic was that their appearance and use resembles that of tobacco smoking, and also that they acquired an image as an unconventional, non-medical and socially acceptable alternative to smoking. Subsequent innovations have generated products that no longer directly resemble a cigarette, and may have improved nicotine purity and delivery, though quality and performance data remain scarce. This lack of information on quality, the lack of controls on marketing and use, their rapid uptake in society and the growing involvement of the transnational tobacco companies in this market have caused considerable concern, particularly in the health professions, about the place of these products in public health. Rather than discuss these and many other concerns in individual detail we have attempted to summarise them, with a response or counter-argument, in Table 1. Collectively, however, they fall into three domains:
the ethics of sustaining a theoretically avoidable addiction in society
the regulatory approach (if any) needed to protect against market abuses or avoidable adverse effects
the engagement of the tobacco industry in a product that could both threaten, or be manipulated to protect, their core business of selling tobacco.
While there are many who are concerned that e-cigarettes provide a means by which existing smokers might continue their nicotine use, and new users may become hooked into a lifetime dependence on nicotine, this argument is countered by the fact that, at present, this same process occurs with tobacco, and kills. Smokers smoke for nicotine but are killed by smoke,10 and despite uncertainty over the potential hazard to health from the nicotine vapour produced by e-cigarettes, any such hazard is evidently minimal in relation to that arising from inhaling tobacco smoke. Therefore, ethical considerations of perpetuating nicotine addiction need to be balanced against those of denying addicts access to an effective yet much less hazardous alternative. They also apply, but have neither been expressed nor emerged as a problem with conventional NRT. As for young people becoming addicted to nicotine – in the UK in 2012, over 40% of people aged 25 years or under have been, and nearly one in four are still, regular smokers.1 Any moral risk of uptake of e-cigarette use needs to be contextualised in relation to the likely alternative, which is that significant numbers of users would otherwise take up smoking. While not without risk, long-term use of nicotine from e-cigarettes is likely to have even less impact on health and life expectancy that that of low-nitrosamine smokeless tobacco.11 While the ideal outcome for society might be to end all nicotine use, the reality is that for as long as people smoke, it is unethical, illogical, paternalist and damaging to both individual and public health to deny access to reduced-hazard products such as e-cigarettes.
The second area of controversy relates to how e-cigarettes should be regulated to maximise their health potential to individuals and society, while minimising risks. Electronic cigarettes are currently marketed in the UK under general product safety regulations which do not impose specific standards of purity or efficacy, and control advertising through voluntary codes of practice.12 These codes of practice are now being reviewed,13 but at the moment deal with breaches reactively, in response to complaints, rather than proactively, through pre-screening. Proponents of this approach maintain that it minimises regulatory barriers and costs to product development and innovation, and that freedom to advertise maximises exposure across the smoking population. Opponents hold that general product regulation does not ensure that products deliver nicotine reliably, or without unnecessary and potentially hazardous components or contaminants, and allows inappropriate marketing, for example to children or to non-smoking adults. To address these concerns the UK Medicines and Healthcare Products Regulatory Agency (MHRA) announced in 2013 that from 2016 e-cigarettes and other nicotine-containing products would be subject to medicines regulation, thus requiring manufacture to medicinal purity and delivery standards, and proactive controls on advertising.12 However, in February 2014 the European Parliament moved to end marketing under general product safety regulations from 2017, when a new Tobacco Product Directive (TPD) will, among other things:
prohibit most advertising of unlicensed nicotine devices
require products to carry health warnings
meet, as yet undefined, purity and emissions standards
require data on nicotine uptake
limit nicotine content
require suppliers to take full responsibility for quality and safety when used ‘under normal or reasonably foreseeable conditions’.13
In practice, this means that from 2017 at the latest, suppliers will have a choice between opting for the probably lower manufacturing costs but greater marketing restrictions imposed by the TPD, or accepting the higher manufacturing costs of MHRA standards but be able to advertise, qualify for 5% (instead of 20%) sales tax in the UK, and be prescribed by health professionals. It remains to be seen which proves more popular.
The involvement of the tobacco industry in the e-cigarette market is perhaps the factor that has caused greatest distaste and concern among health professionals. Long recognised as a pariah industry, their involvement in a product that provides a potential route out of smoking challenges much conventional wisdom that the tobacco industry has no part to play in the solution to the problem it has created. Already British American Tobacco, through a subsidiary company, has applied for UK medicines licenses for both an electronic cigarette and a novel cigarette-like nicotine inhaler device,14 raising the prospect of competition between pharmaceutical and tobacco companies for a much enlarged medicinal nicotine market. Aside from worries over tobacco industry motives, including use of e-cigarettes to sustain or promote smoking, health professionals are soon likely to have to deal with the prospect of prescribing medicines made by, and hence contributing to the profits of, tobacco companies.
Electronic cigarettes thus pose many challenges to conventional thinking on the use of nicotine in society and the treatment of nicotine addiction. However, the evident popularity of these products, and the improvements that further product innovation may bring, indicate that these and other nicotine-containing devices currently in development have the potential to enhance conventional tobacco control policies and achieve significant further reductions in smoking prevalence, particularly in those sectors of society in which more conventional approaches to tobacco control have been relatively ineffective. The RCP supports improved regulation to ensure quality and safety and to protect against unscrupulous marketing, but recognises the important role that such products can play in assisting smokers to give up smoking completely.
- © 2014 Royal College of Physicians
References
- ↵
- Office for National Statistics
- ↵
- Royal College of Physicians, Royal College of Psychiatrists
- ↵
- National Institute for Health and Care Excellence
- ↵
- National Institute for Health and Care Excellence
- ↵
- ↵Tobacco Advisory Group of the Royal College of Physicians. Harm reduction in nicotine addiction: Helping people who can't quit. London: RCP, 2007. www.rcplondon.ac.uk/sites/default/files/documents/harm-reduction-nicotine-addiction.pdf [Accessed 29 May 2014].
- ↵
- West R,
- Brown J,
- Beard E
- ↵
- Herzog B,
- Jerberi J,
- Scott A
- ↵
- Bullen C,
- McRobbie H,
- Thornley S,
- et al.
- ↵
- Russell MA
- ↵
- ↵
- Committees of Advertising Practice
- ↵
- Committees of Advertising Practice
- ↵
- National Institute for Health and Care Excellence
- Wang D,
- Connock M,
- Barton P,
- et al.
- Goniewicz ML,
- Knysak J,
- Gawron M,
- et al.
- The European Parliament and the Council of the European Union
- World Health Organisation
Article Tools
Citation Manager Formats
Jump to section
Related Articles
- No related articles found.