Every year, 700,000 people in the European Union die of tobacco related illnesses. Some experts believe that electronic cigarettes could play a major role in fighting this scourge.

It could eradicate smoking and thus greatly benefit public health, says Peter Hajek, Professor of Clinical Psychology at the Queen Mary University of London. His review article, published last summer, covered more than 100 studies and emphasized the potential of e cigarettes to reduce tobacco induced morbidity and mortality.

TOBACCO FREE VAPOUR

When an e cigarette is activated, the battery (a) lights an atomiser (b) that vaporises an e liquid (c) into aerosols that are then inhaled through a straw (d).

This liquid is made up of water, variable concentrations of tobacco derived nicotine, propylene glycol (a food additive) or vegetable glycerine, along with flavourings and other additives and sometimes, impurities.

HIDDEN DANGERS

Concentrations of toxic and carcinogenic substances in e liquids are far lower than in regular cigarettes.

Nicotine is not toxic, except in pregnant women. It can contain impurities, particularly nitrosamines, carcinogenic compounds found in very small quantities.

Chronic exposure to propylene glycol can cause allergies and respiratory problems in vulnerable individuals.

Vegetable glycerine is in theory benign, but when heated it can produce a toxic substance. Some flavourings can be toxic or allergenic.

A DECADE OF VAPING

2003 Lik Hon invents the e cigarette in Hong Kong.

2006 E cigarettes are sold in Europe and the U.S. for the first time.

2013 The market reaches 2.3 billion, a tiny fraction of the global tobacco market, but enough to cut into sales of nicotine substitutes.

Electronic cigarettes deliver vaporised nicotine without burning tobacco, avoiding the production of carcinogens and other substances that harm the lungs and cardiovascular system (see Tobacco free vapour, at right).

They deliver nicotine to the bloodstream more quickly than patches, and users can still employ the gestures that are part of their regular smoking habit.

Vaping e cigarettes also helps people reduce their consumption of regular cigarettes. Nicotine free e cigarettes, however, are not popular.

Worried authorities

Despite these arguments in their favour, e cigarettes remain a concern for public health authorities. They fear that e cigarettes will lure non smokers, thereby undoing the huge effort that has gone into anti smoking campaigns.

E cigarettes renormalise the act of smoking by introducing a new tool that is particularly attractive to young people, says Hubert Hautmann, a pulmonologist at the Klinikum Rechts der Isar Hospital of the Technische Universit t M nchen (TUM). It s important to note that the number of cigarettes smoked by young Europeans has been falling consistently since 1965.

This concern seems unwarranted for the moment, since current studies indicate that e cigarettes are used primarily by smokers. A study of 26,500 adults published by the University of Crete in June 2014 found that nine out of 10 Europeans who tried e cigarettes in 2012 were ex smokers or smokers, often heavy ones.

Many institutions nonetheless remain sceptical and concerned. In August 2014 the World Health Organisation (WHO) recommended banning the promotion of e cigarettes to non smokers and youth, as well as their use in workplaces and public areas.

Hajek disagrees with these recommendations. This is likely to discourage or even prevent smokers from doing what is right for their health. No study has shown that young people go beyond experimentation and develop a habit of regularly vaping e cigarettes.

Prevention or cure

TUM s Hautmann argues for caution. The health effects of nanoparticles in the vapour are unknown. It took until the 1950s to establish incontrovertible proof of the link between lung cancer and tobacco. We may need 20 years to understand the danger of e cigarettes.

Indeed, e cigarettes expose the body to compounds whose long term health effects are still not understood (see Hidden dangers). Even if they seem to provide a useful way of breaking the smoking habit, we still need to evaluate the effects of chronic exposure, adds Maria Rosaria Gualano, a public health scientist at the University of Turin.

There is also a small risk of second hand vapour exposure. A 2014 University of Southern California study showed that although exhaled vapour contained 10 times fewer toxic substances than smoke, it contained more chromium and nickel particles (probably emitted from the cartridges). Establishing stricter manufacturing standards should reduce these uncertainties. Some studies show that very low quantities of toxic substances are present in e liquids, says University of Geneva public health expert Jean Fran ois Etter. But in my estimation the e cigarette reduces the risks of cigarettes by 99 per cent.

Some public health experts worry that tobacco companies will take over the market and develop e cigarettes that will hook users. This risk must still be weighed against that of tobacco, which kills half of all smokers, Hajek argues. Compared to the ravages caused by cigarette smoking, e cigarettes seem like a lesser evil at least from what science says in 2014.

LEGISLATION A fragmented continent

European countries are not all on the same page when it comes to e cigarettes. Some treat them as regular consumer products, others as tobacco products subject to special taxes. Still others classify them as health products, such as nicotine replacements.

Since market authorisation is a complex and expensive process, big pharmaceutical and tobacco companies have a distinct advantage.

The revision of the European directive on tobacco products, which will go into effect in 2016, includes e cigarettes that contain nicotine. It sets a maximum concentration of 20 mg/ml, requires a health warning and bans advertising. It gives individual countries discretion to determine age limits for consumption.

E cigarettes containing higher nicotine concentrations must be included in the framework of products covered by health regulations.

Some experts deplore this tightening of regulations. It only reinforces the market for cigarettes by raising obstacles to the development of e cigarettes, says University of Geneva expert Jean Fran ois Etter. The maximum concentration of nicotine is too low for really heavy smokers.

Regulating nicotine products

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Nicotine is the addictive element of tobacco but it is the tar and other toxins in tobacco smoke, not nicotine, that cause most of the harm. This section focuses on pure nicotine products such as nicotine replacement therapy and electronic cigarettes. For information on attempts to reduce the harm from tobacco products see the Regulating tobacco products page.

Tobacco harm reduction within a regulated framework, encouraging smokers to use non tobacco nicotine containing products, is supported by the UK government, most of the public health community, the MHRA and NICE.

Currently electronic cigarettes are only covered by consumer product regulation. From the middle of 2016 they will come under the revised EU Tobacco Products Directive, except where therapeutic claims are made or they contain over 20 mg/ml of nicotine, when they will require medicines authorisation under Directive 2001/83/EC. For more details about the two systems of regulation see the ASH briefing on electronic cigarettes and FAQs from the European Commission.

MHRA
The Medicines and Healthcare products Regulatory Agency (MHRA) is responsible for assessing the safety, quality and efficacy of medicines, and authorising their sale or supply in the UK. In 2010, the MHRA held a public consultation on how best to regulate nicotine containing products and decided not to remove them from the market but to look at how they could be most effectively regulated as medicines. Following the decision to bring electronic cigarettes into the Tobacco Products Directive the MHRA continues to encourage companies to voluntarily submit medicines licence applications for electronic cigarettes as medicines. It is expected that some electronic cigarettes will be authorised as medicines in 2014.

NICE
The National Institute for Health and Care Excellence (NICE) issues evidence based guidance on the most effective ways to prevent, diagnose and treat disease and ill health. NICE has now published guidance on tobacco harm reduction. While recognising that quitting smoking is always the best option for smokers, the NICE guidance supports the use of licensed nicotine containing products (NCPs) to help smokers not currently able to quit to cut down and as a substitute for smoking, where necessary indefinitely. Products containing tobacco are not covered by this guidance.

Department of Health Tobacco Plan
In the DH Tobacco Plan, launched in March 2011, a commitment was made to “develop new approaches to encourage tobacco users who cannot quit to switch to safer sources of nicotine.” This includes a commitment to co ordinate, through the MHRA, scientific and market research on the use of nicotine containing products, such as electronic cigaretttes, to inform decisions about the most effective and proportionate form of regulation.

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