The public health impact of tobacco smoking in the UK
- Smoking is the largest preventable cause of disability in the United Kingdom and the world.
- One hundred thousand people die each year in the UK from smoking related diseases.
- Smoking has detrimental effects on third parties (adults and children) leading to cancer, heart disease, sudden infant death syndrome, afflictions of the lungs, meningitis and middle ear disease.
Contribution of smoking to social inequalities in health and poverty
- There is a link between social-disadvantage and smoking; poor people smoke more than rich people.
- Smoking in the unemployed is twice as high as those in employment.
- The numbers of smokers are exceptionally high within prison populations and homeless communities.
- Smoking rates are double for those suffering from mental health issues compared to the general population.
- People taking up smoking within disadvantaged groups are doing so at an ever-younger age.
- Smokers in disadvantaged groups smoke more a day and take more nicotine from each cigarette.
- Smoking, therefore, increases these health inequalities.
- The review of electronic cigarettes is straightforward, only looking at Gen.1 and Gen.2 systems.
Nicotine content, delivery and pharmacokinetics
- The content of e-cigarettes and the constituents of the vapour is limited.
- The evidence cited research by Konstantinos Farsalinos, the 2013 Smoking Toolkit by Robert West and the 2013 ASH UK report.
- Electronic cigarettes deliver more nicotine faster than NRT products as they rely on absorption through the skin whereas vaping delivers nicotine directly to the blood stream via the lungs.
Likely health effects relative to conventional cigarettes
- Nicotine does not cause serious adverse health effects such as acute cardiac events, coronary heart disease or cerebrovascular disease and is not carcinogenic.
- The principal component other than nicotine is propylene glycol, which is not known to have adverse effects on the lung.
- It is difficult to estimate the levels of toxins present in vapour or the potential for harm over the long term.
- The levels of toxins present or the potential for harm are of a much reduced level to that found in cigarettes.
Current trends in prevalence of electronic cigarette use
- The report used out of date statistics, mainly from the USA, to demonstrate the numbers of people.
- It includes the old figure of 1.3million UK vapers. This figure is now acknowledged as being around 2.1million in the recent ASH UK report.
What is harm reduction, and how does it apply to tobacco use?
- Historically nicotine use has not experienced harm reduction approaches (such as wearing a safety belt in a car).
- The focus on smoking has always been a binary approach: stopping altogether and not the use of nicotine in a safer manner.
- Smokers who reduce the number of cigarettes they smoke change how they smoke them to compensate for the drop in nicotine.
- Cutting down the quantity of cigarettes does not lead to an equivalent drop in disease risk.
- In fact, the drop in disease risk is almost negligible.
- NRT products can be expensive relative to cigarettes.
- NRT products provide few if any of the behavioural characteristics of cigarettes.
- NRT products lack social acceptability as an alternative to smoking.
- NRT products medicalise the act of trying to quit smoking.
- Electronic cigarettes are similar to smoking.
- Electronic cigarettes are a socially acceptable non-medical alternative to NRT.
- Electronic cigarettes are cheaper than smoking and NRT.
- No user of NRT has ever started up an online forum akin to vaping ones.
- Electronic cigarettes have a real potential for mass appeal.
- Regarding the use of SNUS in Sweden & Norway: the diminished risks of ill health support the idea that electronic cigarettes may offer similar benefits.
- The data shows similar increase in use of SNUS related to the decline in tobacco use that we see in the UK with the ASH UK report.
Potential hazards of electronic cigarettes
- The purity of the nicotine used.
- Long-term exposure to the vapour.
- The involvement of the tobacco industry and their lack of ethics.
Potential benefits of electronic cigarettes
- The danger to people through second-hand vapour is negligible.
- There is no evidence vaping is a gateway into smoking.
- The best ‘quit’ approach would be to combine the use of electronic cigarettes with a behaviour modification program.
Regulation of electronic cigarettes in the UK
- The report covers the well-trodden arguments for and against, coverage of the MHRA’s position and that of the European Parliament.
- It highlights that come 2017 manufacturers and vendors will either have to accept the restrictions of the Tobacco Products Directive or face increased costs to obtain a medical licence.
- On-going studies are needed into long-term electronic cigarette use.
- Monitoring is required of tobacco company electronic cigarette marketing.
- The use of electronic cigarettes should be promoted in a mental health setting where NRT has been used and failed.
- Research is required into the economic impact of electronic cigarette use.
Summary and conclusions
“Smoking kills, and millions of smokers alive today will die prematurely from their smoking unless they quit. This burden falls predominantly on the most disadvantaged in society. Preventing this death and disability requires measures that help as many of today’s smokers to quit as possible. The option of switching to electronic cigarettes as an alternative and much safer source of nicotine, as a personal lifestyle choice rather than medical service, has enormous potential to reach smokers currently refractory to existing approaches. The emergence of electronic cigarettes and the likely arrival of more effective nicotine-containing devices currently in development provides a radical alternative to tobacco, and evidence to date suggests that smokers are willing to use these products in substantial numbers. Electronic cigarettes, and other nicotine devices, therefore offer vast potential health benefits, but maximising those benefits while minimising harms and risks to society requires appropriate regulation, careful monitoring, and risk management. However the opportunity to harness this potential into public health policy, complementing existing comprehensive tobacco control policies, should not be missed.”