Use of E-cigarettes in England and the Involvement of the Tobacco Industry

Electronic cigarettes allow smokers to obtain nicotine in a much safer form than the traditional cigarette, being free of many of the carcinogens and poisons in tobacco smoke. This makes them substantially safer than traditional cigarettes. The Smoking Toolkit Study (STS) (see www.smokinginengland.info), initiated by Professor Robert West at University College London, has seen a dramatic increase in the use of e-cigarettes by smokers, with around 12% of all smokers in England reporting to have used e-cigarettes so far in 2013 compared with just 2% in mid-2011.

Smokers appear to be using them both as an aid for harm reduction (i.e. smoking reduction which involves attempting to cut down one’s cigarette consumption and temporary abstinence i.e. temporarily abstaining for a period of time) and during attempts to quit smoking; with 1/5th of those reporting an attempt to quit in the previous year using e-cigarettes to help with this. Initially it appeared from the STS that e-cigarettes were cannibalising the NRT market rather than enticing new smokers to use pharmacological support. However, the significant increase in use in recent months suggests that this may no longer be the case.

Although the demographic profile of those using e-cigarettes varies from study to study, in the STS for the period of March 2011 until October 2012, smokers in England who reported using e-cigarettes for harm reduction were more likely to have a professional occupation and report a previous quit attempt than those attempting harm reduction without the help of any nicotine containing product. This finding suggests that e-cigarettes may not be targeting the sub-populations where the need is greatest i.e. smokers in more deprived socio-economic groups who find it harder to quit and those who are less motivated to stop.

Although it is clear that the e-cigarette has the potential to be one of the single most important public health initiatives this century, there is substantial concern about their promotion in some quarters. This is partly compounded by stories of exploding e-cigarettes and mechanical malfunctioning, as well as the erroneous belief that nicotine in the doses obtained from these products is dangerous. Numerous studies have now demonstrated the safety of nicotine and that it is the other chemicals in tobacco smoke that do the harm.

More legitimate concern arises from the fact that the tobacco industry is heavily engaged in the market. There has been speculation as to the motives behind this move. One reason may be to try and ensure profits if a complete tobacco ban was ever implemented. Another may be in the hope that their involvement in manufacturing could result in the MHRA imposing significant licensing constraints; thus ‘cigarettes’ would remain the dominant form of nicotine delivery.

Perhaps the major concern regarding the involvement of the tobacco industry is that it may use them as a ‘gateway’ to entice non-smokers into smoking and as a means to keep smokers smoking. Of course, the Medicines and Health Regulatory Authority (MHRA) in the UK could regulate to prevent e-cigarettes from being marketed or sold to those under the age of 18, or as a means to remain a smoker in the face of smoking restrictions.

It is important the tobacco control community maintain an evidence-based approach to the use of e-cigarettes –draft National Institute of Clinical and Health Excellence (NICE 2012) draft guidance on harm reduction suggests that Health Care Professionals maintain this balance by telling smokers objectively that e-cigarettes may have a place in tobacco control, but this is not yet known; that they are likely to be less harmful than smoking, although this is not definitively known and finally that the best thing that a smoker can do in the interim is to follow the existing evidence base to quit or cut down using the current licensed products and behavioural support, but the choice is theirs to make.

The debate will undoubtedly continue whilst we wait for the evidence of efficacy and safety of e-cigarettes.

About the Author: Dr. Emma Beard is a Research Associate at University College London’s Health Behavior Research Centre. Emma is currently investigating smokers’ attempts at harm reduction, more specifically the use of Nicotine Replacement Therapy (NRT) by smokers as means to cut down their cigarette consumption (i.e smoking reduction) and to tide them over when they are unable to smoke (i.e. temporary abstinence).