E-cigarettes policy

This policy is aimed at supporting pharmacists in their professional practice. It will also be useful for other health and social care professionals to help inform them on the current evidence around the use of e-cigarettes.

Key Policy Points

  • Supporting people to quit tobacco smoking and thereby reducing the associated morbidity and mortality is a priority area for all health professionals
  • E-cigarette aerosols contain fewer numbers and lower levels of most toxicants than smoke from combustible tobacco cigarettes and are generally considered likely to be significantly less harmful than smoking tobacco. However, emerging evidence indicates that they are not completely safe. More research is required on the long-term effects of inhalation of e-cigarette constituents to establish their absolute risk 
  • E-cigarettes are one of several harm reduction options in the short-term to encourage smokers to stop using tobacco products but people should be advised that e-cigarettes are not risk-free and made aware of all the smoking cessation options available to them
  • If e-cigarettes are used to support people to quit tobacco smoking then it is important that, until more is known about the potential risks of e-cigarette use, the ultimate long-term aim should be to support people to stop using e-cigarettes and to be free of nicotine addiction
  • We advocate the precautionary principle approach to minimise exposure to e-cigarette vapour until more safety data becomes available. Non-smokers should not start using e-cigarettes.
  • Smoking cessation services should aim to support people to successfully stop using tobacco products and e-cigarettes. They should be fully resourced to help people overcome their addiction.
  • Dual use of tobacco products and e-cigarettes should be discouraged as the evidence to date suggests that this provides no health benefits
  • E-cigarettes should be treated in a similar way to tobacco products and not be used indoors, in enclosed places, or near children. This exposes other people to the negative effects of poorer air quality, particularly when groups of people are using e-cigarettes in the same place at the same time. Non-smokers should not have to inhale e-cigarette vapour without their permission  
  • Advertising and marketing at point of sale should be restricted for e-cigarettes in the same way as for tobacco products to reduce the appeal to young people and the potential for people who have never smoked to start using e-cigarettes
  • Better enforcement of the age of sale regulations for tobacco and e-cigarettes is needed, including effective age of sale verification processes to prevent illegal sales to those under 18 years old 
  • Sweet flavouring agents should be banned to minimise the appeal to young people 
  • Pregnant women need to seek advice and support from a health professional to reduce foetal exposure to nicotine to the lowest possible level. Behavioural support to stop smoking is recommended first line, but there should be clear public health messaging that when behavioural support alone has failed, nicotine replacement therapy is the recommended next option. Use of e-cigarettes without support to minimise the use of nicotine is not a safe alternative to smoking in pregnancy. 

Background

The morbidity associated with tobacco smoking is now well established. Smoking is the leading cause of preventable death and disease in the UK. Around half of all life-long smokers will die prematurely1, losing on average about 10 years of life2.

E-cigarette use has risen in popularity in recent years, being promoted as a safer alternative to smoking tobacco. In 2019, an estimated 3.6 million adults in Great Britain used e-cigarettes, an increase from 700,000 in 20123.

In general, the evidence from recent reviews suggests e-cigarettes are significantly less harmful than smoking tobacco cigarettes, but that e-cigarettes are not without risk.4

The overall harm or benefit from e-cigarettes appears to depend on three factors:

  • How much they can support adults to stop smoking tobacco products
  • How harmful to health they are overall
  • Whether they encourage young people or non-smokers to start using tobacco products and/or e-cigarettes. 

We have reviewed the recent evidence and have focused on areas where there is currently the most robust evidence available. It is important that emerging evidence is monitored, and that health policy evolves to take account of future findings.

We support the need for more research and safety data on the long-term risks and benefits. While many of the substances used in e-cigarettes may be considered safe for oral ingestion little is known about the long-term effects of inhalation5 6,  or how the heating process can alter their chemical composition. The full picture of health risks from smoking tobacco products did not emerge until decades after cigarettes were first introduced. We therefore advocate a precautionary principle approach. 

Cigarette smoking in public (in indoor areas and certain outdoor locations) is legally prohibited and today’s young people have grown up with very little public exposure to tobacco smoke. We suggest further restrictions on e-cigarette use in enclosed places are considered.

Role in Smoking Cessation

A Cochrane review in 2016 found a very limited amount of good quality evidence available7.  However, a 2018 randomised controlled trial found that e-cigarettes were more successful in supporting many people to quit tobacco smoking than nicotine replacement therapy (NRT).  While this is encouraging as a move away from tobacco, the same study also found that after one year 80% of participants continued using e-cigarettes compared to 9% who were still using NRT, which suggested that it was easier for people to stop using NRT products than e-cigarettes.8

The reasons for this are likely to be multi-faceted. Many of the social and behavioural habits and sensory cues associated with tobacco smoking continue with e-cigarette use9.  Use of e-cigarettes does not break the hand-to-mouth action associated with smoking cigarettes. Users sometimes still have “smoking breaks” at work and then congregate in the same designated areas as tobacco smokers. The speed of delivery of nicotine to the brain with e-cigarettes is closer to the sensation from tobacco smoking and this could mean the addiction to nicotine is harder to break. 

Quitting E-cigarettes

Health professionals should aim for people ultimately to be free of nicotine addiction by stopping their use of tobacco products and e-cigarettes. 

We have concerns that there has been a move in some areas to reduce resources for smoking cessation services and that using e-cigarettes instead of tobacco smoking may be seen as a successful end result in itself.

It is well established that quitting tobacco smoking is most successful with ongoing behavioural support10. This principle should be extended to also support quitting of e-cigarettes. Further research is required to establish what type of tailored behavioural support would be most successful in aiding people to stop using e-cigarettes. In addition, more research is required into which medicinal options would be most helpful to support quitting e-cigarettes. Currently, marketing authorisations for both NRT products and varenicline are specific for use in quitting tobacco products only. The concept of broadening the scope to include use in quitting e-cigarettes should be explored and encouraged.

All the options available to smokers and e-cigarette users should be discussed with them to find the one most suitable for them to support them to quit. Until more is known about the long-term effects of e-cigarette vapour, with or without nicotine, those who choose to use e-cigarettes should not be excluded from smoking cessation services. They should have follow-up support to encourage them to gradually decrease their use of e-cigarettes with the aim of stopping altogether whenever possible.

Pharmacists and their teams should be trained and resourced to provide the support required to help people overcome their nicotine addiction and reduce the long-term use of e-cigarettes. NHS Scotland has produced a resource to support the prison population to cut down on vaping11.  A similar toolkit and guidance would be useful for practitioners in the community. 

Dual Use of E-cigarettes and Tobacco Cigarettes

Action on Smoking and Health (ASH) has estimated that across GB around 44% (1.4 million) of e-cigarette users are still also smoking tobacco. While the increase in e-cigarette use and assumed decrease in tobacco use is encouraging, the data also indicate that almost half of e-cigarette users have not been able to quit tobacco completely.

While switching completely to e-cigarettes is considered to be less risky than tobacco smoking, using both e-cigarettes and tobacco products is an emerging area of concern. There are no health advantages for anyone who continues to smoke any tobacco cigarettes along with e-cigarettes. It has been reported that using both products at the same time carries more cardiovascular16 and respiratory12 risk than using either one separately. Tobacco smoking is associated with a threefold increase in cardiovascular risk compared to nonsmokers,13 and is likely to be reduced in e-cigarette users.  However, these risks seem to be largely independent of one another and therefore dual use could increase risk15. More good-quality research in this area is required. 

Health Benefits and Risks

The main danger from tobacco smoking comes from the inhalation of, and exposure to, tobacco smoke. Although some of the most harmful components of tobacco smoke are found in e-cigarette vapour, they are fewer in number and present in lower concentrations, and so the health risks are likely to be less16.  Second-hand e-cigarette vapour may be less dangerous to health than tobacco smoke, but it is still not risk-free. Emerging evidence, primarily from the USA, is showing a potential for respiratory complications when e-cigarette use is mixed with vitamin E acetate and where other co-morbidities are present. Reports in 2019 of lung injury and death in the USA appeared to be primarily, but not exclusively linked to the use of e-cigarettes containing cannabis and vitamin E acetate17.  Inclusion of vitamins in e-cigarette products in the UK is prohibited and the Medicines and Healthcare products Regulatory Agency (MHRA) have now provided guidance for extra vigilance when adverse reactions associated with use of e-cigarettes or vaping are suspected18

At present, it is difficult to know the exact risk attached to e-cigarette use, particularly if their use becomes an ongoing lifestyle choice. E-cigarettes have been claimed to be 95% safer than tobacco smoking19, although the scientific basis of this figure has been questioned20.  Much of the current research has been from laboratory studies and work in animals and the real impact of e-cigarette use in humans will not be known until more data become available.

Nicotine is a highly addictive substance with unwanted physiological effects21 23 23. The amount of nicotine inhaled via e-cigarettes is very variable. The absolute risk of e-cigarettes is dependent on the type of device used, frequency of use and user preferences. Quality control issues have also been reported from New Zealand and the United States, which have resulted in discrepancies being found between the actual concentration of nicotine and that stated on the label22 23.  All of these factors will have an impact on the overall health risk and extent of e-cigarette dependence. 

Respiratory

E-cigarette aerosols contain fewer numbers and lower levels of most toxicants than smoke from combustible tobacco cigarettes. However, a major review by the National Academies of Science Engineering and Medicine (NASEM) in 20184 concluded that there is now substantial evidence that e-cigarette use increases airborne concentrations of particulate matter and nicotine in indoor environments compared with background levels. When several e-cigarette users are present levels can rise to above the recommended limits advised by the World Health Organisation (WHO)4. The WHO states that people should expect no harm from the air they breathe24.  As with second-hand cigarette smoke, children, pregnant women, the elderly, and patients with cardiovascular or respiratory diseases may be at particular risk1.

Public Health England have stated that, to date, there have been no identified health risks of passive inhalation of e-cigarette vapour, but they have also acknowledged the need for more long-term research25.

Cardiovascular

Nicotine is known to raise blood pressure and increase heart rate26. A recent meta-analysis concluded that “existing evidence on the cardiovascular effects of the electronic cigarette is concerning”27.  The authors suggested that unless supported by stronger evidence, electronic cigarettes should not be labelled as a cardiovascular safe product. One small study has concluded that habitual use is associated with a shift in cardiac autonomic balance toward sympathetic predominance and increased oxidative stress, both associated with increased cardiovascular risk28.   However the VESUVIUS29 trial in 2019, also a small study, has shown that switching completely from tobacco cigarettes to using e-cigarettes for one month can improve vascular health. More research is required in this area, particularly for dual use as outlined above. 

Cancer

It is widely accepted that there may be considerably less exposure to carcinogens with e-cigarettes than with tobacco smoke1. However, chemical analyses of e-cigarette vapours and liquids have confirmed the presence of some of the same toxins and carcinogens as those found in cigarette smoke4. (see Appendix for details ) There is no known safe level of human exposure to carcinogens and more long-term studies are required before the definitive risks will be known.

Use in Adolescence

Human and animal data indicate that nicotine exposure during periods of developmental vulnerability has multiple adverse health consequences30.

It is known that nicotine can adversely affect adolescent brain development and increase the likelihood of addiction31.  Nicotine can induce changes in the brain and sensitise the brain to the effects of other drugs, which may predispose it to be susceptible to other forms of substance misuse32.

Any increase in nicotine use in young people is therefore a cause for concern. Opinions vary on whether the availability of e-cigarettes is leading to increased use in adolescents, so ongoing monitoring of trends will be necessary. 

ASH and Public Health England have reported that the published evidence does not support increased e-cigarette use among adolescents in the UK to date18 33. A 2019 study29 conducted with 248,324 young people aged between 13 and 15 in the UK found a sustainable decreasing trend in the acceptability of cigarettes, but no apparent upsurge in experimentation or regular use of e-cigarettes in this age group34.  Findings from five surveys across the UK show a consistent pattern: most e-cigarette experimentation does not turn into regular use, and levels of regular use in young people who have never smoked remains very low35

However, one study in Wales36 showed an increasing trend in use with age. The percentage of children who had ever used an e-cigarette, and were currently smoking, increased from 6.9% among 10 to 11 year olds to 39.2% in 15 to 16 year olds. Many young people (including those who have never smoked) have tried e-cigarettes and whilst regular e-cigarette use was low among young people, an association was found between regular e-cigarette use and use of tobacco cigarettes. It is too early to draw definite conclusions but cross-sectional studies from other countries have indicated associations between e-cigarette use and intentions to smoke tobacco37 38.

ASH Wales surveyed 671 people between13 and 18 years old and found that while around 40% of them reported having tried e-cigarettes to help them stop smoking, 16% tried them for novelty value and 14% in order to try nicotine but without tobacco39.  Focus groups in the north of England have also reported that generally young people viewed e‐cigarettes as products in their own right, suggesting that many young people use them simply for the sake of it, for fun, or to try something new40. There is also an association with alcohol, and young people most likely to use e-cigarettes are already engaged in risky substance use behaviours4 41.

There appears to have been growing use among adolescents in the USA42 43.  The authorities in the USA are concerned about the evidence of escalating use among young people44,  and the NASEM review4 in 2018 concluded that there is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.

The highly addictive nature of nicotine even after one exposure45,  combined with fruity flavours, appears to enhance the appeal of e-cigarettes to first-time users, especially teenagers. Concern over this has led to a ban from 2018 on selling flavoured e-cigarettes to young people in the USA36. We support this approach, which minimises exposure and risk in a group known for experimentation with psychoactive substances.

Use in Pregnancy

Pregnant women need to seek advice and support from a health professional to reduce foetal exposure to nicotine to the lowest possible level. E-cigarettes can be wrongly perceived as a safe alternative to smoking in pregnancy. The toxicity of nicotine during developmental processes in the brain has particular significance for use in pregnancy. Recent evidence strongly supports that many of the effects of smoking during pregnancy on offspring lung function may be mediated by nicotine and total abstinence is recommended46 47. It is highly likely that e-cigarette use during pregnancy will have the same harmful effects on offspring lung function and health as smoking tobacco cigarettes48.

If women are not fully informed of the risks and are under the impression that e-cigarette use is safe for their baby, they may use them freely and without any support to quit nicotine. This could result in large doses of nicotine reaching the foetus at critical stages of development. Many of the adverse postnatal health outcomes associated with maternal smoking during pregnancy may be attributable, at least in part, to nicotine alone43.

Behavioural support to stop smoking is recommended first line. We advocate that there should be clear public health messaging that when behavioural support alone has failed, then NRT, with defined minimal quantities of nicotine, is the best way forward for any pregnant woman who smokes tobacco49.  Where a woman is using e-cigarettes we advise a  similar approach. The ultimate goal should always be to expose the foetus to the minimum amount of nicotine possible, for the shortest possible period of time.

International Position

There is a wide variation in the policy position and regulation of e-cigarettes across the globe50.  Currently around 40 countries have banned e-cigarettes. While legislation has been passed to implement change, the rationale for the different positions is not always clear.

Australia has adopted a precautionary approach51, acknowledging potential risks and scientific uncertainty. E-cigarettes have been banned from indoor use in several countries in Europe, such as France, where laws prohibit use in schools, closed workspaces and on public transport. E-cigarettes have been banned entirely from Thailand52,  and India53.

The USA has moved to ban flavoured e-cigarettes other than those with menthol and tobacco flavourings. In 2019, San Francisco became the first US city to ban the sale of e-cigarettes from 202054.  Flavoured tobacco and flavoured e-cigarette liquids have already been banned from being used on playing fields. The US Food and Drug Administration (FDA) has said that sweet flavours can encourage e-cigarette and subsequent tobacco use in teenagers, but tobacco and menthol flavours could encourage adults to move away from tobacco smoking40.

UK Regulation

The MHRA operates a notification scheme for e-cigarettes under the UK Tobacco and Related Products Regulations 2016. This sets minimum standards for tobacco and related products on the UK market, requiring producers to provide ingredient and emission information55 56. The Regulations also specify additional prohibited ingredient standards to those set out in the EU Tobacco Products Directive53. UK regulations do not permit compounds such as formaldehyde, acrolein and acetaldehyde in e-cigarettes or e-cigarette liquids sold in the UK52.

The Regulations apply to all producers of e-cigarette products and refill containers (but not nicotine-free solutions and devices) for supply and consumption in the UK. A producer is anyone who manufactures or imports these products or who re-brands any product as their own.

E-cigarettes are classed as consumer products under the Regulations, rather than medicinal products or medicinal devices, for which a marketing authorisation would be required. Notification to the scheme for e-cigarettes under the Regulations is not equivalent to the issue of a marketing authorisation, for which full assessment of the quality, efficacy and safety of the product is made. 

Sales of e-cigarette products to under 18-year olds are banned in the UK. Purchases of e-cigarettes via the internet which contravene the UK regulations are illicit purchases and as such are subject to MHRA enforcement action. Advertising is prohibited on the internet, in print and broadcast media. Advertising is allowed at point of sale and out of home but must not target or feature children.

Any adverse effects noted with the use of e-cigarettes should be reported to the MHRA through the Yellow Card Scheme.

Appendix - Toxicity of E-cigarette Ingredients

The concentration of potentially harmful ingredients is less in e-cigarettes than in tobacco products. Concerns around the toxicity of excipients in e-cigarettes are primarily around the lack of long-term data on prolonged and frequent exposure and the lack of data on systemic effects from deep inhalation.

Many of the ingredients used in e-cigarettes have been shown to be safe when given by the oral route such as in foods and medicines. However, if a compound or ingredient is considered safe by the oral route it cannot be assumed to be safe when given by the inhalation route as absorption and metabolism mechanisms may differ. Some inhaled molecules will have local adverse effects on contact with the respiratory tract mucosa and heating some compounds will result in them breaking down to potentially more toxic vapours. 

A 2017 USA health impact assessment looked at disability-adjusted life years (DALYs) lost due to exposure to second-hand e-cigarette aerosols. The authors concluded that the overall impact depended on the voltage and characteristics of the e-cigarette device. In general, DALYs for secondhand e-cigarette vapour were lower than those estimated for second-hand tobacco smoke, but in some instances were comparable57

Carriers

Propylene glycol is a major component of the vapour in e-cigarettes and has been reported to precipitate asthmatic attacks in susceptible people55. Asthma UK have expressed concerns about the risks of exposure to second-hand vapour for susceptible people. In their 2018 Annual Asthma Survey, 14% of respondents reported that their symptoms were triggered by using e-cigarettes or through exposure to second-hand e-cigarette vapour58.

Flavourings

Most of the debate around flavourings in e-cigarettes has focused on the potential for them to increase the attractiveness of e-cigarettes to young people. There are, however, also concerns about the potential for toxicity from some of the constituents of the flavourings themselves. Aldehydes can cause irritation to the respiratory tract59. Cinnamaldehyde is found in the vapour of many brands of e-cigarettes at levels that are toxic to human cells in laboratory tests60.  In addition, the saccharides used to make sweet e-cigarette flavours degrade and produce furans and aldehydes when heated61.

Other Compounds

Formaldehyde, acrolein, acetaldehyde and O-methyl benzaldehyde are found in the vapours of many e-cigarettes4. Formaldehyde is classified as a human carcinogen and acetaldehyde is classed as being possibly carcinogenic to humans62.

Metals

There is some evidence suggesting that the concentration of metals in e-cigarette aerosols could be greater than the number of metals in combustible tobacco cigarettes, except for cadmium, which has been found in markedly lower concentrations in e-cigarettes compared with combustible tobacco cigarettes4. E-cigarettes may be a source of toxic metal exposure. Nickel and chromium are components of e-cigarette heating coils and both are known carcinogens4. The amount of exposure to metals depends on the type of e-cigarette device and potential adverse clinical effects are unknown.

References

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Contributors to the policy

We would like to acknowledge the contribution of the RPS Science and Research Board (SRB) e-cigarette working group members.

  • Dr Simon White, Keele University, Chair of working group
  • Professor Christine Bond, University of Aberdeen, Chair of SRB
  • Dr Adam Mackridge, RPS Welsh Pharmacy Board
  • Dr Andrew Teasdale, SRB
  • Valerie Sillito, Practice Pharmacist, Aberdeen
  • Professor Peter Hylands, King’s College London
  • Professor Gino Martini, Chief Scientist, RPS
  • Aileen Bryson, Policy Lead, RPS Scottish Directorate (Author)
  • Dr Colin Cable, Assistant Chief Scientist, RPS (Author)

We would also like to thank the RPS Policy team, the RPS Science and Research team, RPS National Board members, and those listed below who contributed to this work:-

  • Professor Clive Page, King’s College London. Independent Expert Reviewer
  • Dr Amira Guirguis, Swansea University Medical School and SRB member
  • Professor Jayne Lawrence, Manchester University and SRB member
  • Dr Nicola Gray, RPS Regional Liaison Pharmacist

About Us

The Royal Pharmaceutical Society is the dedicated professional body for pharmacists and pharmacy in England, Scotland and Wales. We are the only body which represents all sectors of pharmacy in Great Britain. We lead and support the development of the pharmacy profession including the advancement of science, practice, education and knowledge in pharmacy.

We make sure the voice of the profession is heard and actively promoted in the development and delivery of health care policy and work to raise the profile of the profession.

We put pharmacy at the forefront of healthcare and we aim to be the world leader in the safe and effective use of medicines. We are committed to supporting and empowering our members to make a real difference to improving health care.

Publication date: February 2020

Review date: February 2021