Earlier this year, we reported that people who smoke are almost twice as likely to have a heart attack compared with people who have never smoked and noted that tobacco is the leading cause of preventable death (Mendes, 2019). Encouragingly, NHS Digital (2019) has just published its annual figures and found that the proportion of cigarette smokers in England has fallen from 14.9% in 2017 to 14.4% in 2018.
Although tobacco use has declined by 0.5% between 2017 and 2018, the use of e-cigarettes has increased and the number of e-cigarette users has risen by 0.8% in the same time period (The Pharmaceutical Journal, 2019a; 2019b). Whether or not this is a ‘win’ is up for debate.
How safe is vaping?
The research surrounding the risks of vaping is conflicting, as e-cigarettes contain nicotine, and are addictive and toxic; however, its effects appear less detrimental to a person's health than tobacco smoking (Mendes, 2019). Ideally, the aim would be for people not to engage in neither tobacco nor e-cigarette smoking; but walking before running can be seen as a reasonable approach to take.
Studies indicate that vaping is toxic to the cells of the lungs (Jensen et al, 2015; Sohal et al, 2019). Despite this, two hospitals in the West Midlands have just opened e-cigarette shops (The Pharmaceutical Journal, 2019b). The reason for this is that Sandwell General Hospital in West Bromwich and Birmingham City Hospital have both gone ‘smoke-free’ – meaning that Sandwell and Birmingham NHS Trust, which runs both hospitals, has banned smoking tobacco anywhere on its premises and anyone caught smoking will be fined £50 (The Pharmaceutical Journal, 2019b).
While vaping shouldn't be encouraged in any way among non-smokers, research has shown sizeable reductions in carcinogens and other toxic compounds in people who have quit smoking completely, but who still vape, compared with people who smoke conventional cigarettes (Shahab et al, 2017).
There have been concerns that vaping could serve as a route into tobacco smoking for younger people. However, only 0.8% of people who have never smoked currently vape (Office for National Statistics (ONS), 2019). In an article recently published in The Pharmaceutical Journal, medical director of the Trust, David Carruthers, also said:
‘We know that vaping is a route to cutting down or quitting smoking, and there is evidence that it is not a route into smoking among young people, a group whom we would actively discourage from taking up vaping. Switching completely from smoking to vaping conveys substantial health benefits, with the aim of stopping both smoking and vaping in the long-term.’
How unsafe?
Interestingly, however, a study published in Thorax last year found that the fluid contained in e-cigarettes becomes increasingly toxic during vaping (Clinical Pharmacist, 2018). This is important because previous research investigating the safety of e-cigarettes had been considering unvapourised fluid, and had not taken into account the effect of the vaping process itself (Clinical Pharmacist, 2018).
Scott et al (2018) compared the cytotoxic effects of unvaped e-cigarette liquid (ECL) to those of e-cigarette vapour condensate (ECVC). Specialised immune cells in the lungs called alveolar macrophages were treated with both ECL and ECVC and their viability, as well as cell death (apoptosis), necrosis, cytokine, chemokine and protease release, reactive oxygen species release, and bacterial phagocytosis were assessed. ECVC was found to be cytotoxic at lower concentrations and lead to greater cell death than the ECL (Scott et al, 2018).
The researchers found that an excessive production of reactive oxygen species significantly inhibited phagocytosis, possibly leading to an impaired bacterial clearance (Scott et al, 2018). This combined with inflammatory cytokines and chemokines induced by the vapour may induce inflammation in the alveolar macrophages, which is partly dependent on nicotine (Scott et al, 2018).
Further research is of course needed. However, the study concluded that ECVC is significantly more toxic to these immune cells in the lungs than the non-vaped ECL, which is usually studied, and the authors caution against the commonly held view that e-cigarettes are safe (Scott et al, 2018). For example, in 2016, more than 70% of smokers surveyed believed that e-cigarettes are less harmful than conventional cigarettes (NHS Digital, 2018).
Regulations post-Brexit
At the end of last year, the Government committed to reviewing the way e-cigarettes are regulated once EU legislation ceases to apply post Brexit (Wickware, 2018). This was, at the time, scheduled for March 2019, but of course no deal has been reached and Brexit continues to hang in the balance.
In its parliamentary report on e-cigarettes, the House of Commons Science and Technology Committee recommended a review on e-cigarette regulation in an effort to make restrictions, advertising and taxes more risk-proportionate based on the evidence regarding the relative harms of e-cigarette and tobacco products (Wickware, 2018).
The Department of Health and Social Care (DHSC) responded in agreement, stating it would seek to identify where deregulation may be achieved without harming public health and would also consider reviewing its position on snus—a moist powder tobacco product which is banned across the EU, but which is legal in Sweden, where smoking rates are the lowest in Europe (Wickware, 2018; NHS Digital, 2019).
Future of vaping
There are currently somewhere between 2.8 and 3.6 million vapers in Great Britain (ONS, 2019). This equates to 6.3% of the total population, compared with 3.7% in 2014 where these data began being collected (ONS, 2019). The most common reason given for e-cigarette use is to aid in smoking cessation (51.5%); more than half of vapers reported using e-cigarettes for that purpose in 2018 (ONS, 2019). This was followed by ‘other’ reasons (21.5%), including enjoyment and as a social activity with friends (NHS Digital, 2018).
While these types of reasons may seem to be somewhat of a concern, particularly as e-cigarettes have been demonstrated to be toxic to health, in a recent evidence review, Public Health England (2019) found that vaping poses only a small fraction of the risk of smoking. Furthermore, it estimates that e-cigarettes contribute to at least 20 000 successful quit attempts a year.
‘The research surrounding the risks of vaping is conflicting’
Therefore, while the risks of e-cigarette use continue to be investigated and should not be ignored, cigarette use is of a much greater concern, with 77 800 deaths, which were attributable to smoking in 2018 (ONS, 2019). The recent news of Sandwell and Birmingham NHS Trust banning smoking on the premises of two of its hospitals is highly welcome, although it is hoped that the e-cigarette shops won't lead to an increase in vaping among non-smokers. Furthermore, it is understandable that the shops are there to help smokers to quit; but it is possible that the investment in these shops has been premature, considering the possibility that studies may continue to uncover the risk and toxic effects of e-cigarette use, and the long-term effects will not be known for a number of years.