In 2017, people in Wales could be banned from using e-cigarettes in pubs, restaurants and their workplace.

The new Welsh Public Health Bill has divided public and professional opinion. Public Health Wales, local health boards and the BMA support the ban while Cancer Research UK, Tenovus and ASH Wales (the anti-smoking campaign group) are against it. A few, such as the Royal College of Physicians Wales, the British Heart Foundation and the British Lung Foundation are undecided in the absence of evidence [1].

Some of the evidence is strong, and some bodies provide well argued cases for both sides of the argument, primarily on the basis of the health and social risks.

But some of the evidence is far from clear cut. Although desire to quit smoking is an oft-stated reason for using e-cigarettes, no e-cigarette solution has yet been evaluated and approved for smoking cessation by a government agency [2], although the UK’s Medicines and Healthcare Products Regulator Agency is currently reviewing some products.

It is also often suggested that the use of e-cigarettes (often known as ‘vaping’) is a gateway to tobacco smoking for young people. Recent studies in the US have indicated an increased take-up of smoking in high school students who had ever smoke e-cigarettes [3, 4] whereas the UK Office for National Statistics data suggest that the only people smoking e-cigarettes are already either smokers or ex-smokers (except for a tiny 0.14% who have never smoked) [5]. Graham Moore, lead author on one of the studies in Wales, is on record as saying that ‘it doesn’t look like they [e-cigarettes] are acting as a gateway’ [6].

If the ban is implemented, those who are trying to use e-cigarettes to quit will be sent outside to join the smokers, to passive-smoke with the very smoker community they are trying to leave.

Health risks

Nicotine is still addictive whatever route you choose. Although it is not itself a carcinogen, it is thought to function as a tumour promoter and to increase resistance to cancer treatment [7] along with producing a wide range of other physiological effects such as increased blood pressure, heart rate etc.

But the health risks may extend beyond nicotine. Contrary to some comments in the popular press, e-cigarette vapour is more than just water! Granted, the chemical components and particulates are significantly less than cigarette smoke, but nonetheless it is wise to be cautious until more is known about the health effects of these low-level constituents. Studies have found diethylene glycol, tobacco-specific nitrosamines (human carcinogens), some heavy metals such as tin, nickel, lead and chromium, and other tobacco-specific impurities such as anabasine, myosamine and beta-nicotyrine. There is also doubt about the cytotoxicity of some of the chemicals used to flavour some e-cigarette liquids [8 and references therein].

It is a reasonable to assume that if existing smokers switched to e-cigarettes, there would be a lower disease burden, but the evidence available is that e-cigarettes are being used together with conventional cigarettes, primarily for purposes of cutting down or quitting [9] but also as a way of saving money and circumventing smokefree legislation [10]. This so-called ‘dual use’ clearly has no place in helping smokers to quit.

Safety

In addition to the question of health risk, there are several critical safety issues.

E-cigarettes are basically a mechanism to delivery nicotine as a vapour. The typical e-cigarette comprises a battery, a heating element, an air-flow sensor and the ‘juice’ (a liquid suspension of nicotine in propylene glycol and glycerine, with or without flavourings). When the user sucks on the device a sensor detects the air flow and heats the liquid in the cartridge to deliver nicotine to the user as vapour.

There is currently very little regulatory control of the manufacture of e-cigarettes which means that quality control of e-cigarettes is very variable. Electrically the devices present a fire risk, especially in the presence of home oxygen cylinders.

The nicotine delivery from e-cigarettes is highly variable, and is influenced by the concentration of nicotine in the ‘juice’, the design of the vapourising technology and the user’s puffing behaviour [see 8].

But a greater concern is the nicotine-based liquid used in refillable e-cigarettes. The liquid nicotine can be accidentally ingested or absorbed through skin contact so the refills must be child proof and carefully stored to avoid accidental exposure [8].

Regulation and licensing of e-cigarettes as medical devices could resolve some of these product quality issues, but would also raise the spectre of e-cigarettes available on prescription!

What is abundantly clear is that regulation is needed to control the quality and safety of e-cigarettes offered for sale and to ban their sale to people under 18. Healthcare professionals must also take care to ensure that vaping doesn’t undermine smoking cessation attempts.

High-quality trials are needed in the near future to provide a solid evidence base for the role of e-cigarettes in smoking cessation and for a fuller understanding of the safety issues.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

1. BBC News. E-cigarette ban in enclosed spaces in Wales pushes ahead [Internet]. BBC News. [cited 2015 Sep 2]. Available from: http://www.bbc.co.uk/news/uk-wales-33025872
2. WHO. World Health Organization, Electronic nicotine delivery systems (2014) [Internet]. [cited 2015 Sep 1]. Available from: http://apps.who.int/gb/fctc/PDF/cop6/FCTC_COP6_10Rev1-en.pdf?ua=1
3. Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA. 2015 Aug 18;314(7):700–7.
4. Wills TA, Sargent JD, Knight R, Pagano I, Gibbons FX. E-cigarette use and willingness to smoke: a sample of adolescent non-smokers. Tob Control. 2015 Aug 10;
5. Office for National Statistics. 5 facts about smoking [Internet]. 2014 [cited 2015 Sep 2]. Available from: http://www.ons.gov.uk/ons/rel/ghs/opinions-and-lifestyle-survey/adult-smoking-habits-in-great-britain–2013/sty-facts-about-smoking.html
6. Osborne S. E-cigarettes are popular with teenagers – but few of those who try them become regular users [Internet]. The Independent. [cited 2015 Sep 2]. Available from: http://www.independent.co.uk/life-style/health-and-families/health-news/ecigarettes-are-popular-with-teenagers–but-few-of-those-who-try-them-become-regular-users-10179570.html
7. Warren GW, Singh AK. Nicotine and lung cancer. J Carcinog. 2013;12:1.
8. BMA. BMA calls for strong regulation of e-cigarettes (BMA briefing) [Internet]. 2014. Available from: http://bma.org.uk/-/media/files/pdfs/working%20for%20change/policy%20and%20lobbying/pa-e-cigarettesbriefing-03-12-2014.pdf
9. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014 May 13;129(19):1972–86.
10. Action on Smoking and Health. Use of electronic cigarettes (vapourisers) among adults in Great Britain [2015] [Internet]. [cited 2015 Sep 2]. Available from: http://www.ash.org.uk/files/documents/ASH_891.pdf