Mounting evidence

It’s getting harder to dispute the contribution of vapor products to smoking cessation.

By Emma Dorey

Evidence that e-cigarettes greatly benefit public health continues to mount. A raft of recent research findings show that e-cigarettes are effective at helping people quit smoking or reduce consumption—and are mostly used for this purpose—crushing the claims widely peddled by the anti-vaping lobby that e-cigarette use encourages smoking and is just as hazardous.

In-depth analysis of smoking and e-cigarette use across all 28 EU member states has revealed that e-cigarettes have helped more than 6 million people quit smoking and more than 9 million reduce how much they smoke—the highest rates seen in a population study. Scientists analyzed responses from some 27,460 people aged over 15 years in the Eurobarometer survey, which provided detailed information about patterns of smoking and e-cigarette use, differentiating between experimentation and regular use, current and past use, and nicotine versus non-nicotine. They found that among the 7.5 million current users of e-cigarettes, 35.1 percent have quit smoking while an additional 32.2 percent have reduced smoking consumption (Addiction, June 2016).

“These are probably the highest rates of smoking cessation and reduction ever observed in such a large population study,” said Konstantinos Farsalinos, the principal investigator of the study and a researcher at the Onassis Cardiac Surgery Center in Athens, Greece.

Thought to be one of the most detailed ever used in analyzing e-cigarette use on a population level, the Eurobarometer data also demonstrated that e-cigarette use is largely confined to current and former smokers; although some nonsmokers experiment with e-cigarettes, regular use is rare. “Just 1.3 percent of nonsmokers reported current use of nicotine-containing e-cigarettes and 0.09 percent reported daily use,” said Jacques le Houezec, a neuroscientist at the French National Institute of Health and Medical Research who was also involved in the study. “Practically, there is no current or regular use of nicotine-containing e-cigarettes by nonsmokers, so the concern that electronic cigarettes can be a gateway to smoking is largely rejected by our findings.”

“Our study shows that e-cigarettes seem to have a beneficial role for the EU population, mainly because of the substantial proportion of smoking cessation and reduction and because of extremely minimal use by never-smokers,” says Farsalinos. “Moreover, there is no initiation with e-cigarettes; thus the gateway to smoking theory cannot be substantiated.”

These two key findings tally with those from other studies. Researchers at University College London, for example, estimate that the use of e-cigarettes helped 16,000 to 22,000 smokers in England to quit for a year or more (Addiction, March 2016). “E-cigarettes appear to be helping a significant number of smokers to stop who would not have done otherwise—not as many as some e-cigarette enthusiasts claim but a substantial number nonetheless,” said professor Robert West, who led the research team.

To assess the real-world effectiveness of e-cigarettes when used to aid smoking cessation, West and colleagues conducted a cross-sectional population study using 2014 data from monthly national surveys. Previous research has found that using e-cigarettes increases the chances of quitting success by around 50 percent compared with using no support or one of the traditional nicotine products such as gum or skin patches. This amounts to an additional 16,000–22,000 people stopping who would otherwise have continued smoking, say the researchers.

Detractors claim that e-cigarettes undermine quitting if smokers use them just to cut down tobacco consumption, and that they act as a gateway into smoking conventional cigarettes, particularly among young people who would otherwise not have tried smoking. “These claims stem from a misunderstanding of what the evidence can tell us at this stage,” said West.

Indeed, the 2.8 million regular users of e-cigarettes in Britain are almost entirely current and ex-smokers, according to Action on Smoking and Health (ASH), a campaigning public health charity that works to eliminate the harm caused by tobacco. The 47 percent who are ex-smokers are mainly using e-cigarettes to help them quit smoking, while the 51 percent who are current smokers are using e-cigarettes to help them cut down on smoking. Additionally, use among adults and young people who have never smoked is negligible and has not changed since 2012, and there is no evidence in Britain that use of e-cigarettes leads to a takeup of smoking.

Furthermore, a team with researchers from the U.S., Canada and Australia has shown that, rather than acting as a gateway to smoking, e-cigarettes and other vaping products could actually cut smoking-related deaths in young people by 21 percent.

The researchers modeled the public-health impact of vapor products in terms of how their availability or absence alters smoking patterns among those who would or would not have otherwise smoked cigarettes. Significantly, the model, which was based on the 1997 birth cohort, focused on young people. It also accounted for possible changes in behavior, such as moving from experimenting to regular use and using both e-cigarettes and tobacco cigarettes. Based on current usage patterns and conservative assumptions, the researchers project a 21 percent reduction in smoking-attributable deaths when vapor products are available, compared to when they are not (Nicotine & Tobacco Research, July 2016).

“While vaping by youth is a concern, the gateway hypothesis that vapers will become smokers is not as strong a threat as the media has portrayed,” says David Levy, one of the researchers and professor of oncology at Georgetown University.

This view is consistent with that of the Royal College of Physicians (RCP), which has also concluded that, in the U.K. at least, e-cigarettes are not a gateway to smoking. They are used almost exclusively by smokers who are trying to cut down or quit, and use by nonsmokers is rare. After analyzing the latest available evidence, the RCP concluded that e-cigarette use is likely to lead to attempts to quit smoking that would not otherwise have happened (“Nicotine without smoke: Tobacco harm reduction,” April 2016).

It is a common misconception that nicotine is the cause of death and disease caused by cigarettes; most of the diseases associated with smoking are actually caused by the smoke formed from the combustion of tobacco. Because e-cigarettes are tobacco-free, they deliver nicotine without the toxicants generated by conventional cigarettes—considerably safer for both smokers and bystanders. If smokers switched from conventional cigarettes to e-cigarettes, millions of lives could be saved—a no-brainer in terms of public health.

Unfortunately, around 8.7 million people in the U.K. alone still smoke tobacco cigarettes. And even though awareness of e-cigarettes is widespread in Britain, only 15 percent of the public accurately believes that e-cigarettes are a lot less harmful than smoking, according to ASH.

Although the precise long-term health risks associated with e-cigarette use are unknown, Public Health England has concluded that e-cigarettes are around 95 percent less harmful than conventional cigarettes and have the potential to help smokers quit (“E-cigarettes: An evidence update,” August 2015). The RCP has gone further, stating that, despite not being entirely risk-free, the health risks of e-cigarettes are unlikely to exceed 5 percent of those associated with smoked tobacco products and may well be substantially lower.

“[The RCP] report lays to rest almost all of the concerns over these products and concludes that, with sensible regulation, e-cigarettes have the potential to make a major contribution towards preventing the premature death, disease and social inequalities in health that smoking currently causes in the U.K.,” said John Britton, chair of the RCP’s Tobacco Advisory Group.

Yet, because nicotine is derived from tobacco, the U.S. Food and Drug Administration has decided to heavily regulate e-cigarettes and other nicotine-containing vaping devices as tobacco products, imposing what many believe to be unjustified and costly demands on producers that are likely to hamper growth of the industry and, with it, efforts to cut smoking-related deaths.

In the EU, e-cigarettes are regulated under the Tobacco Products Directive, “a strange collection of arbitrary restrictions and expensive but pointless burdens devised in secret by politicians and officials with minimal transparency or accountability,” according to Clive Bates, former director of ASH and a public health commentator who blogs at The Counterfactual. Any e-cigarettes claiming to help with smoking cessation in the U.K. are regulated as medicinal products by the Medicines and Healthcare products Regulatory Agency.

“We’ve seen a series of studies painting a clear picture of the beneficial impact of vapor products,” says Bates. “Given the RCP’s estimate that e-cigarettes are unlikely to exceed 5 percent of the risk of smoking and are likely to be substantially less than that, we are witnessing the early stages of a major public health success. And it is driven by technology, consumers and innovators—no taxpayers are harmed and no health care resources are consumed.

“Governments and regulators just need to allow the process to unfold, without smothering the industry with excessive regulation, bans or misclassifying the products as medicines, most of which has the effect of protecting the cigarette trade and encouraging continued smoking.”

However, there are a huge variety of e-cigarettes, few of which are properly tested. There is no question that, to properly safeguard consumers and reassure those who are concerned about product quality, standards are needed to regulate manufacturing methods, ingredient disclosure and performance.

According to the RCP’s Morgan Evans, “The RCP would like to see a nicotine regulatory system that applies controls on products in proportion to their potential harm, to promote innovation and diversity, ensure reasonable levels of protection for consumers and, above all, discourage tobacco use.”