The Royal College of Physicians' new report, ‘Nicotine without smoke: tobacco harm reduction’, has concluded that e-cigarettes are likely to be beneficial to UK public health. Smokers can therefore be reassured and encouraged to use them, and the public can be reassured that e-cigarettes are much safer than smoking.
Tobacco smoking is addictive and lethal with half of all lifelong smokers dying early, losing an average of about 3 months of life expectancy for every year smoked after the age of 35 (some 10 years of life in total). Although smoking prevalence in the UK has reduced to 18%, 8.7 million people still smoke. Harm reduction provides an additional strategy to protect this group of smokers from disability and early death.
Since e-cigarettes became available in the UK in 2007, their use has been surrounded by medical and public controversy. This new 200-page report examines the science, public policy, regulation and ethics surrounding e-cigarettes and other non-tobacco sources of nicotine, and addresses these controversies and misunderstandings with conclusions based on the latest available evidence:
- E-cigarettes are not a gateway to smoking – in the UK, use of e-cigarettes is limited almost entirely to those who are already using, or have used, tobacco.
- E-cigarettes do not result in normalisation of smoking – there is no evidence that either nicotine replacement therapy (NRT) or e-cigarette use has resulted in renormalisation of smoking. None of these products has to date attracted significant use among adult never-smokers, or demonstrated evidence of significant gateway progression into smoking among young people.
- E-cigarettes and quitting smoking - among smokers, e-cigarette use is likely to lead to quit attempts that would not otherwise have happened, and in a proportion of these to successful cessation. In this way, e-cigarettes can act as a gateway from smoking.
- E-cigarettes and long-term harm - the possibility of some harm from long-term e-cigarette use cannot be dismissed due to inhalation of the ingredients other than nicotine, but is likely to be very small, and substantially smaller than that arising from tobacco smoking. With appropriate product standards to minimise exposure to the other ingredients, it should be possible to reduce risks of physical health still further. Although it is not possible to estimate the long-term health risks associated with e-cigarettes precisely, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.
The report acknowledges the need for proportionate regulation, but suggests that regulation should not be allowed significantly to inhibit the development and use of harm-reduction products by smokers. A regulatory strategy should take a balanced approach in seeking to ensure product safety, enable and encourage smokers to use the product instead of tobacco, and detect and prevent effects that counter the overall goals of tobacco control policy.
Professor John Britton, chair of the RCP’s Tobacco Advisory Group, said:
The growing use of electronic cigarettes as a substitute for tobacco smoking has been a topic of great controversy, with much speculation over their potential risks and benefits. This report lays to rest almost all of the concerns over these products, and concludes that, with sensible regulation, electronic 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 UK.
Smokers should be reassured that these products can help them quit all tobacco use forever.
RCP president Professor Jane Dacre said:
Since the RCP’s first report on tobacco, Smoking and health, in 1962, we have argued consistently for more and better policies and services to prevent people from taking up smoking, and help existing smokers to quit. This new report builds on that work and concludes that, for all the potential risks involved, harm reduction has huge potential to prevent death and disability from tobacco use, and to hasten our progress to a tobacco-free society.
With careful management and proportionate regulation, harm reduction provides an opportunity to improve the lives of millions of people. It is an opportunity that, with care, we should take.
The report is free to download from the RCP website on Thursday 28 April. To arrange interviews please contact RCP Head of PR and public affairs Linda Cuthbertson on 020 3075 1254, 07748 777919, linda.cuthbertson@rcplondon.ac.uk.
Report summary
- Smoking is the biggest avoidable cause of death and disability, and social inequality in health, in the UK.
- Most of the harm to society and to individuals caused by smoking in the near-term future will occur in people who are smoking today.
- Vigorous pursuit of conventional tobacco control policies encourages more smokers to quit smoking.
- Quitting smoking is very difficult and most adults who smoke today will continue to smoke for many years.
- People smoke because they are addicted to nicotine, but are harmed by other constituents of tobacco smoke.
- Provision of the nicotine that smokers are addicted to without the harmful components of tobacco smoke can prevent most of the harm from smoking.
- Until recently, nicotine products have been marketed as medicines to help people to quit.
- NRT is most effective in helping people to stop smoking when used together with health professional input and support, but much less so when used on its own.
- E-cigarettes are marketed as consumer products and are proving much more popular than NRT as a substitute and competitor for tobacco cigarettes.
- E-cigarettes appear to be effective when used by smokers as an aid to quitting smoking.
- E-cigarettes are not currently made to medicines standards and are probably more hazardous than NRT.
- However, the hazard to health arising from long-term vapour inhalation from the e-cigarettes available today is unlikely to exceed 5% of the harm from smoking tobacco.
- Technological developments and improved production standards could reduce the long-term hazard of e-cigarettes.
- There are concerns that e-cigarettes will increase tobacco smoking by renormalising the act of smoking, acting as a gateway to smoking in young people, and being used for temporary, not permanent, abstinence from smoking.
- To date, there is no evidence that any of these processes is occurring to any significant degree in the UK.
- Rather, the available evidence to date indicates that e-cigarettes are being used almost exclusively as safer alternatives to smoked tobacco, by confirmed smokers who are trying to reduce harm to themselves or others from smoking, or to quit smoking completely.
- There is a need for regulation to reduce direct and indirect adverse effects of e-cigarette use, but this regulation should not be allowed significantly to inhibit the development and use of harm-reduction products by smokers.
- A regulatory strategy should, therefore, take a balanced approach in seeking to ensure product safety, enable and encourage smokers to use the product instead of tobacco, and detect and prevent effects that counter the overall goals of tobacco control policy.
- The tobacco industry has become involved in the e-cigarette market and can be expected to try to exploit these products to market tobacco cigarettes, and to undermine wider tobacco control work.
- However, in the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK.