Vice Nation: Smoking III – E-Cigarettes: The Facts

(Title Image: Times-Herald)

One of the most contentious parts of the Welsh Government’s Public Health Bill is a proposed ban on the use of electronic cigarettes (e-cigs/“vaping”) in enclosed spaces in Wales (Tattoos, Bans & Bogs).


In August 2015, Public Health England (PHE) published a updated report on e-cigs (pdf) which could be a game-changer in the debate.
What are e-cigarettes and how do they work?

E-cigs were introduced onto the market circa 2004 and work by atomising a liquid by heating it using a battery and filament. The user then breathes in the vapour/aerosol via a cartridge, mimicking smoking a cigarette. E-cig kits normally cost around £40-50 and are rechargeable.

In addition, the liquids come in different flavours – such as fruits – or even mimic the smell and taste of cigarette smoke. The liquid can even be sold without containing nicotine at all, though each refill cartridge can contain the same nicotine as 25 cigarettes and you can usually by a pack of them for under £10.

What chemicals are in e-cigs and their vapour?

E-liquids predominantly contain propylene glycol, vegetable glycerol, water, flavourings and nicotine.
Propylene glycol and glycerol are routinely used in food and pharmaceutical manufacturing and are almost entirely safe on their own – you have to be exposed to large, undiluted quantities to be harmed. However, it’s true to say that these chemicals do change when heated and there’s evidence that propylene glycol is an irritant when inhaled; it’s actually used in theatre fog. People can also have allergic reactions to it (Grana et. al 2014).

There’s little evidence on the long-term effects of inhaling heated propylene glycol, but some industrial chemical companies warn against inhaling it for long periods of time, while it’s also been linked to behavioral changes and spleen damage.

Water is, of course, one of the deadliest chemicals known to man.

The flavourings are largely the same chemicals used to flavour jellies, sweets etc. which are themselves more concentrated versions of the chemicals that produce smells and tastes in nature. When these flavours are combined excessively, they might produce harmful compounds – though at a significantly lower level than cigarettes, to the point of being a background risk.

Nicotine is the active component of e-liquids. PHE reviewed 14 academic studies and found that although e-cigs leave deposits on surfaces, one particular study concluded the air in homes of e-cig users contained six-times less ambient nicotine than the homes of smokers (Ballbe 2014). The nicotine has the same effect as that found in cigarettes (on the circulatory system etc.) so isn’t 100% safe in itself.

Who uses e-cigarettes?

As I demonstrated in Part I, smoking tends to be more common amongst deprived groups and in deprived areas. For e-cigarettes (p12), uptake has increased at the same rate across all social classes, though e-cig use is highest amongst ABs (managers and professionals) and C1s (skilled manual workers).

According to the report, a pilot with disposable e-cigarettes has been launched in three prisons in EnglandandWales as offenders and people with mental illnesses are more likely to smoke.  The report even says it’s inappropriate to restrict the use of e-cigs in hospitals or prisons unless “there’s a strong rationale to do so”. Despite this, a ban on smoking in prisons in Wales and south west England is due to come into force in 2016 as part of a phased ban across EnglandandWales.

In terms of e-cigs and their impact on smoking behaviours, in England e-cigs have become the most popular quit smoking aid, overtaking over-the-counter nicotine replacement therapies (like nicotine gum and patches) in 2012-13.

The report states a mix of curiosity, and a desire to quit smoking, are the main reasons for the take up of e-cigs, recommending that people finding themselves in that situation should be offered support to quit smoking completely.

Do e-cigs act as a gateway to cigarette smoking?

This issue has been in the headlines recently following experimental preliminary findings from the National Health Survey (pdf p6) – though it comes with a warning that the results haven’t been properly weighted.

It says 6% of Welsh adults currently use e-cigs and 14% had ever used one.

More importantly, use of e-cigs is significantly more common amongst current and former smokers, with only 1% of adults who’ve never smoked ever using e-cigs, and no recorded current users of e-cigs had taken it up having never smoked before.

One of the Welsh Government’s concerns is that e-cigs will normalise and encourage people to take up cigarette smoking (“act as a gateway”), undermining efforts to clamp down on it. There doesn’t appear to be any current evidence of it.

However, this isn’t necessarily backed up by the PHE report (p37-39), which suggests that although the very concept of the “gateway hypothesis” is flawed, there’s a genuine need to carefully monitor “dual-use” (smoking and using e-cigs at the same time), particularly amongst young people.

What are the wider benefits of e-cigs?

A quit smoking aid – There’s some evidence that e-cigs help smokers either reduce or completely quit smoking tobacco. The Cochrane Review of randomly controlled trials showed e-cigs which contain nicotine resulted in reduced smoking amongst users when compared to a placebo – however, it was cautioned that the confidence in the results was “low” (p46). Another trial in Flanders (Adriaens et. al. 2014) produced results where 34% of a group of smokers quit within eight weeks of using e-cigs, compared to 0% for those not given e-cigs. Many smoking cessation advisers and practitioners in England are now said to support the use of e-cigs as a quit smoking aid.

Only 4%-5% of the relative risks of smoking – Working to UK Advisory Council on Drugs guidelines, experts concluded that e-cigs have 4% of the relative harm of tobacco (including social harm) and 5% of the relative harm to the user. There’s a note of caution : it’s accepted there was “a lack of hard evidence for the harms of most of the nicotine products on most of the criteria” during the study. 

“Passive vaping” is unlikely to exist – PHE’s report states e-cigs, “release negligible levels of nocotine into ambient air with no identified health risks to bystanders” and that the levels of nicotine absorbed by passive vaping were also negligible (p64-65). E-cig steam is exactly that – mostly water vapour with a trace of nicotine. There’s certaintly an argument that public vaping is impolite, but it’s massively less harmful than exposure to tobacco smoke.

What are the wider risks of e-cigs?

The liquid can be poisonous if drunk directly – There are high-profile examples of young children being hospitalised after drinking e-cig liquids, and the PHE report says there’s at least one unconfirmed death of a 2 year old, as well as attempted suicides through nicotine poisoning. Nearly all e-cig liquids post no real threat as long as they’re used as intended and come in child-proof containers.

Poor labelling of contents
– The PHE report says poor labelling is now less common and poses “no major concerns”, but there have been examples of nicotine concentrations varying from the label by between -17% and +6%, while trace nicotine has been found in e-liquids labelled as 0% nicotine. They say poorly labelled liquids are more likely to contain lessnicotine that the stated amount, which makes it a trading standards issue rather than a health issue.

Faulty rechargers have been linked to house fires – Smoking is a fire hazard in itself, but there’ve been a number of incidents – including in Wales – where the e-cig chargers have started house fires. It was reported by fire services in EnglandandWales that up to 100 house fires have been linked to e-cig chargers since 2013. Fire services have subsequently issued warnings about the use of fake or faulty chargers.

E-Cigs in Welsh Politics

The Welsh Government are keen to make what they call “evidence-based policy” – meaning they use facts and research to guide policy-making. In the case of the Public Health Bill, Health Minister Mark Drakeford (Lab, Cardiff West) has publicly stated the Welsh Government “are not going to wait for proof of harm” with regard e-cigs and will press ahead with an enclosed space ban.

Although the British Medical Association, Public Health Wales and other public health professionals support the Welsh Government, some key opponents to the policy include Ash Cymru, the Royal College of Physicians, the British Heart Foundation, Cancer Research UK and Tenovus – presumably because they believe that e-cigs are significantly less harmful than tobacco smoking, so it’s better to reduce harmful behaviours than try and change behaviour through force.

In addition, all of the opposition parties in the National Assembly – but the Welsh Lib Dems in particular – have spoken out against the proposal.

In June 2014, a petition was submitted to the National Assembly – which has since gone on to gather 1,200 signatures online – calling for the Welsh Government to re-consider the ban.

What the Welsh Government are doing is illiberal but, like it or not, there’s a logic behind the Welsh Government’s “precautionary” approach. There are numerous examples throughout history of new products, chemicals and drugs being hailed as wonderful innovations but without the risks or side-effects being rigorously tested beforehand.

Radium and thalidomide are the two of the best examples. Radium was used in all sorts of things, from making glow in the dark paint for signs and clocks, to even being used in bread due to quackery surrounding the supposed “benefits” of being exposed to it. Thalidomide was hailed as a treatment for morning sickness in the 1950s and 1960s.

We now know radium is one of the most radioactive chemicals, and thalidomide led to serious birth defects (though it’s still used to treat certain cancers and arthritis). We didn’t know these things at the time, and there’s always a danger that there could well be something in e-cigs we don’t know about too.

Those worries may be misplaced as the quality of chemical and medical testing are as rigorous as they’ve ever been. If there were seriously dangerous side-effects to e-cigarettes, they probably would’ve been discovered by now – a few sensationalist headlines in the Mail and Express don’t count.

That doesn’t, in any way, negate the need for a ban on sales to under-18s, a ban on e-cig advertising, proper regulation of e-cigs and full research on the long-term effects of e-cig use.

It also doesn’t, however, justify bans and curbs on usage based on nothing better than a gut feeling.

Part IV looks at the possible policy options with regard smoking and e-cigs post-independence.