E-cigarettes, also known as vapourisers or ENDS (electronic nicotine delivery systems), are handheld battery-operated devices which can deliver nicotine-containing vapour
- devices can come in a variety of forms and generally consist of a cartridge containing liquid nicotine (or 'e-liquid'), an atomiser (heating device) and a mouthpiece
- solutions of e-liquid typically contain nicotine, propylene glycol and/or glycerol, as well as flavourings
- increasing numbers of smokers are using e-cigarettes, with many people finding them helpful in cutting down or quitting cigarette use
- in 2017, there were 2.9 million adults in Great Britain using ECs. There were more ex-smokers (52%) in Great Britain using ECs than dual users of both cigarettes and ECs (45%) (2)
- a review of the latest available evidence suggests that e-cigarettes are at least 95% less harmful to health than tobacco smoking (1)
- evidence so far shows that e-cigarettes have significantly reduced levels of key toxicants compared to cigarettes, with average levels of exposure falling well below the thresholds for concern. (2)
- study evidence showed that long-term e-cigarette users (who had been using their product for 17 months on average) had significantly lower levels of key toxicants in their urine than those who still smoked - with levels in e-cigarette users similar to exclusive Nicotine Replacement Therapy (NRT) users (2)
- no good evidence to suggest that passively breathing vapour from e-cigarettes is likely to be harmful (2)
- E-cigarettes have become the most popular aid to quitting smoking in the UK (1)
- RCGP position statement suggests that "...Using their clinical judgement on an individual patient basis, Primary Care Clinicians (PCCs) may wish to promote EC use as a means to stopping. Patients choosing to use an e-cigarette in a quit attempt should be advised that seeking behavioural support alongside e-cigarette use increases the chances of quit success further..." (2)
MHRA states that (3):
As part of routine clinical practice, clinicians are advised to document the use of e-cigarettes or vaping devices in medical records for all patients as they would with smoking.
Clinicians should routinely document:
- Name or brand of product used
- Type of product (if known)
- Duration and frequency used
- Substances vaped (for example, nicotine or recreational substances)
- Strengths of substances
MHRA has issued guidance regarding E-cigarette use or vaping-associated lung injury (EVALI) (3).
NICE states (4):
- give clear, consistent and up-to-date information about nicotine-containing e-cigarettes to adults who are interested in using them to stop smoking (for example, see the NCSCT e-cigarette guide and Public Health England's information on e-cigarettes and vaping)
- advise adults how to use nicotine-containing e-cigarettes. This includes explaining that:
- e-cigarettes are not licensed medicines but are regulated by the Tobacco and Related Products Regulations (2016)
- there is not enough evidence to know whether there are long-term harms from e-cigarette use
- use of e-cigarettes is likely to be substantially less harmful than smoking
- any smoking is harmful, so people using e-cigarettes should stop smoking tobacco completely.
- Discuss:
- how long the person intends to use nicotine-containing e-cigarettes for
- using them for long enough to prevent a return to smoking and
- how to stop using them when they are ready to do so
- Ask adults using nicotine-containing e-cigarettes about any side effects or safety concerns that they may experience. Report these to the MHRA Yellow Card scheme, and let people know they can report side effects directly
- Explain to adults who choose to use nicotine-containing e-cigarettes the importance of getting enough nicotine to overcome withdrawal symptoms, and explain how to get enough nicotine.
Effectiveness of E-cigarettes versus nicotine replacement therapy and smoking cessation
- E-cigarettes versus nicotine replacement treatment (6)
- review (78 studies; n=22,052) found high-certainty evidence that use of nicotine electronic cigarettes was associated with higher quit rates than nicotine replacement therapy (an additional 4 quitters [95% CI 2 to 6] per 100), with a similar rate of adverse events
- also found quit rates with nicotine e-cigarettes were higher than those seen with non-nicotine e-cigarettes (RR 1.94; 95% CI 1.21 to 3.13) and with behavioural support or no support at all (RR 2.66, 95% CI 1.52 to 4.65)
- E-cigarettes and smoking cessation in pregnancy (7)
- a study found e-cigarettes were more effective than nicotine patches for abstinence at the end of pregnancy (6.8% vs 3.6%, RR 1.93, 95%CI 1.14-3.26) after excluding abstainers using non-allocated products. Adverse events and adverse birth outcomes were similar between arms
A review suggests with respect to acquiring a vaping history (8):
- be empathetic:
- young adults may be reluctant to share their history of vaping use. Familiarity with vaping terminology, asking in a non-judgmental manner, and asking in a confidential space may help
- enquire about what vape products and where the patients source them from:
- vape products - vape pens commonly contain nicotine or an alternative active ingredient, such as THC (tetrahydrocannabinol) or CBD (cannabidiol)
- may also inquire about flavourings, or other vape solution additives, that their patient is consuming, particularly if vaping-related lung injury is suspected
- source
- ask where they source their product from. Sources may include commercially available products, third-party distributors, or friends or local contacts.
- enquire about details of vaping:
- device
- what style of device are they using?
- frequency
- how many times a day do they use their vape pen (with frequent use considered >5 times a day)? Alternatively, providers may inquire how long it takes to deplete a vape solution cartridge (with use of one or more pods a day considered heavy use)
- nicotine concentration
- for individuals consuming nicotine-containing products, clinicians may inquire about concentration and frequency of use, as this may allow for development of a nicotine replacement therapy plan
- is the patient using other inhaled produced in his/her vaping device?
- clinicians should ask patients who vape about use of other inhaled products, particularly cigarettes. Further, clinicians may ask about use of water pipes, heat-not-burn devices, THC-containing products, or dabbing
- concurrent smoking
- simultaneous use of multiple inhaled products is common among vape users, including concurrent use of conventional cigarettes, water pipes, heat-not-burn devices, and THC-containing or CBD-containing products (6)
- among those using marijuana products, gathering a history regarding the type of product use, the device, and the modality of aerosol generation may be warranted
- "dabbing" is the practice of inhaling heated butane hash oil, a concentrated THC wax - which may also be associated with lung injury
Prevalence of use of long-term vaping
- study (n=179,725) found the prevalence of long-term vaping increased substantially among adults in England during 2013-23 (1.3% to 10.0%), particularly from 2021, coinciding with the rise in popularity of disposable e-cigarettes (9)
- much of this increase occurred from 2021, coinciding with the rise in popularity of disposable e-cigarettes
- most disposable e-cigarette brands use e-liquids with nicotine salts
- half of long-term vapers now mainly or exclusively use disposable devices
- growth was concentrated among people with a history of regular smoking, but an increase also occurred among people who never regularly smoked, especially young adults
Reference:
- McNeill A, Brose LS, Calder R, Bauld L, Robson D. Evidence review of e-cigarettes and heated tobacco products 2018: a report commissioned by Public Health England. 2018.
- RCGP Position Statement on the use of electronic nicotine vapour products (E-Cigarettes) - Updated September 2017.
- MHRA (28/1/2020). Drug Safety Update volume 13, issue 6: January 2020: 1.
- NICE (November 2021). Tobacco: preventing uptake, promoting quitting and treating dependence
- Myers Smith, K., Phillips-Waller, A., Pesola, F., McRobbie, H., Przulj, D., Orzol, M., and Hajek, P. (2021) E-cigarettes versus nicotine replacement treatment as harm reduction interventions for smokers who find quitting difficult: Randomised controlled trial. Addiction, https://doi.org/10.1111/add.15628
- Hartmann-Boyce J et al. Electronic cigarettes for smoking cessation (Review). Cochrane Database of Systematic Reviews November 17th 2022
- Przulj D, Pesola F, Myers Smith K, McRobbie H, Coleman T, Lewis S, et al. Helping pregnant smokers quit: a multicentre randomised controlled trial of electronic cigarettes versus nicotine replacement therapy. Health Technol Assess 2023;27(13)
- Jonas A. Impact of vaping on respiratory health BMJ 2022; 378 :e065997 doi:10.1136/bmj-2021-065997
- Jackson S E, Tattan-Birch H, Shahab L, Brown J. Trends in long term vaping among adults in England, 2013-23: population based study BMJ 2024; 386 :e079016 doi:10.1136/bmj-2023-079016