Given that smoking tobacco is the leading cause of preventable death and chronic illness, it is encouraging to see in NHS Digital's (2019) newly published annual figures that the proportion of cigarette smokers in England has fallen somewhat from 14.9% in 2017 to 14.4% in 2018. The Government has also recently made several new and, some, very bold proposals in a Prevention Green Paper called ‘Advancing our health: prevention in the 2020s', including one to make England smoke-free by 2030 (British Heart Foundation, 2019).
One of the ways in which tobacco smoking is decreasing, however, is through the use of e-cigarettes as a stop-smoking aid. As tobacco use has declined by 0.5% between 2017 and 2018, the number of e-cigarette users has increased by 0.8% in this same time period (The Pharmaceutical Journal, 2019a; 2019b).
Sandwell General Hospital in West Bromwich and Birmingham City Hospital in the West Midlands have opened e-cigarette shops as both went ‘smoke-free’ on 5 July 2019 (The Pharmaceutical Journal, 2019b). Sandwell and Birmingham NHS Trust, which runs both hospitals, has banned smoking tobacco on its premises, and anyone caught smoking will be fined £50 (The Pharmaceutical Journal, 2019b).
In an article recently published in The Pharmaceutical Journal (2019b), medical director of the Trust, David Carruthers, said:
‘We know that vaping is a route to cutting down or quitting smoking, and there is evidence that it is not a route into smoking among young people, a group whom we would actively discourage from taking up vaping. Switching completely from smoking to vaping conveys substantial health benefits, with the aim of stopping both smoking and vaping in the long term’.
How safe is vaping?
The research surrounding the risks of vaping is conflicting, as e-cigarettes do contain nicotine, which is addictive and toxic to the cells of the lungs, but its effects certainly appear to be less detrimental to health than tobacco smoking (Mendes, 2019). Ideally, the aim would be for people not to engage in tobacco or e-cigarette smoking; however, substantial reductions in carcinogens and other toxins have been noted in people who have quit smoking completely but who still vape, compared with people who smoke conventional cigarettes (Shahab et al, 2017). While there have been concerns that vaping could serve as a route into tobacco smoking for younger people, according to the Office for National Statistics (ONS) (2019), only 0.8% of people who have never smoked currently vape.
How dangerous is vaping?
A study published in Thorax last year found that the fluid contained in e-cigarettes becomes increasingly toxic during vaping (Clinical Pharmacist, 2018). This is an important consideration, because previous research investigating the safety of e-cigarettes had been considering unvapourised fluid, and had not taken into account the effect of the vaping process itself (Clinical Pharmacist, 2018).
Scott et al (2018) compared the cytotoxic effects of unvaped e-cigarette liquid (ECL) to those of e-cigarette vapour condensate (ECVC). Specialised immune cells in the lungs called alveolar macrophages were treated with both ECL and ECVC, and their viability; cell death (apoptosis); necrosis; cytokine, chemokine and protease release; reactive oxygen species release; and bacterial phagocytosis were assessed. ECVC was found to be cytotoxic at lower concentrations and led to greater cell death than ECL (Scott et al, 2018).
The researchers found that excessive production of reactive oxygen species significantly inhibited phagocytosis, possibly leading to impaired bacterial clearance (Scott et al, 2018). This, combined with inflammatory cytokines and chemokines, induced by the vapour may cause alveolar macrophages to be in the inflammatory state, which is also partly dependent on nicotine (Scott et al, 2018).
Further research is, of course, needed, but the study concluded that ECVC is significantly more toxic to these immune cells in the lungs than the non-vaped ECL that has usually been studied, and the authors caution against the commonly held view that e-cigarettes are safe (Scott et al, 2018). For example, in 2016, more than 70% of smokers surveyed believed that e-cigarettes are less harmful than conventional cigarettes (NHS Digital, 2019).
Conclusions
There are between 2.8 and 3.6 million vapers in Great Britain (ONS, 2019). This equates to 6.3%, compared with 3.7% in 2014 when these data were first collected (ONS, 2019). The most common reason given for e-cigarette use is to aid in smoking cessation (51.5%); in 2018, more than half of vapers reported using e-cigarettes for that purpose (ONS, 2019). This was followed by ‘other’ reasons (21.5%), including enjoyment and as a social activity with friends (NHS Digital, 2019).
While these types of reasons may seem concerning, particularly as e-cigarettes have been demonstrated to be harmful to health, Public Health England (PHE) (2019) found in a recent evidence review that vaping poses only a small fraction of the risk of smoking. Moreover, the review estimated that e-cigarettes contribute to at least 20 000 successful quit attempts a year (PHE, 2019).
Therefore, while the risks of e-cigarette use should not be ignored, cigarette use is of a much greater concern, with 77 800 deaths attributable to smoking in 2018 (ONS, 2019). The recent news of Sandwell and Birmingham NHS Trust banning smoking on the premises of two of its hospitals is welcome, although it is hoped that the establishment of its e-cigarette shops will not lead to an increase in vaping among non-smokers and that long-term studies will not eventually uncover more harmful effects of prolonged e-cigarette use.