Electronic cigarettes: A safer way to puff

E-cigarettes could save hundreds of thousands of lives, according to their makers. So why are many health experts opposed to them?

Around two-thirds of the UK's smokers - about six million people - made new year’s resolutions to get healthier by giving up in 2012, according to a recent study. Despite their best intentions, the majority will fail. Smoking is recognised as a chemical addiction to nicotine and a physical addiction to the act of lighting up, both of which are difficult to conquer. The NHS and most anti-smoking health groups focus their efforts on helping people to quit the habit completely, but most smokers only manage to stop after several failed attempts and that last cigarette is not always as final as it is intended to be.

So what happens to those smokers who want to be healthier but find they can't quit, or don't really want to? Simply, they continue to smoke. But there is a growing argument in the UK which supports the idea that there need not be only two camps - the smokers and the non-smokers - with little in between.

A number of harm-reduction tools offer an alternative to smoking - the most controversial of which is the electronic cigarette, or e-cigarette. Nicotine patches, gums and tablets have been available for years, but debate still surrounds the safety and effectiveness of e-cigarettes as a path to quitting, and perhaps more importantly, as a smoking substitute which can reduce the harm caused to smokers by tobacco.

Marketed as a healthier alternative to smoking, e-cigarettes do not contain tobacco but do contain nicotine-infused water which is inhaled as an odourless vapour. Pure nicotine is highly addictive but is not considered particularly harmful, unlike the lethal effects of tobacco.

"Electronic cigarettes satisfy the two elements of addiction without the harmful side effects," says Tony Jones, director of the Cheshire-based e-cigarette brand 10 Motives. "The e-cigarette supplies nicotine, which has been proven to be as relatively harmless as caffeine, and it also provides smokers with something to draw on. It is possible to have all the upsides of smoking without the downsides," says Jones.

An Italian team of scientists, led by Riccardo Polosa of the University of Catania, recently gave e-cigarettes to 40 hard-core smokers. After six months, more than half of the smokers had cut their cigarette use by over 50 per cent and almost a quarter had quit ordinary cigarettes altogether.

However, despite results such as these, Jones stresses that he cannot and does not claim that his 10 Motives product is a 'cessation aid' to help smokers quit. In the UK, e-cigarettes cannot be called a nicotine replacement therapy (NRT) and cannot be displayed next to patches or gums in shops because they are not approved by the Medicine and Health products Regulatory Agency (MHRA).

E-cigarette firms in the UK are regulated by Trading Standards, but because they contain nicotine and deliver a drug, critics say the devices should be treated as a medicine and approved by the MHRA before they are considered safe to use.

However, Jones argues that e-cigarettes "are not medicines" and are safe. He says the tests involved in gaining MHRA approval would cost his company around £250,000 to achieve the moniker 'cessation aid', which he deems unnecessary. "Any electronic cigarette company worth its salt would have had their product tested independently in the UK. We have a whole rack of safety certificates, we just don’t have the ability to market the product as a smoking cessation tool," he says.

The MHRA says it is 'concerned' that such products are sold without having demonstrated their 'safety, quality and efficacy'. But it says it has also listened to users of unlicensed e-cigarettes who are 'concerned that an immediate move to medicines regulation would lead to potentially useful products being taken off the market'.

The Department of Health is responsible for NHS Stop Smoking Services and NHS 'Quit Kits', which do not contain e-cigarettes. It says it "would encourage smokers to use licensed nicotine replacement therapy (NRT) such as patches, gum, inhalators, lozenges or mouth sprays as the safest source of nicotine, in place of smoking", but does not endorse e-cigarettes due to a "lack of evidence".

When asked if the NHS focus on helping smokers to quit is becoming an outdated and ineffective method for attempting to improve their health, a DoH spokesperson said: "We know that the majority of smokers want to quit."

"The ideal scenario is for smokers to stop and never go back to tobacco again," says Amanda Sandford of the public health charity Action on Smoking and Health (ASH). But she admits that "harm-reduction is something we will have to embrace" because "it's not enough to say that smokers should simply just quit". She says "e-cigarettes clearly offer an alternative to smoking", but also voices concerns over the chemicals some may contain and the long-term effects.

Sandford says a comparison can be made between the arguments for and against NRT treatments for smokers and those that flared when methadone was introduced in the UK as a safer alternative to heroin. But, as she also points out, there is little time to argue over the morality of harm reduction. Smoking, unlike heroin, kills more than 80,000 people in the UK every year on average.

Smokers appear to be divided over whether e-cigarettes are to their taste. Some swear by them, others say they feel 'ridiculous' smoking them. One criticism of early e-cigarettes was that they contained too little nicotine, though a friend of mine who calls herself a 'heavy smoker' says she finds them 'very strong'. 10 Motives e-cigarettes contain between 16-18mg of nicotine per gram of atomised liquid. This amounts to less for the smoker than an ordinary cigarette, but Jones claims it is more than enough. "Smokers finish a cigarette because it's lit, but a full one actually contains far more nicotine than they need to get their fix," he says.

There is little argument over whether the devices are cheaper. With a pack of 20 cigarettes now nearing £8, some e-cigarettes offer the nicotine equivalent of 80-100 cigarettes for the same price.

The MHRA will make a final decision on how e-cigarettes will be regulated in 2013. In the meantime, sales of e-cigarettes are increasing and a range of companies including some of the biggest names in tobacco are set to launch similar devices.

The Royal College of Physicians has argued in favour of e-cigarettes as a harm-reduction tool. It acknowledges that little is known of their long-term effects but said in a 2007 report: "In any circumstance, the use of NRT [including e-cigarettes] is many orders of magnitude safer than smoking."

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