E-cigarettes an evidence update A report commissioned by Public Health England

E-cigarettes: an evidence update1. IntroductionDespite the decline in smoking prevalence observed over the last few decades, thereremain over eight million smokers in England. Most of these are from manual and moredisadvantaged groups in society, including those with mental health problems, on lowincome, the unemployed and offenders. In some such population groups, the proportionwho smoke is over two or three times higher than that in the general population, a levelof smoking observed in the general population over 40 years ago. For those whocontinue to smoke regularly, much of their lives will be of lower quality and spent inpoorer health than those who don’t smoke, and they will have a one in two chance ofdying prematurely, by an average of 10 years, as a direct result of their smoking.Smoking is therefore the largest single contributor to health inequalities as well asremaining the largest single cause of preventable mortality and morbidity in England.Moving forward, it is therefore important to maintain and enhance England’scomprehensive tobacco control strategy in order to motivate and support all smokers insociety to stop smoking as quickly as possible, and prevent the recruitment of newsmokers. Harm reduction guidance, published by the National Institute for Health andCare Excellence in England in 2013, recognised that some smokers struggled to quitabruptly and that cigarettes were a lethal delivery system for nicotine [1]; it is widelyaccepted that most smokers smoke for the nicotine but die from the other smokeconstituents. Harm reduction has been identified as one of the more promising policyoptions to reduce smoking induced inequalities in health [2]. All experts agree that awell-resourced comprehensive strategy, involving cessation, prevention and harmreduction should make the goal of a smoke-free society in England quickly achievable.However, the advent of electronic cigarettes (EC) over recent years has causedcontroversy. In 1991, Professor Michael Russell, a leading English smoking cessationexpert from the Institute of Psychiatry, argued that ”it was not so much the efficacy ofnew nicotine delivery systems as temporary aids to cessation, but their potential aslong-term alternatives to tobacco that makes the virtual elimination of tobacco a realisticfuture target”, and he recommended that “tobacco should be rapidly replaced bycleaner, less harmful, sources of nicotine” [3]. Professor Russell was one of the first torecognise the critical role that nicotine played in tobacco use and he identified thatwhilst there were good ethical and moral reasons not to promote nicotine addiction insociety, the harm caused by nicotine was orders of magnitude lower than the harmscaused by cigarette smoke. Professor Russell was also a pioneer of new treatments forsmoking cessation, in particular, nicotine replacement therapies (NRT). Since then, thenumber of NRT products has proliferated such that there are now several differentdelivery routes and modes and countless different dosages and flavours. However,even with a relaxation of the licensing restrictions which increased their accessibility,NRT products have never become popular as an alternative to smoking.14