When is a cigarette not a cigarette? It may look the same and perform identically; the satisfying draw, the nicotine hit, and the languid release of ‘smoke’. Yet this cigarette is advertised on national television and elbows chocolate displays for front-of-counter space at petrol stations and corner stores. It is smoked in restaurants, in bus stations and, until very recently, in hospitals.

This is the electronic cigarette, a meteoric fad that has divided opinion as to whether it is an ominous new phase of the nicotine epidemic or a game-changer that could help smokers transform their health and welfare.

Thriving in its lucrative niche between regulation and taxes, the e-cigarette has provoked voices of dissent, warning of unknown health risks and claiming that e-cigarettes may increase harm by creating a new pathway for young people to become addicted to nicotine. Countering this, supporters insist that e-cigarettes represent a potential public health miracle, which could positively impact on cancer and heart disease rates associated with traditional tobacco cigarettes. 

As the European Parliament approves tough new rules on e-cigarettes, the HSE introduces an all-out ban in hospitals and health facilities, and Minister for Health James Reilly threatens to restrict their sale to over 18s and clamp down on any fad that glamorises smoking, is the booming e-cigarette industry about to go up in smoke?

What are e-cigarettes?

E-cigarettes may range in style from look-a-like versions of their tobacco-containing cousins to the theatrical Cruella-de-Vil-sized varieties, but they are all basically battery-powered devices designed to supply nicotine through inhaled water vapour. 

They consist of a cartridge – disposable, replaceable or refillable – containing ‘e-liquids’ and an atomiser that heats the cartridge ingredients to create a vapour, which is then inhaled. The liquid solution usually contains four ingredients: a propylene glycol or vegetable glycerine base (produces the smoke-like vapour when the e-cigarette is exhaled), nicotine, water and flavourings, such as chocolate, bubble-gum, fruit, or tobacco. They do not contain tobacco and there is no combustion, no smoke and no odour.

Many e-cigarette specialist stores and online shops now encourage aficionados to customise their device by mixing components, allowing user control of battery size, nicotine concentration and flavour. The craze has also given rise to its own vocabulary, for example, puffing on an e-cigarette is called ‘vaping’ and those doing the puffing are ‘vapers’. 

Big business

The e-cigarette industry is continuing to expand apace, growing from several thousand users in 2006 to several million worldwide, who now have hundreds of brands to choose from. Global e-cigarette sales doubled to more than €2 billion last year compared to 2012 (based on Euromonitor International data), with one US financial analyst, Bonnie Herzog, forecasting profits of about €7 billion by 2017.

Although there are no official figures for the number of ‘vapers’ in Ireland, an industry insider claims that 6-7% of smokers in the Republic have already switched to e-cigarettes, amounting to more than 50,000 people. 

This surge in ‘vaping’ has also been documented in the UK. New statistics from ASH (Action on Smoking and Health) identified 1.3 million people who are now using e-cigarettes. The ASH UK survey also found that 35% of tobacco smokers have tried an e-cigarette and 11% currently use them. 

While the addictive properties and long-term effects of using e-cigarettes as a nicotine delivery system are unknown, many people anecdotally believe that they are safer than traditional tobacco products. 

There is no doubt that tobacco consumption is the largest avoidable health threat in the EU. Each year, 700,000 people die from tobacco-related illnesses in the EU, of which approximately 5,200 lives are lost in Ireland from smoking.

Ireland celebrated the 10th anniversary of the smoking ban on March 29 this year. Research published by the TobaccoFree Research Institute Ireland (TFRI) has shown that this historic legislation prevented well over 3,700 smoking-related deaths in the three years following the ban and provided an incentive for thousands of smokers to kick the habit.

However, a leading anti-tobacco campaigner, Prof Luke Clancy has warned that the unrestricted availability of e-cigarettes could undermine the lifesaving achievements of the smoking ban by ‘renormalising’ smoking in society.

“We’ve spent a lot of time and effort trying to denormalise the act of smoking and now this device could be used to renormalise it. Proponents want to have the debate about the actual substance – nicotine – and whether being addicted to e-cigarettes would be less harmful than being addicted to tobacco, but the question should be, what is the overall effect of the use of this product likely to be? Is it going to diminish the number of people who are smoking cigarettes? I don’t think so,” said Prof Clancy, director general of the TFRI and consultant respiratory physician.

Smoking prevalence in Ireland is dropping by degrees year-on-year. New figures released by the Irish Cancer Society in March stated that 19% of adults are smokers, which compared favourable to a smoking rate of 29% in 2007, demonstrating that Ireland is making good progress in the aim of being Tobacco Free by 2025.

Regulating e-cigarettes

The next phase of tobacco control in Europe will be heralded by the long-awaited revision of the EU Tobacco Products Directive (TPD), on which approval was finally granted on Wednesday, February 26. This new Directive will also, for the first time, address the manufacture, presentation and sale of e-cigarettes in member states.

The revised Directive states that e-cigarettes must be licensed as medicinal products if they have a nicotine concentration of greater than 20mg/ml, and/or are marketed as a smoking cessation aid. Products below this nicotine threshold may be sold as consumer products provided they are childproofed, carry health warnings, and are subject to the same advertising restrictions as tobacco products. 

Once it comes into force this May, member states will have two years to introduce the legislation but Prof Clancy urged the government not to wait that long.

“It is wrong that e-cigarettes are being advertised openly, encouraging addiction,” he told Cancer Professional. “Children experiment with cigarettes all the time, now they’re being told here’s a safer cigarette, so they’ll probably try that as well. For instance, surveys in France have shown that 7% of children who are non-smokers have tried e-cigarettes, so it is likely that there are some children who are not even smokers who will become addicted to nicotine using e-cigarettes, and the likelihood for them is to progress onto tobacco cigarettes.”

Prof Clancy pointed out that many tobacco companies are now buying into the booming e-cigarette market, which he believes is a sinister development. 

“What is emerging is that increasingly the tobacco industry is getting involved in this business and you have to ask why? Is this so that they can help people to stop smoking? That seems inherently implausible. In my opinion, with regard to tobacco control, e-cigarettes will prove to be a bad development; I’ve no doubt about that.”

‘Vaping’ as a smoking cessation aid

Advocates are unflappable in their claim that e-cigarettes are a less harmful alternative to tobacco smoking, arguing that the device may help smokers to cut back or quit smoking altogether. 

Prof Clancy, who runs a free weekly smoking cessation clinic at St James’s Hospital, Dublin, remarked that e-cigarettes offer a better nicotine delivery system than currently available, and therefore, might prove useful as a smoking cessation aid, but this has not yet been definitively proved in clinical trials. 

Research in this area is scant and at times contradictory. A study published in The Lancet last year was the first moderately sized, randomised controlled trial of the use of e-cigarettes to quit smoking. Researchers compared e-cigarettes to nicotine patches and to e-cigarettes that only contained flavourings (no nicotine). They found essentially no differences in the quit rates for the products after six months of use. 

However, a 2011 study led by Boston University School of Public Health, revealed that the electronic cigarette produced tobacco abstinence rates nearly double those for traditional nicotine replacement products. Almost one-third (31%) of respondents had quit smoking six months after first purchasing an e-cigarette, compared to between 12-18% for traditional nicotine replacement products. In addition, more than two-thirds (67%) of smokers reported having reduced the number of cigarettes they smoked after using e-cigarettes.

An Italian study of 300 smokers who had no intention of quitting also demonstrated the potential of e-cigarettes as a quitting aid. The 2013 ECLAT study found that 23% of smokers had cut back their daily cigarette intake by more than half and 14% hadn’t smoked during the first three months of using e-cigarettes. A full year into the study, 10% were still smoking significantly less and 9% had kicked the habit entirely. Of these quitters, almost three-quarters (73%) had also stopped using e-cigarettes.

Health benefits or risks

Instead of inhaling a cigarette’s nicotine and carbon monoxide, e-cigarette users inhale vaporised pure nicotine, on which very little research has been conducted. The World Health Organisation recently warned that the potential risks e-cigarettes pose for the health of users remains undetermined.

Kevin O’Hagan, health promotion manager at the Irish Cancer Society, agreed: “There is currently not enough evidence to say conclusively that e-cigarettes are a healthy alternative to cigarettes. While they may not have the many poisonous cancer-causing chemicals that tobacco smoke contains, it is unclear yet what the long-term health impact of e-cigarettes will be.

“Furthermore, scientific testing indicates that the products vary widely in the amount of nicotine and other chemicals they deliver and there is no way for consumers to find out what is actually delivered by the product they have purchased.” 

Mr O’Hagan stressed: “To ensure the safety and efficacy of e-cigarettes, they need to be regulated as either a medical product or a medical device. We are delighted that e-cigarettes will be regulated in the UK in a similar way to other nicotine replacement therapy products. We are hopeful that similar regulation will be implemented here in time.”

In the absence of appropriate regulation and evidence, he said the ICS couldn’t recommend e-cigarettes. 

“Until the safety and efficacy of these products are established and we can be assured that they do not pose a hazard to a person’s health and wellbeing, we are unable to recommend them.”

Research is still needed to determine the medium- to long-term health impact of e-cigarettes. The studies that have been conducted to date seem to raise more questions than are answered. 

Researchers from the Onassis Cardiac Surgery Centre in Athens, Greece, performed the first clinical study of the acute effects of electronic cigarettes on heart function. Their results, published in 2012, found that smoking one tobacco cigarette led to significant acute myocardial dysfunction but electronic cigarettes had no acute adverse effects on cardiac function.

However, another 2012 study from the University of Athens revealed that an e-cigarette caused an immediate increase in airway resistance, lasting for 10 minutes. In both smokers and non-smokers, there was a statistically significant increase in airway resistance from approximately 180% to 210%, suggesting “e-cigarettes can cause immediate harm after smoking the device”.

Although e-cigarettes do not contain the many cancer-causing ingredients of tobacco cigarettes, research in mice has indicated that nicotine may be a carcinogen, which would put ‘vapers’ back into the cancer-risk category. This 2012 study by University of California Ervine researchers found that injecting mice for two years with nicotine caused 78% to develop cancer, as well as transient hair loss. 

On-going research 

A study in the US is currently investigating the effects that inhaling vaporised nicotine has on a person’s heart rate, blood pressure, resting metabolic rate, physical work capacity and brain blood flow.

The scholars from two universities in Texas will be examining whether vaporised nicotine stimulates the human nervous system in ways that could seriously impact daily living. 

They believe that the inhalation of vaporised nicotine has the potential to increase a person’s resting metabolism, making exercise problematic, could prevent the cardiovascular system from properly regulating arterial pressure and decrease the brain’s ability to regulate blood flow. Their results should be ready by the end of the year.

Among other current studies, research into the cytotoxic effects of e-cigarette use was launched at the University of California in July 2013 and is set to conclude in 2016. This investigation will also examine the effects of e-cigarette use by pregnant women on early prenatal development.

Harm reduction

Proponents of e-cigarettes, some of whom rank among the medical profession, say that the key advantage of the e-cigarette lies in its capacity to reduce harm, not eliminate it. 

People report that they feel better using the device than they did when they were smoking tobacco cigarettes, indeed, the ECLAT study found that shortness of breath was substantially reduced in smokers – from 20% to 4% – after only two weeks of using e-cigarettes. 

Dr Gilbert Ross, medical and executive director of the American Council on Science and Health, recently remarked: “Yes regulate them, by all means: age restrictions, ingredients labels, and good manufacturing practices all need to be mandated. But making e-cigs inaccessible for desperate smokers by inane restrictions will send this message: ‘Keep on smoking.’”

Appropriate regulations should safeguard against quality deficits and prevent e-cigarettes from becoming a tool to enlarge the number of smokers. Concern that e-cigarettes, which mimic and normalise the action of smoking, could develop into a gateway to nicotine addiction for young people, and ultimately traditional tobacco consumption, may be well founded and should be further investigated. 

Adopting a restrictive approach to the advertisement of these devices and limiting their availability to over 18s would strike most people as reasonable measures. Also, continued research is essential in uncovering any possible health consequences, as well as the social and cultural implications of embracing this new trend of ‘vaping’.