The media is full of bias and misinformation about vaping and it can be hard to find the truth. Leading tobacco harm expert Clive Bates has done this for us and gives answers to the common questions asked about vaping. Clive is a former director of Action on Smoking and Health UK. The article was first published in Drug Science here.

1. Are e-cigarettes less harmful than cigarettes?

Yes. Beyond any reasonable doubt, e-cigarettes are much less harmful. Almost all the harm done by cigarettes arises from the smoke, and e-cigarettes do not produce smoke. Though we cannot have 50-year studies of a product that has only been in use for about 10 years that does not mean we have no data. We have extensive data on the toxins in the vapour and measurements of ‘exposure biomarkers’ in the blood, urine and saliva of users – all suggest very much lower risks than smoking.

2. How much less harmful are e-cigarettes than cigarettes?

The US National Academies of Sciences Engineering and Medicine said they are “likely to be far less harmful” than cigarettes. The premier British medical organisation, the Royal College of Physicians, said e-cigarettes are “unlikely to exceed 5% of those associated with smoked tobacco products and may well be substantially lower than this figure”. The main English government public health agency, Public Health England, said that “stating that vaping is at least 95% less harmful than smoking remains a good way to communicate the large difference in relative risk”. None of these bodies, or the experts advising them, has any connection to the e-cigarette or tobacco industries. In each case, the experts based their view on a comprehensive published review of the evidence.

3. Do the recent cases of severe lung injury and deaths prove that e-cigarettes are harmful?

No, definitely not. These cases have gained worldwide publicity, but they are completely unrelated to normal nicotine e-liquids and e-cigarettes. The cases occurred in users of illegal cannabis vaping products and were caused by use of a particular additive used for thickening cannabis (THC) oils – Vitamin E Acetate. It is possible other additives were also involved. This cannot be used in nicotine-based e-liquid and would serve no purpose. The lung injury cases are a tragedy, but they are caused by the illegal supply of cannabis vapes and provide no basis for changing policy on e-cigarettes. They do, however, provide a warning about creating black markets by banning products – and that would be an additions risk of bans on e-cigarettes or flavours: a black market will develop.

4. Do e-cigarettes help people quit smoking?

Yes. Smokers are at serious risk of cancer, heart disease, or COPD. There are now four strands of evidence that suggest e-cigarettes are effective in helping people to quit smoking: (1) evidence from randomised controlled trials; (2) observational studies (watching what happens when people use e-cigarettes); (3) population data (unusually rapid reductions in smoking prevalence and cigarette sales), and; (4) the testimonials of users who have struggled to quit using other methods. All four point towards e-cigarettes displacing smoking.

5. Do e-cigarettes appeal to adolescents?

Most adult or illicit products or behaviours will appeal to some adolescents – this applies to alcohol, drugs, gambling, pornography etc. There has been a recent rapid increase in e-cigarette use by American adolescents. But the definition used includes anyone taking one puff in the past 30 days before the survey. Drilling down into this data shows most US teen vaping is infrequent. Among frequent users, the vast majority had already smoked and for them, e-cigarettes may be beneficial. Amongst users with no prior tobacco use, there is little sign of adolescent vaping causing addiction.

6. Should e-cigarettes be banned?

No, absolutely not. This would prevent smokers (of any age) accessing much less risky alternatives to cigarettes, protect the cigarette trade from disruptive competition, and cause more disease and death. It would also put legitimate suppliers out of business, create a large black market and stimulate international internet trade. If nicotine is a legal drug, like alcohol or caffeine, then policymakers should be encouraging the least risky options to use it – not banning it to create a monopoly for the most dangerous nicotine products, cigarettes.

7. Should flavours be banned to stop youth vaping?

No. E-cigarettes are inherently flavoured products. Banning all or most flavours would be like banning all or most toppings on pizzas – it would effectively prohibit all or most of the products, leaving only the unattractive base or tobacco-flavoured liquids. This would make e-cigarettes nearly useless as alternatives to smoking for adults, promote a black market and may even increase risks to young people if it encourages them to smoke or to access black markets. It may make sense to ban certain flavour descriptors (the names given to flavours), if these are designed to appeal to youth.

8. Should limits on the strength of nicotine be imposed?

No. The danger of limiting nicotine is that it leaves cigarettes in place as the most rapid and effective way of delivering nicotine. Such limits will make e-cigarettes ineffective alternatives for heavier smokers or those struggling to convert from smoking to vaping. It also may be a block on current and future innovation (e.g. to make products safer, smaller, easier to use) and make them more dangerous by forcing users to consume more liquid for a given dose of nicotine. Limits should only be set for poison-safety reasons (for example 7.2% or approximately 72mg/ml is a poison threshold in the UK) and not to limit nicotine uptake as this would provide an advantage to cigarettes.

9. What can be done to protect young people?

Regulations to protect youth should always be targeted at youth and not indiscriminately affect adults (for example through flavour bans, nicotine limits, blanket advertising bans, or taxes). There are three main legitimate policy approaches to protect young people: (1) control access by setting age limits and restricting where and how products can be purchased; (2) control marketing, packaging and branding to prevent marketing targeted at adolescents; (3) provide campaigns, information and warnings targeted at young people.

10. What the right approach to regulating e-cigarettes?

Regulation of tobacco and nicotine products should be “risk-proportionate” – with more stringent controls placed on the highest risk products. This means:

1. high taxes on cigarettes, but low or no taxes on e-cigarettes;
2. bans on cigarette advertising, but controls on content and placement of e-cigarette advertising to prevent marketing to teens;
3. bans on smoking in public places, but vaping policy should be a decision for the owners or managers of buildings;
4. large graphic health warnings on cigarettes, but messages encouraging switching on e-cigarettes;
   plain-packaging for cigarettes, but not e-cigarettes;
5. regulation of product formulation that makes switching to vaping relatively more attractive than continuing to smoke;
6. differential age restrictions, for example, age 21 for cigarettes, but 18 for e-cigarettes;
7. bans on internet sales of cigarettes, but not on e-cigarettes;
8. campaigns to discourage smoking, but to encourage switching.

11. Should there be a special tax on e-cigarettes?

No. In any country with high rates of smoking, most vapers will be using e-cigarettes to cut down or quit smoking – they are doing this on their own initiative and at their own expense to improve their own health. Policymakers should be trying to make this as economically attractive as possible by using taxes to maintain a difference in the cost of vaping and smoking. At this stage, the priority is to reduce smoking as deeply and as rapidly as possible and a tax on e-cigarettes would slow that down, protect the cigarette trade, and increase the burdens of disease and premature death.

12. Should e-cigarettes be regulated like cigarettes?

No. Cigarettes are likely to be at least twenty times as harmful as e-cigarettes and e-cigarettes can help people quit smoking. For these two reasons alone, the policy needs to take account of difference in risk and the potentially large benefits of e-cigarettes. The aim should be to encourage switching from cigarettes to e-cigarettes while controlling safety risks and preventing youth uptake of all tobacco and nicotine products.

13. Should vaping be banned by law in public places and workplaces?

No. There is a case to ban indoor smoking as there is some science showing that second-hand cigarette smoke is harmful to bystanders. However, e-cigarette vapour is quite different chemically and physically. The evidence suggests vaping creates exposures far below thresholds that would be allowed for occupational health limits. The force of law should be reserved for protecting people from material harm caused by others. Vaping may still be disagreeable to some people, but it is primarily a matter of etiquette and respect for the preferences of others. E-cigarette policy should be decided, therefore, by the owners and managers of premises (hotels, bars, restaurants, shops, transportation, offices, public buildings etc). The hospitality industry may be more open to vaping and to welcome vapers, but public buildings will be most likely to prohibit it. The point is that owners and managers make the decisions that are right for them and their clientele.

14. Should e-cigarette sales be restricted to people aged 18 and over?

Yes, probably. It is widely held that under-18s should not be using any tobacco or nicotine products and therefore it should be against the law to sell such products to them. Though this is necessary to reassure parents and to give legitimacy to products and an industry aimed at adults, it may have possible unintended consequences. There is some evidence that when e-cigarette age restrictions were introduced in the United States, there was a relative increase in teenage cigarette smoking. It is possible that under-18s benefit from e-cigarettes by displacing or not initiating smoking and therefore that making them more difficult to access could be a source of unintended harm.

15. Are e-cigarettes a tobacco industry ploy to keep people smoking?

No. Modern e-cigarettes were not invented by the tobacco industry and there are thousands of suppliers who are not part of the tobacco industry. The tobacco industry has realised that its customers want to switch to these products and has entered the market. The industry deserves to be mistrusted and should always be handled with caution. However, it is positive that the industry is marketing low-risk alternatives to its core product, the cigarette. A long-term transition of the industry from selling combustible products to non-combustible is in the interests of public health and is the most likely and rapid way to end the worldwide epidemic of smoking-related disease.

---