A voice for women's health

Smoking

E-cigarettes – an effective method of quitting smoking

November 2015 

Electronic cigarettes (e-cigarettes) have been on the market since 2001 when Hon Lik from China designed an e-cigarette to help him quit smoking. Since Hon Lik designed this first generation e-cigarette, which looks like a cigarette and is called a ‘cig-a-like’, second and third generation e-cigarettes have been designed. These second and third generation e-cigarettes deliver nicotine to the user (vaper) more effectively and are more effective stop smoking aids.
 
E-cigarettes can contain nicotine or not. In New Zealand e-cigarettes that do not contain nicotine can be legally sold in supermarkets, pharmacies and other retail outlets but the liquid for e-cigarettes (e-liquid) that contains nicotine cannot be sold. If vapers want to buy nicotine for their e-cigarettes they have to buy it online.
 
The rise in popularity of e-cigarettes among smokers has been phenomenal. Smokers worldwide are turning to them to help them stop smoking. Public health people the world over have been taken by surprise. It has always been envisaged ending smoking would happen over time, as we increment-ally moved towards smokefree with the help of tax increases, smokefree environments, plain packaging and, in New Zealand, smokefree cars. Smokefree environments have helped reduce smoking in the past but we are running out of options of what to do next – plain packaging has been shown to be effective in Australia and annual tax increases do help.
 
Other than these usual standard interventions there is uncertainty about what the focus should be to achieve the Smokefree 2025 goal of less than 5%. Most public health units and non-government organisations working in tobacco control are spending 90% of their time lobbying local councils to get parks, malls, streets (particularly outside bars and restaurants), snowfields, golf courses etc smokefree. Banning smoking in cars carrying children under the age of 12 years old is high on their list of priorities and councils have now requested Government make areas outside bars and restaurants non-smoking. Whilst smokefree environments provide a backdrop to achieving our Smokefree 2025 goal they will not actually reduce the prevalence rate of smoking. 
 
Most smokers need more than smokefree environments to get them off smoking. In the flurry to get a perfect non-smoking world we seem to have forgotten about smokers. We continue to ply them with nicotine replacement products and other medications that are generally unappealing and not very effective. The pharmaceutical industry has been unbelievably slow at bringing new and innovative products onto the market and smokers have largely been left to struggle alone in their bid to quit smoking.  
 
You would think that public health people would be ecstatic at the emergence of e-cigarettes as another tool for smokers to quit smoking but unbelievably ‘no’. Some are even committing all their time trying to prevent more accessible nicotine for e-cigarettes. Initially their concern was about the safety of e-cigarettes but now that we know they are at least 95% less harmful than smoking[1] their concern has shifted to non-smokers potentially taking up vaping, particularly young people, who may then go on to start smoking. There is very little evidence that adult non-smokers are taking up vaping but some evidence that some young people are. However, we do not know whether they go on to smoke, and if they do would they have taken up smoking anyway? Recent research suggests that in areas where e-cigarettes are freely available smoking rates among young people are decreasing.[2]
 
Addiction to nicotine is another concern among public health experts and not just for young people, who it is perceived could get addicted to nicotine in e-cigarettes and if e-cigarettes weren’t easily accessible they would then start smoking.  However, it is quite likely that young people who are vaping are using e-cigarettes that do not contain nicotine. Many studies ask partici-pants about their vaping but do not clarify whether the e-cigarettes they are using actually contain nicotine or not. Many vapers (particularly new vapers) do not actually know if their e-cigarettes contain nicotine or not. Health professionals worry that smokers who switch to e-cigarettes to stop smoking will use the e-cigarette as a replacement product and will continue to be addicted to nicotine. However, they are currently happy to prescribe NRT endlessly to patients or clients to get them off smoking, so why can’t an e-cigarette be a de facto nicotine replacement product?
 
Looking back at the history of tobacco control in New Zealand and probably elsewhere it would seem that from the early 1990s the concern of public health people has been more about non-smokers than smokers. Isn’t it time we made smokers a priority? They are the ones that are dying in their thousands – around 4,500 per annum in New Zealand. Our concern should be evidence-based but in the case of e-cigarettes the evidence for continuing a ban on nicotine for e-cigarettes is sadly lacking.  There is evidence that e-cigarettes containing nicotine help smokers quit smoking.[3] Non-smokers are not taking up vaping in their droves and where young people are taking up vaping there is emerging evidence that smoking is decreasing.
 
There is some support among public health people for e-cigarettes containing nicotine to be made accessible to smokers, but generally they want the health sector to take control of them, medicalise them, turn them into boring pharmaceutical-like products that smokers will not be interested in using. I’m told by vapers that one of the reasons they like e-cigarettes is that they’re fun. They don’t feel like they’re quitting smoking and they can choose whatever colour, size, shape they want. Many serious vapers have an array of e-cigarettes of all different shapes and colours – one for every occasion. This is exactly what many health professionals find difficult – quitting smoking is not a fun activity!
 
Public health people have worked for years to reduce smoking and have always expected that it would be their role to end it. However, e-cigarettes have come from left field threatening smokefree environments and other strategies that have been really important in reducing smoking. Has all that work gone to waste?
 
I do not believe it has. Smokefree environments should be maintained in the future for smoking but not for vaping. After all vaping is not smoking, it’s a separate activity which produces a lot of hot air. Vapers should not be forced outside to vape in smoking areas, where they may be tempted back into smoking.
 
Lastly I can only imagine how wonderful it would be if public health people, vapers’ alliances and vaping retailers all came together to create a world where vaping was acceptable. E-cigarettes that contain nicotine should be made readily available as a consumer product and smokers should be encouraged to transition to e-cigarettes.
 
As a starting point End Smoking has produced a leaflet offering pragmatic information on supporting smokers to switch to vaping –  http://www.turanga.org.nz/node/346
 
Trish Fraser
 
Global Public Health, and
AWHC executive committee member.
 
[1] McNeill, A, Brose, LS, Calder, R, Hitchman, SC, Hajek, P, and McRobbie, H. E-cigarettes: an evidence
update. Public Health England. August 2015. https://www.gov.uk/government/publications/e-cigarettes-an-evidenceupdate (Accessed 11 September 2015))
[2] Friedman A. How does Electronic Cigarette Access affect Adolescent Smoking? Journal of Health Economics. Available online 19 October 2015.In Press, Accepted Manuscript.
[3] McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews. 2014;12:CD010216
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