Public Health England (PHE) released a landmark report in 2015 that concluded e-cigarettes were significantly less harmful than smoking tobacco. The paper went even further though, proposing that e-cigarettes could actually help smokers quit.
Much has changed since 2015, as vaping continues to attract more attention, both positive and negative, with policies surrounding it becoming more stringent. In that time though PHE has been conducting further research and in 2018 commissioned an updated evidence review that builds on the findings of the 2015 report.
Written by leading independent researchers, the 2018 PHE evidence review strengthens the original claim that vaping is a healthier option for smokers. Going beyond science, it also talks about what we should do with this information—which regulations affect e-cigarettes, especially in the light of new policies such as the EU Tobacco Products Directive (EU TPD), and where vaping in the UK is going next.
The overall tone is optimistic, and the report as a whole supports making e-cigarettes more accessible, especially as an alternative to smoking. As Professor John Newton, Director for Health Improvement at PHE, states “our new review reinforces the finding that vaping is a fraction of the risk of smoking, at least 95% less harmful, and of negligible risk to bystanders.”
Highly influential as it is, anybody who’s involved in vaping—vapers, as well as manufacturers and retailers—would benefit from knowing what the report is all about, in preparation for large-scale changes to the industry and hopefully the public attitude to it.
E-Cigarettes in the UK
Over the past few years, e-cigarettes have become more popular in the UK, reaching around 3 million vapers or 6% of adults. These tend to attract a loyal customer base, as most e-cigarette users vape every day and have been doing so for more than six months. For convenience, refillable mods are the most commonly used.
E-cigarettes are often sourced from specialist vape shops, which aren’t hard to find because there were already around 2,000 independent stores all over the UK as of 2017. Only those above 18 years old are allowed to purchase e-cigarettes. While more than 25 countries don’t allow vaping in public spaces, there’s no ban in the UK. However, it’s up to the discretion of the property owner, and vaping is typically restricted in settings such as schools and public transport. Unlike smoking, some hospitals also allow e-cigarettes.
Vaping as a Healthier Alternative to Smoking
As for why Public Health England is such a strong supporter of vaping, the report is unequivocal in its reasoning. Simply put PHE have found vaping to be immeasurably safer than smoking (there are over 7,000 lethal smoking chemicals inhaled when smoking a cigarette) with smokers being more likely to quit when they turn to vaping. Smoking accounts for around 79,000 deaths every year in the UK and not one death has been attributed to vaping.
Whilst vaping isn’t risk-free, PHE found it to be safer by at least 95% with toxins found either in extremely small amounts or not at all. While the experience of vaping is similar to smoking, the key difference is that most people who use e-cigarettes don’t become addicted and are able to reduce the nicotine content down in their e-liquid to wean themselves off the drug.
More smokers have been transitioning completely to vaping, and it’s estimated that e-cigarettes play a key role in at least 20,000 people quitting successfully each year. Alongside the increased use of e-cigarettes, quit success rates in England have been reaching their highest levels. Healthcare professionals have a strong incentive to promote e-cigarettes since negative health outcomes lessen as more smokers in the UK turn to vaping.
Policies and Regulations
Given shifts in the vaping market as innovations are produced and more vape related businesses are established, there is a need to regularly revise, review, and assess the impact of policies. According to the PHE report, policies should have the ultimate goal of supporting smokers to reduce and even stop smoking. Vaping should be seen as a part of the solution, not as part of the problem in other words.
There have been changes to regulations since the 2015 PHE Report. The most important among these is the Revised European Union Tobacco Products Directive (EU TPD), which was first adopted in 2014 then translated into UK law through the UK Tobacco and Related Products Regulations in 2016. It covers e-cigarettes and nicotine-containing e-liquids without a medical license, and the revised version enforces stricter restrictions, tackling product registration, safety and quality, advertising, labelling, and packaging.
As stated by the TPD, producers of e-cigarettes and e-liquids have to go through a notification process implemented by the Medicines Healthcare Regulatory Agency (MHRA). New producers have to notify the MHRA about each product at least 6 months before they can be released on the market. This requires submitting information such as a list of ingredients and a description of the production process. If the MHRA assesses the product as unsafe for consumers, producers won’t be allowed to sell it. In addition, submissions have to be updated when products are modified or removed.
Notifying one product costs £150, and producers also have to pay an annual fee of £60 for each product on the market. These fees are meant to fund the MHRA’s efforts of managing the notification system and publishing the data on a website. Depending on how much the actual cost is after a year or so of implementation, the fees may be reduced.
When the report was written in 2018, around 32,000 e-cigarettes and e-liquids from more than 400 producers have been registered, indicating that the system is usable.
Safety and Manufacturing Standards
Aside from EU TPD regulations, e-cigarettes also have to follow regulations about classification, labelling, and packaging that are based on a United Nations System.
E-cigarettes must have a maximum tank capacity of 2 mL, while e-liquid refill containers must be at 10 mL maximum. In turn, the highest nicotine strength for e-liquids is 20 mg/mL
To comply with safety standards, products must:
- Be protected against breakage and leakage
- Have a mechanism for refilling without leakage
- Have child-resistant and tamper-evident packaging
- Not contain additives like caffeine, taurine, and colourings
The packaging must include a health warning in clear black text against a white background: “This product contains nicotine which is a highly addictive substance.” It should also list down information such as ingredients and nicotine content.
Unless already written on the packaging, each product should have a leaflet detailing the following:
- Instructions for use and storage
- Contra-indications and possible negative effects
- Contact details of the producer
Medicinal claims, offers, and discounts aren’t allowed to be shown on the product.
E-cigarettes and e-liquids can’t be advertised on newspapers, magazines, and commercial emails, but outdoor advertising, posters on public transport, and leaflets are allowed.
Applying for a Medical License
Manufacturers can apply to have their nicotine-containing products medically licensed under the MHRA. If these products claim to reduce the harms of smoking, then they can be considered as medicinal products instead. Rather than following EU TPD and other regulations for e-cigarettes, they have to comply with the MHRA’s standards instead.
Once a product is licensed, it can be prescribed by professionals to smokers so quitting would be easier. Manufacturers can choose from licenses for General Sales List, Pharmacy Medicines, or Prescription Only Medicines.
E-liquids without nicotine don’t fall under the TPD, but they still have to follow general product regulations. Short-fill e-liquids, which have zero nicotine, take advantage of this exemption with sizes that can reach up to 100 mL or more rather than the 10 mL that ordinary e-liquids are restricted to.
The report contains a separate section for tobacco heated products, which were a new entry to the market. These have a different notification process, and policy-makers are working on regulations for these that are as strict as those for e-cigarettes.
Smokers who use e-cigarettes while supported by a local NHS Stop Smoking Service have the greatest quit rates, which is why these services should receive funding from local authorities. To make e-cigarettes even more accessible, the PHE suggests that these should remain affordable compared to traditional cigarettes and other combustible tobacco products. NHS Trusts should make sure that e-cigarettes are available for sale in hospital shops, along with removing smoking shelters and encouraging frontline staff to do their best in helping patients to quit.
There’s also an emphasis on education for both those in healthcare and the general public. Misconceptions about tobacco, nicotine, and e-cigarettes are very common. For example, most people don’t know that nicotine doesn’t cause most of the harmful effects of smoking, and many still believe that vaping is as unhealthy as smoking, which prevents smokers from considering a transition.
According to the PHE, stating that vaping is at least 95% less harmful than vaping is a good way to start raising awareness and addressing misconceptions. On the healthcare side, the National Centre for Smoking Cessation and Training launched a training course on e-cigarettes for healthcare professionals.
Helping Smokers Quit Through Vaping
The world of vaping moves fast. From 2007, when the first e-cigarette was approved for sale in the UK, the industry has evolved and expanded at a breakneck speed, with social and political institutions still catching up. There are more vapers than ever with millions of vaping products, e-liquids and accessories being manufactures and new models hitting the market every day. Both brick-and-mortar and online stores are thriving and it’s clear that vaping is here to stay.
The 2018 PHE Evidence Review reflects all of this, as well as the role vaping can play in reducing the number of deaths from smoking, drawing from research and analyses by top healthcare scientists and proceeding to discuss policies, social impact, and action steps. At more than 200 pages, it covers exhaustive ground. The core message that it presents, though, is the same as the original report: vaping is healthier than smoking, and it can help smokers quit.
As vaping becomes more widely accepted and its effects better understood, regulations and systems are gradually refined so that we can maximise the benefits of e-cigarettes—not only for enjoyment but also for moving towards a smoke-free society.