Can People Be Helped to Quit Smoking?
E-cigarettes are often sold as an alternative to regular cigarettes that can help smokers quit because they are supposedly a healthier substitute for tobacco. Despite e-cigarettes lacking the majority of substances known to cause smoking-related diseases, the scientific evidence that they are 95% safer than smoking, as is often claimed, is scant.1
Still, the assumption that harm is reduced through using e-cigarettes is understandable, given the powerful evidence showing smoking tobacco is deadly. Tobacco kills nearly six million people each year: one in two smokers die as a direct result of their habit.
All big tobacco companies sell tobacco-free e-cigarettes that mimic "real’’ cigarettes. Several are piloting “heat-sticks,” which warm up rather than burn tobacco to create nicotine-infused vapour, and are marketing them as yet another alternative, further blurring the distinction from traditional smoking.2
For insurers, the question is, are people really trying to use e-cigarettes to help them quit tobacco for good?
Despite being associated with relapse prevention in former smokers and smoking cessation in current ones, only half of e-cigarette users say their main motivation is to stop smoking, according to a survey by the UK Office of National Statistics.3 Encouragingly, however, 53% of e-cigarette users report they use vaping as an aid to quitting tobacco.
Around 2.2 million people in the UK use e-cigarettes and 59% also smoke cigarettes. A further 3.9 million people are former users of e-cigarettes while 2.6 million tried one but did not continue using them. Of the former e-cigarette users, around 75% said they were currently smoking cigarettes.
Inevitably in an arena where science and belief compete, a patchwork of inconsistent regulation has developed. While some countries treat e-cigarettes as tobacco products, others regulate them as medicines along with nicotine replacement therapies or ban their sale.
Regardless of the regulatory framework, insurers should continue to treat e-cigarette users as smokers because the use of these devices is strongly associated with smoking behaviour. Current evidence suggests many smokers use both tobacco and e-cigarettes. E-cigarettes appeal almost exclusively to current and recent smokers; less than 1% of people who have never smoked traditional cigarettes use e-cigarettes.4
There are concerns that widespread use of e-cigarettes could result in a future epidemic of related lung disease, meaning users will have swapped one deadly vice for another. Recent studies report that some devices may also generate chemicals that have the potential to damage DNA and cause cancer under certain conditions, raising legitimate concerns about safety.5
In April 2016 the Tobacco Advisory Group of the UK’s Royal College of Physicians labelled e-cigarettes a “gateway from smoking” and urged they be prescribed to help smokers stop in order to put to an end the mixed messages from those sceptical of the benefits. The report says there is no evidence use of e-cigarettes renormalizes smoking or that they attract use from adult never-before-smokers. It also maintains that while some long-term harm from e-cigarette use is a possibility, it is likely to be small and substantially smaller than that arising from smoking regular cigarettes.
Two conclusions seem evident: While avoiding the inhalation of tobacco smoke is likely to be beneficial to health, dual-smoking - using e-cigarettes and smoking traditional cigarettes - is not the same as quitting. On the other hand, any regulation that restricts access could put the potential benefits of switching to e-cigarettes at risk.6
It’s also worth noting that any plans to turn to graphic warnings on cigarette packs as a “demand reduction measure” may not be as effective as highlighting the benefits of “harm reduction measures” such as encouraging the use of e-cigarettes. The WHO, which will announce the importance of plain packaging with graphic warnings on World No Tobacco Day (May 31), might do better stressing harm reduction instead of only focusing on demand reduction.
- Britton J and Bogdanovica I, (2014) Electronic Cigarettes, A report commissioned by Public Health England, UK Centre for Tobacco and Alcohol Studies.
- Adult Smoking Habits in Great Britain 2013, UK Office of National Statistics, 2014.
- The Scottish Health Survey 2014 (published September 2015).
- Jensen RP (2015) Hidden Formaldehyde in e-cigarette aerosols, N Engl J Med 2015;372:392-394.
- Nicotine without smoke: tobacco harm reduction, a report by the Tobacco Advisory Group of the Royal College of Physicians, London, April 2016.