Close, But No Cigar –
E-Cigarette Users Are Mostly Smokers Not Quitters
E-cigarettes, the tobacco-free devices that deliver nicotine in an aerosol vapour, appeal almost exclusively to current and recent smokers.1 Fewer than 1% of people who have never smoked use e-cigarettes.2,3,4 This may be reason enough to ask people to disclose their use on application forms for life and health insurance. 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.5
Smokers are encouraged to switch to e-cigarettes as they represent a healthier alternative to tobacco.6 However, recent studies reported 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.7,8
On the other hand, the emerging public health consensus says that e-cigarettes are significantly less harmful than smoking – perhaps 95% safer as they do not contain the majority of the chemicals that cause smoking-related disease.9,10,11
Scientific evidence to support such claims remains scant, but the assumption that harm is reduced is understandable, given the contrasting powerful evidence showing smoking tobacco is deadly. This assumption makes the fear that widespread use – possibly swapping one deadly vice for another – will result in a future epidemic of e-cigarette related lung disease seem unfounded.
Anti-smoking campaigners claim e-cigarettes will undermine their message, drawing non-smokers into nicotine dependence as smoking becomes “renormalized”. It may not help that the giant tobacco companies exclusively sell devices that look like “real’’ cigarettes. Alternative tank-style devices make up just 25% of the market yet are three times more likely to lead to quitting for daily users.12 Again, hard evidence to support this “gateway” belief is lacking, so the debate continues.13
Inevitably in an arena where science and belief compete, a patchwork of inconsistent regulation has developed. Some countries treat e-cigarettes as tobacco products while others bracket them as medicines along with other nicotine replacement therapies.
In an attempt to bring consistency to the legislation, the EU Tobacco Products Directive will impose significant restrictions on the sale and manufacture of e-cigarettes in 2016.14 The UK medical regulator (MHRA) is currently accepting applications that would allow sellers to market electronic cigarettes as treatment for nicotine addiction. The costs of obtaining a license could prove prohibitive for smaller independent manufacturers; perhaps explaining why British American Tobacco was among the first to secure one.15
So, while avoiding tobacco smoke is likely to be beneficial to health, dual-smoking and consuming nicotine using e-cigarettes is not the same as quitting. Moreover, any regulation that restricts access puts the potential benefits of switching at risk.
The levels of cancer-causing compounds in e-cigarettes are significantly lower than those in tobacco smoke.16 While the health risks posed by e-cigarettes remain unknown, they may be relatively small, while we know for certain the constituents of tobacco smoke are directly linked to heart disease and cancer.
Insurers should continue to treat users as smokers because e-cigarettes are strongly associated with smoking behaviour and current evidence suggests many use both tobacco and e-cigarettes.