E-cigarettes: A mixed blessing?

E-cigarettes were barely heard of ten years ago and yet they are now the most widely used tobacco product within the US. E-cigarettes have been shown to be helpful in assisting adult smokers in quitting. Regarded as 95 per cent less harmful than conventional smoking, e-cigarettes have equally drawn praise and criticism. Regarding the latter, in 2018 the US FDA stated that e-cigarette use among youth had become an 'epidemic', and more recently the US President called to ban flavoured e-cigarettes. There are also worries that whilst e-cigarettes may help adult smokers to stop smoking, it is by no means only adults who are using these devices. According to the UK anti-smoking group Action on Smoking and Health, approximately 40 per cent of adult current vapers in the UK are current smokers, 54 per cent are former smokers whilst 6 per cent are never smokers. It is these two latter groups where the level of concern is at its greatest.

Research is needed to understand former smokers' beliefs about taking up vaping, and the extent to which the likelihood of vaping may be influenced by such factors as the age they began smoking, the frequency and heaviness of past smoking, their perception of the relative harm of normal cigarettes and e-cigarettes, and the likely duration of vaping. It is important to understand why never smokers may still be drawn to these devices, what the appeal is for these people, and whether their vaping is indeed going to lead on to initiating smoking.

The worry is that never smokers' use of e-cigarettes might result in a transition at some point to smoking, perhaps as a result of having become dependent upon nicotine. This 'gateway theory' states that e-cigarettes may act as a route to smoking. There is also concern at the extent to which e-cigarettes are used by former smokers. Some former smokers may be reducing the likelihood of resuming smoking by vaping. The worry is that some may re-acquire a taste for and dependence upon nicotine which in time may result in resuming smoking.

Regarding the attraction of e-cigarettes, it is possible that never smokers' interest in vaping has more to do with the perception of these devices as fashion or lifestyle products. For former smokers, part of the attraction may be to do with the hand to mouth and inhalation experience that reminds them of smoking and may for that reason offer some kind of comforting substitute for smoking. E-cigarettes though are not harmless.

E-cigarettes are now available in the UK as retail products and appealing to adult smokers with evidence accumulating that they are helping many of those to quit. For some critics of e-cigarettes, these devices should only be available on prescription following assessment by a medically-qualified professional. Sensible as such a policy might seem, the result could be that fewer adult smokers use these devices thereby reducing their impact on cutting smoking rates. The challenge is to ensure that adult smokers can continue to access these devices as a smoking alternative and that they are used much less widely by former and never smokers. Further discussion and research are crucial to better understand to what extent and under what circumstances former and never smokers start vaping and perhaps later (re)initiate smoking.

Dr Evangelos Katsampouris & Dr Neil McKeganey
Centre for Substance Use Research, Glasgow