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The heated debate around electronic cigarettes shows no sign of abating but more clarity around their position as both an alternative to smoking and a quit aid now seems to be emerging. Asha Fowells reports

Several documents supporting the use of electronic cigarettes have now been published and, earlier this month, e-cigarettes were mentioned for the first time in official NHS guidance in Scotland aimed at smokers seeking to quit. Although the NHS in Scotland still strongly recommends that smokers use licensed NRT products in quit attempts, prevention of relapse to smoking is the main priority.

People wanting to use e-cigarettes should not be told to stop if there is a risk they could return to smoking tobacco. Figures show that the number of quit attempts using NHS stop smoking services is declining sharply, a drop that may be explained by the rise in popularity of e-cigarettes.

Health chiefs are increasingly concerned that if stop smoking services don't acknowledge that e-cigarettes may have a role in keeping people off tobacco, smokers could lose out on the extra support on offer.

Potential benefits

A report commissioned by Public Health England¹, written by John Britton and Ilze Bogdanovica of the UK Centre for Tobacco and Alcohol Studies, doesn't hold back in its support of e-cigarettes, stating that they offer €vast potential health benefits€ and going on to declare: €The opportunity to harness this potential into public health policy, complementing existing comprehensive tobacco control policies, should not be missed.€

The document suggests that the devices have a role for smokers looking for an alter- native as a lifestyle choice, rather than being added to the current pharmacological armoury employed by quit services, and adds: €Evidence to date suggests that smokers are willing to use these products in substantial numbers.€

However the report is not unconditional in its support. In the summary, the authors write: €Maximising those benefits while minimising harms and risks to society requires appropriate regulation, careful monitoring and risk management.€

A second PHE-commissioned report¹, published at the same time, underlines the size of the e-cigarette market. The sector is extensive and growing, fuelled by widespread and expensive multimedia campaigns, and the decision made by many pharmacy retailers to stock such products, say the authors.

Product innovation continues to grow and a €tiered€ market is beginning to emerge as some manufacturers attempt to differentiate themselves on price and quality, the report says.

A public consultation on e-cigarette advertising, with the aim of introducing measures to protect young, vulnerable and non-nicotine users, was launched in February 2014 and is due to report later this year.

Growing support

Support for e-cigarettes continues to grow with the publication of a study that revealed that people trying to quit without professional help were around 60 per cent more likely to succeed if they used the devices.

The work, conducted by a team at Cancer Research UK's health behaviour research centre at University College London (UCL), involved some 5,863 adult smokers who had made at least one quit attempt in the past 12 months using either an e-cigarette, OTC nicotine replacement therapy or no aid.

In the paper, which was published in the journal Addiction², the authors admit that assessing the effectiveness of e-cigarettes poses many challenges because of the wide variety of brands available, the way they are used and the type of people who choose to use them. This means that randomised controlled trials €“ often considered the gold standard of medical research €“ is not the most appropriate study method, they suggest.

The authors add that, although their research points towards e-cigarettes being more effective for quitting than self-selected NRT, current evidence still favours a combination of behavioural support and medication as providing the best chance of success.

Pragmatic approach

With electronic cigarettes riding high on the health agenda, an open letter to the World Health Organization on the topic last month gained a great deal of national media coverage. The letter €“ which was signed by 53 specialists in nicotine science and public health policy from across the world, including PHE report author Professor Britton and UCL study author Professor Robert West €“ called for the body to reconsider its intention to classify e-cigarettes in the same way as tobacco products.

Doing so overlooks the benefits of tobacco harm reduction, says the letter, describing it as €the idea that the 1.3 billion people who currently smoke could do much less harm to their health if they consumed nicotine in a low-risk, non-combustible form€.

The letter offers a pragmatic approach, stating: €Even though most of us would prefer people to quit smoking and using nicotine altogether, experience suggests that many smokers cannot or choose not to give up nicotine and will continue to smoke if there is no safe alternative available that is acceptable to them.€

Tobacco harm reduction should be considered part of the solution and not part of the problem, the letter goes on to say, describing it as €strongly consistent with good public health policy and practice€ and saying that not allowing people the option of using such products is €unethical and harmful€.

Banning advertising of e-cigarettes is counterproductive, states the letter, highlighting that although promotion of tobacco is not allowed due to the harm caused by smoking, no such argument applies to products that are, in fact, likely to reduce harm by reducing smoking.

Controlling advertising to young people and non-smokers is justified, say the signatories, but targeting marketing campaigns at existing smokers is low risk with €potentially huge€ benefits. WHO is currently reviewing the evidence for e-cigarettes.

Pharmacists split

However pharmacists remain deeply split on the issue. Speaking at last month's OTC Bulletin conference, 'Cutting through the smoke: the way forward for e-cigarettes', Numark managing director John D'Arcy argued that despite the current lack of safety and efficacy evidence for e-cigarettes, pharmacists could not be expected to just ignore them when they could play a crucial role in stopping people from smoking. €On balance e-cigarettes seem a safe option and they should become part of pharmacy smoking cessation programmes,€ he said. To exclude e-cigarettes would be €to miss a trick€.

Howard Duff, director for England at the Royal Pharmaceutical Society, disagreed. Reflecting current Society policy, he told the conference that if pharmacists stocked and sold e-cigarettes, there was a risk of misleading patients into believing that these were approved products that had been through a regulatory process.

€However they are not medicines and there is no science behind their use,€ Duff insisted. €There are licensed alternatives [to e-cigarettes], so we must support these.€

• Additional reporting by Richard Thomas and OTC Bulletin

References

1. www.gov.uk/government/news/public-health-england-publishes-independent-evidence-papers-on-e-cigarettes
2. Brown J, Beard E, Kotz D, Michie S, West R. Addiction