Following reports of an outbreak in the US of serious lung disease and recent deaths linked to vaping the US Centre Disease Control (CDC) have discouraged people from vaping and there are moves to ban them in various US states such as San Francisco. Countries across the world such as Australia have already followed this line. The debate on e-cigarettes for and against is at its height and has become even more polarising than before. So what should we make of the US position and what does it mean for the UK?
A full investigation is not yet available but early indications are that these cases in the US have been linked to people using illicit vaping fluid bought on the streets or homemade, with many containing cannabis products like THC or synthetic cannabinoids like Spice, and others i.e. Vitamin E acetate oil.
As of the 5th November, 2016 cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC. Forty Seven deaths have been confirmed (20th Nov). The outbreak appears to be largely among young men: 68% of patients are male and the average age is 24 and 77% were under the age of 35.
Furthermore recent CDC laboratory test results from 29 patients identified vitamin E acetate in 100% of samples. THC was confirmed in 82% of the samples and nicotine was identified in 62% of the samples. Because many EVALI patients used THC- and nicotine-containing products, nicotine-containing products were evaluated as well. None of the nicotine-containing products tested contained alpha tocopherol, gamma tocopherol, MCT, THC, or vitamin E acetate.
UK regulated nicotine products do not contain THC or Vitamin E acetate.
In line with the CDC/PHE recommendations we urge the public to not take the risk and avoid buying illicit products and combining them with other substances such as the above. Vaping products should only be sourced from reputable shops who are compliant with the TPD regulations See here for public information leaflets on e-cigs.
The CDC have stated that the outbreak does not appear to be associated with long term use of nicotine e-cigarettes, which have been used in the US for over 10 years. 9 million people vape in the US. The first case was reported at the end of March this year.
The UK has not, despite recent press reports, been hit by a similar epidemic: among a vaping population that stands at 3.6 million there are only two known cases of lipid pneumonia/lung injury.
And one recent case study, published in Archives of Disease in Childhood, (11 Nov 2019) reports that a 16 year old boy who has been taken ill with lung inflammation was linked to e-cigarettes. This is worrying but does not evidence we are seeing the same level of lung injury as in the US.
Dr Nick Hopkinson, British Lung Foundation Medical Director and Reader in Respiratory Medicine at Imperial College London, said:
“It’s possible the patient’s illness could have been due to an allergic response to a component of e-cigarette vapour. However, in this kind of condition it can often be difficult to make an accurate diagnosis or know for certain what the cause is. This kind of lung disease can sometimes occur spontaneously without any obvious trigger. If this was a common problem or a significant risk we would expect many more cases”
Inhaling any foreign material is inherently likely to be harmful, and the recent US experience speaks strongly in favour of regulating electronic cigarette contents and emissions to protect the user.
As a reminder: Unlike the US the UK Tobacco Product Directive requires all vaping products and e-liquids containing nicotine to be registered with the Medicines and Healthcare products Regulatory Agency before they are sold in local shops.
Information on the Tobacco Product Directive: Regulations and Standards can be found here.
If a product is not registered, it may not meet the minimum quality and safety standards. The MHRA operate the Yellow Card Scheme, encouraging vapers to report any adverse effects.
You can also report products suspected to be defective or non-compliant to your local Trading Standards or to TPDsafety@mhra.gov.uk. Retailers must not sell nicotine containing products that are not registered with the MHRA. The public and retailers can check the list here.
Following a review of the emerging evidence our stated position in Sheffield on e-cigarettes and advice to smokers remains the same.
Stop smoking completely and immediately, access support via the Yorkshire Smokefree Sheffield Service and utilise a combination of behavioural support and stop smoking medication such as Nicotine Replacement Therapy (NRT) or Champix or switch to e-cigarettes to give you the best chance of achieving success in quitting. More information on the Sheffield policy position statement can be found here.
Effectiveness of e-cigs as a quit aid
Three studies this year have shown e-cigarettes to be around twice as effective as NRT for smoking cessation Around 20,000 smokers are quitting with e-cigs each year in England. A ban on flavours would make vaping much less tolerable; nicotine vapour causes irritation and can be difficult to inhale. The Hajeck trail (2019) demonstrated that flavours were crucial to success in quitting. Banning flavours diminishes adult smokers ability to realise the full benefits of switching and risk relapse back to smoking.
Safety of e-cigs US and UK
Leading agencies (PHE, RCP, BMA, NCSCT) in the UK and the US (US National Academy of Sciences, American Cancer Society) agree vaping is far safer than smoking and there continues to be no evidence of harm from passive exposure.
Vaping is NOT risk free but nor are many things in life. Crossing the road is not risk free. A non-smoker who takes up vaping will harm their health but the smoker who switches to vaping will gain massively and reduce their risk of developing smoking related illness. Tobacco free and vape free is the ideal in the long term.
Banning vaping altogether is irrational since it would push millions of ex-smokers back into using tobacco. Also we don’t ban other products because we have found illicit versions to cause harm i.e. Alcohol for example why would we ban vaping and a further question why would we ban vaping and not cigarettes which do the most harm?
E-cigs and misperceptions about harm
The Annual ASH Smokfree survey in Britian shows that misperceptions about the saftey of e-cigarettes exists and some smokers believe they are as harmful as smoking. The latter is not surprising with so much inaccurate reporting taking place on health benefits and risks of vaping – The two main reasons smokers give for not using an e-cig are “don’t want to swap one addiction for another” and “concerned they are not safe enough”
Some recent reports and speculation based on scaremongering and sensationalism not fact have the potential to do much harm. It is immoral and unjust not to give smokers the chance to rid themselves of a lethal addiction that kills 1 in 2 users.
Children and Vaping US vs UK
We continue to believe there is a role for e-cigarettes in helping adult smokers quit, but it is vitally important that we do all we can to protect children and young people from taking up vaping. That is why we supported the introduction of substantial restrictions on advertising, promotion and sale of e-cigarettes in the UK. We are pleased that the UK Government has committed to review the regulations within five years of their implementation to ensure that they continue to provide adequate protection for children and young people.
Whilst there is evidence of high experimentation of vaping amongst our youth, there’s little evidence re: large scale take up of vaping among young people in the UK, regular use remains confined to youth who have previously smoked. A stark contrast to the US who estimated around 20% of their youth vape (vaping products are heavily marketed to these audiences there). The US has no regulatory standards and few marketing restrictions. They also have significantly higher nicotine content in their vaping products e.g. JUUL. E-cigarettes are not renormalizing smoking, in the years when youth vaping was increasing, smokefree norms were hardening and youth smoking is at an all-time low.
In Sheffield we are currently reviewing our local evidence on vaping and young people collated via our schools survey and the C&YP service. We will keep a watchful eye on all of the above and review/update our position as the evidence emerges. It is essential to remain vigilant in detecting and preventing adverse effects from vaping but also to keep sight of the benefits.
Those who cite the precautionary principle as justification to discourage or prohibit electronic cigarettes ignore the fact that for the great majority of users, the counterfactual is premature death from tobacco smoking. Smoking kills. Vaping saves lives.
The British Thoracic Society offers some helpful advice on what we should tell patients!
Sarah Hepworth – Health Improvement Principal, Sheffield City Council
Tobacco Control Lead
On behalf of Greg Fell, Director Public Health, Sheffield City Council
 UK RCT – Hajek, Peter, et al. “A randomized trial of e-cigarettes versus nicotine-replacement therapy.” New England Journal of Medicine 380.7 (2019)
New Zealand RCT
Walker, Natalie et al. “The effectiveness and safety of combining nicotine patches with e-cigarettes (with and without nicotine) and behavioral support, on smoking abstinence: findings from a large randomised trial” SRNT 2019
UK Population study Jackson, Sarah, et al. “Moderators of real‐world effectiveness of smoking cessation aids: a population study.” Addiction (2019)