What should you tell your patients about e-cigarettes?

This summary is based on the article published in the British Dental Journal: Patients are asking about e‑cigarettes. What do we tell them? (July 2014)

D. J. Worsley, K. Jones and Z. Marshman

Context

E-cigarettes (also known as electronic cigarettes, electronic vaping devices or electronic nicotine delivery systems [ENDS]) are battery operated devices with the function to vaporise nicotine. This creates a smoke like effect that can then be inhaled and exhaled, replicating smoking behaviour without the use of tobacco. (1)

Since their introduction on the markets, people are increasingly asking health professionals about them.

Purpose of the Article

• This article gives an overview of e‑cigarettes, their use, their regulatory status and evidence for their safety, quality and efficacy.
• Advice about e‑cigarettes for dental health professionals to give patients is provided, as well as the five questions, proposed by Action on Smoking and Health, to consider when deciding whether to permit or prohibit use of e‑cigarettes on premises.

Key Messages

• In 2013, the World Health Organisation (WHO) (2) stated, ‘the safety of ENDS has not been scientifically demonstrated’ and ‘the potential risks they pose for the health of users remain undetermined’.
• ‘although there is no evidence to suggest that using electronic cigarettes is more harmful than smoking tobacco cigarettes there remains a paucity of scientific evidence on the long-term effects’. (3)
• While the use of ‘e-cigarettes may be useful in reducing the harm of cigarette smoking in those unable to quit’ (4) it ‘may involuntarily expose non-users to nicotine’. (5)
• The efficacy of e‑cigarettes as a smoking cessation tool has yet to be scientifically demonstrated (2) but anecdotal findings from newspaper articles (6) and comments from online newspaper threads indicate that some users are reporting that use of e‑cigarettes has enabled them to quit smoking tobacco.
• A recent randomised control study by (7) found no statistically significant difference between the quit rate in the group using e‑cigarettes delivering nicotine (quit rate 7.3%), compared with the group using nicotine patches (quit rate 5.8%).
• There are concerns that the use of e‑cigarettes containing nicotine, a highly addictive psychoactive drug, may act as a ‘gateway’ to the use of tobacco products by those who have never smoked. (8-9)

Advice about e-cigarettes for patients

• The long term safety of e-cigarettes is not yet established (3, 10, 2)
• E-cigarettes are likely to be less harmful than tobacco cigarettes (1, 11)
• The effectiveness of e-cigarettes as either a smoking cessation tool or a harm reduction tool is not yet established (10, 2)
• At present no e-cigarettes are licensed as a medicine (3, 12) and patients are recommended to use licensed nicotine-replacement therapy (NRT) products to quit or reduce tobacco consumption. (1, 13, 14)
• Advice to patients who are unable or unwilling to use licensed NRT products is that although the safety of e-cigarettes cannot be assured they are likely to be a lower risk option than continuing to smoke. (1)
• Advise patients that there is the potential for advice about e-cigarettes to change as findings from research about the safety and effectiveness of e-cigarettes is published.

References

1. British Medical Association. BMA calls for stronger regulation of e‑cigarettes. London: BMA, 2013. Online article available here
2. World Health Organization. Electronic cigarettes (e-cigarettes) or electronic nicotine delivery systems. Geneva: WHO, 2013. Online article available here
3. Medicines and Healthcare Products Regulatory Authority, Working Group on Nicotine Containing Products. Quality, safety and efficacy of unlicensed NCPs. MHRA, 2013. Online article available here
4. Goniewicz M L. E‑cigarettes: a review of their efficacy and potential for harm reduction. Presentation given by Dr Maciej Goniewicz, Queen Mary University of London, at an APPG meeting on harm reduction, 2013. Online presentation available here
5. Czogala, J, Goniewicz M L, Fidelus, B, Zielinska-Danch, W, Travers M J, Sobczak A. Second-hand exposure to vapours from electronic cigarettes. Nictoine Tob Res 2013; 16: 655–662.
6. Ranfanelli S. Why I vape. London. p 24a. The Guardian, 4 January 2014.
7. Bullen C, Howe C, Laugesen M et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382: 1629–1637.
8. Grana R A. Electronic cigarettes: a new nicotine gateway? J Adolesc Health 2013; 52: 135–136.
9. Pepper J K, McRee A L, Gilkey M B. Healthcare providers’ beliefs and attitudes about electronic cigarettes and preventive counselling for adolescent patients. J Adolesc Health 2014; 54: 678–683.
10. European Commission. Questions & answers: new rules for tobacco products. European Commission, 2014. Online press release available here
11. Action on Smoking and Health. Electronic cigarettes (also known as vapourisers). ASH, 2014. Online article available here
12. Public Health England. Smoke-free and smiling. Helping dental patients to quit tobacco. 2nd ed. Public Health England, 2014. Online guidance available here
13. Action on Smoking and Health. Will you permit or prohibit e‑cigarette use on your premises? ASH, 2014. Online article available here
14. Cancer Research UK. Smoking statistics. Cancer Research UK, 2013

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