LAST WEEK, THE JOURNAL published the opinion article “why are we waging war on e-cigarettes when they help smokers quit”. I have been given the opportunity to explain why this is a war that should be pursued.

In 2013, the government launched a bold plan for Ireland to become Tobacco Free by reducing the prevalence of tobacco smoking to 5% by 2025. As of 2021, 18% of the Irish adult population are current smokers so we will not meet this ambitious target.

The opinion piece last week argued that Ireland needs to embrace e-cigarettes as a way to help more people quit tobacco but is there evidence to support such an approach?

Recently, the Oireachtas Health Committee published its report on the Public Health (Tobacco and Inhaled Nicotine Products) bill. In addition to recommending a ban on the sale of e-cigarettes to children under 18 years of age, the committee has also recommended a ban on the sale of all flavours except tobacco flavours, the introduction of plain packaging and the prohibition of all forms of advertising for e-cigarettes.

This has restarted the conversation on where e-cigarettes fit into Ireland’s tobacco control policy. In medicine, rather than looking at the findings of one paper on a topic, we need to examine systematic reviews and meta-analyses which identify and critically appraise many papers on a topic. These types of reviews offer a more robust scientific analysis of a particular issue and several systematic reviews have been published on e-cigarettes in recent years.   

Adolescents

The first point to address is e-cigarettes and adolescent use. The findings from the European Schools Project on Alcohol and other drugs (ESPAD) published by the TobacccoFree Research Institute in 2020, reported a 50% rise in e-cigarette current use in adolescents aged 16-17 years, since the previous study in 2015.

Nearly four in 10 (39%) adolescents have tried them and one in 5 (18%) were found to be current users. The ASH UK survey on vaping in adolescents was recently published and found that ever use of e-cigarettes in 11- to 17-year-olds rose from 11.2% in 2021 to 15.7% in 2022.

Worryingly, this rise in e-cigarette use coincided with a significant rise in the use of disposable vape products among adolescents. The report found a seven-fold increase in the use of disposable vapes in this age group between 2020 and 2022. Almost half of the adolescents surveyed who reported seeing e-cigarettes being promoted saw them on Tiktok. Increased regulations on the marketing of e-cigarettes are urgently required, particularly online marketing.   

The article last week raised the concern that a ban on e-cigarette flavourings will result in an increase in the number of smokers in Ireland. There is no published evidence stating a ban on e-cigarette flavours will lead to increased tobacco smoking prevalence. However, there is substantial evidence that flavours attract young people to the products and make them perceive vaping to be a harmless activity.

While adults may also be attracted to flavours, the risks of e-cigarette initiation in adolescents and young adults are likely to outweigh the benefits of ex-smokers using flavoured e-cigarettes. 

Gateway?

While no one argues that the sale of e-cigarettes should be banned for children under 18 years of age, the article last week claimed that e-cigarettes are not a gateway to tobacco smoking. A systematic review on the topic found that adolescents who ever used e-cigarettes are between 3 and 5 times more likely to start smoking compared with adolescents who have never used e-cigarettes.

The evidence is now irrefutable that we must protect children against the dangers of both tobacco smoking and e-cigarettes. Passing the proposed Public Health bill by just banning the sale of e-cigarettes to children under the age of 18 would not go far enough and government officials need to take on board the Oireachtas Committee’s recommendations on the bill.

We are proposing, based on current evidence, that the packaging, advertising and marketing of e-cigarettes are restricted in the same way that tobacco products are and that only tobacco flavoured should be made available in Ireland. This would allow ex-smokers continued access to tobacco-flavoured e-cigarettes and curb their use in adolescents and young adults.

With respect to whether e-cigarettes are an effective stop-smoking tool, a systematic review published last year examined ten randomised controlled trials and found there was no evidence that e-cigarettes were any better at helping smokers quit when compared to approved and regulated nicotine replacement therapy (NRT).

The evidence for e-cigarettes as a stop-smoking tool is mixed at best and healthcare professionals should be recommending the tried and trusted methods such as NRT over e-cigarettes. In January, Ireland’s first National Stop Smoking guideline was published and made no recommendation in relation to e-cigarettes as a stop-smoking tool due to insufficient evidence and substantial uncertainties with these products.

Best advice

In addition, to recommending effective treatments, healthcare professionals need to be confident that the care they recommend to patients is safe. The Health Research Board published a review of over 361 studies on the harms and benefits of e-cigarettes in 2020 and found that e-cigarettes have negative effects on the heart and lungs.

Some proponents of e-cigarette use as a stop-smoking tool say they are 95% safer than tobacco products. This statement has no scientific basis and is derived from the opinions of a small group of doctors back in 2013 when we knew little about the harmful effects of e-cigarettes. While it is important to acknowledge that e-cigarettes are less harmful than tobacco products, they are not harmless and the public needs to be aware of this fact.  

The harm reduction argument for e-cigarettes is belittled by the fact that they’re not any more effective than proven treatments and there are too many uncertainties about their long-term safety profile. Also, research shows us that many e-cigarette users continue to smoke. The Healthy Ireland survey from 2018 demonstrated that for every ten adults who use e-cigarettes, four also use tobacco.

For e-cigarettes to be a viable option in the harm reduction strategy, they would have to demonstrate that they are safe products which help people quit smoking that are regulated by the Health Products Regulatory Authority (HPRA). This has not been done.
 
In conclusion, the evidence as it stands in 2022 does not support the argument for the use of e-cigarettes as a stop-smoking tool. There remain significant concerns regarding their long-term safety and they have now been proven to be a gateway to tobacco smoking for adolescents.

Until clearer research emerges, healthcare professionals should promote safe and effective stop-smoking methods such as NRT above unproven methods such as e-cigarettes. Most smokers want to quit and the good news is that there is help is out there. The HSE www.quit.ie service offers proven stop-smoking assistance given by experienced trained professionals. 

Professor Des Cox is Chair of the Royal College of Physicians in Ireland policy group on tobacco and consultant in respiratory medicine at Children’s Health Ireland, Crumlin.