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“I feel like there is a new toy in the market, let’s try this you know because it’s supposed to be healthy and not cause any health problems, but it’s a chemical that they don’t need. It’s not going to benefit them so that’s that, the danger it may open up a door for an addiction they did not have to begin with. Yeh it’s a double edge sword” (Stop Smoking Advisor)

 “It is an exciting time for e cigarettes. I think smoking cigarettes will be wiped out eventually maybe in 20, 30 years, completely gone” (Stop Smoking Advisor)

The e-cigarette market is booming. In the UK, e-cigarettes use has grown threefold in the last two years from 700,000 to 2.1 million users, and although they are not licensed, many smokers are finding e-cigarettes helpful to quit smoking. By 2015 the market is expected to be worth £340 million and it is worth noting that the tobacco industry is “increasingly taking ownership of the market”.  Are e- cigarettes dragging us backwards by re-normalising smoking or alternatively are e-cigarettes paving the way to a future in which smoking related ailments are eradicated? How are e-cigarettes positioned within wider tobacco control?

Usage of e-cigarettes shows two distinctive scenarios: one where people are using them as an alternative to traditional smoking. In other words as a medium to deliver ‘bad nicotine’ as a recreational drug. On the other hand, people are using e-cigarettes to help them quit smoking – as a pharmaceutical substance to deliver ‘good nicotine’.

Recently the Director General of the World Health Organisation (WHO) received two opposing letters about e-cigarettes.  The first was signed by more than 50 scientists from different parts of the world, calling on the WHO to reconsider their intention to classify e-cigarettes as regular cigarettes saying:

these products could be among the most significant health innovations of the 21st Century –perhaps saving hundreds of millions of lives

In contrast, the second letter,  signed by more than 100 leading public health doctors and specialists from around the world called for new controls on e-cigarettes and warned against  falling for the strategy of the tobacco industry to be present as partner.

Moreover, a report commissioned by WHO to review the available evidence of e-cigarettes concluded that they are a source of air pollution and therefore called for them to be banned in public places and workplaces and for their marketing to be restricted. The evidence presented in the report has been criticised by some experts at the tobacco field to be selective, misinterpreted, misleading and ignoring the potential public health benefit of e-cigarettes.

Although e-cigarettes will be licenced to be used as medicine in 2016, the Stop Smoking Service is seeing a substantial number of their clients using e-cigarettes already. However, there is no available official data about the exact number of e- cigarette users in the service. Research carried out for my PhD suggests that Stop Smoking Advisors are facing a dilemma. They are unable to prescribe or promote e- cigarettes, yet they see their potential to help ‘certain types’ of people to quit smoking. They also see evidence of clients who have successfully quit smoking using them. 

“I am ambivalent I don’t know where I am, I tell you there are certain cases I will be for it… these are people who has to stop for health reasons and although it’s not regulated, we don’t know what it does to the body, but if they are suffering from emphysema and they are waiting for operations and all sorts of… you name it… and this is what comforts them and helps them, this is maybe better than having a cigarette

“I don’t know I am not certain, I think for people who are very addicted to the nicotine and very addicted to the habits surrounding the smoking, it could be the e- cigarette is the thing that helps them to stop”

At the moment the advisors are dealing with e-cigarettes with the best knowledge they have, and it is quite challenging:

“We have got this dilemma of like we cannot reject the person, this is the key point, although we are not a fan of using e-cigarettes, we are not turning people away…  so what would wed o? Have you thought of another way? So, first of all we will direct them to other products, straight away we explain to the client about the dangers. This is not really kicking the behaviour, this is you avoiding…”

The advisors however are concerned about the unknown harm of e-cigarettes; the concept of re-normalising smoking; the influence on kids; the marketing influence; the role of tobacco companies and the role of e-cigarettes as a gateway to smoking, for younger people in particular. Nearly all of the advisors I spoke with did consider the resemblance of e-cigarettes to actual cigarettes to be a real hindrance to their efforts to vanquish the habit of smoking, and are against their use in public places.

“If a pregnant lady would use it I would be against it big time although even if it’s not [got] tar and chemicals, I would be still concerned… because it is not regulated. If I get an 18 year old; 20 year old who is trying to stop smoking I would be again concerned because it keeps the habit. So if I were to bet money I would say that these people are going back to cigarettes… sooner or later…”

 “It seems from speaking to pharmacists that young people are using them [e-cigarettes]; are buying them and when they do not get the hit them any more, then they are buying cigarettes.  So from e-cigarette to cigarettes. A lot of feedback is that that’s the danger because they look very glamorous, the packaging and they are easy to get hold of” 

Some advisors are welcoming regulating e-cigarettes as a medicine and are willing to prescribe them to their clients.  Others while acknowledging their potential as an effective aid to stop smoking, are not keen to add e-cigarettes to their medication list.

“I will still have the same argument about the psychological bond people can actually create with the e-cigarette, and I will never be happy to recommend” them “so if [e-cigarettes] would be going to be a frontline recommendation, oh my God, I wouldn’t like that”

There is a consensus among the advisors that smoking is a behavioural habit which is embedded in the smokers’ personality not simply a nicotine addiction. An e-cigarette may reinforce the habit of smoking and make long term relapse more likely. Therefore there is an emphasis that e-cigarettes should be used as a short term treatment similar to Nicotine Replacement Therapy (NRT).

Interestingly, some challenges are emerging on the horizon; as an advisor asked:

What if people got addicted to e-cigarettes? What will happen if they want to come off the e-cigarette and they come to our service to get help to get off the e-cigarette? Will we be able to help them? How we will help them?”

In some ways the position of e-cigarettes in the field of tobacco control is proving to be bewildering. Where do they fit? Will the licensed e-cigarette be classified as pharmaceutical nicotine similar to NRT and used under the guidance of health professionals with a defined treatment course? What about the unlicensed e-cigarettes? Are they going to be widely accepted as substitution to traditional cigarettes, consequently igniting the historical battle between tobacco industry and public health? The advisors openly admit that the field is fast moving and for some ‘sitting on the fence’ is the only reasonable option. As one service advisor wistfully explains:

“I am letting the professionals do their debate and research, until one of them comes out with conclusive evidence, but at the minute, I let them have their health battle and I will wait.”

About the author: I have a multi-disciplinary background, I have a Bachelor Degree in Dentistry, an MSc In Dental Public Health and I started my PhD in Medical Sociology at Brunel in 2012. My research interests are: the use of Electronic Cigarettes as part of Harm Reduction Approach, health and social policy, health inequality, and smoking and periodontal diseases.  Twitter: @nancytamimi