RCP advice on vaping following reported cases of deaths and lung disease in the US

This briefing note outlines the current situation in the US, describes why the US is different to the UK, including the different products available and the different regulatory situation, the UK evidence so far and our continuing advice to current smokers that vaping is still far less harmful than smoking tobacco.

What we know about the disease and deaths so far

In October 2019 the US Centers for Disease Control reported that there have been 1,479 cases of lung disease, including 33 deaths, largely among young male users of cannabis products.[1] 77% of those affected report vaping THC — a cannabis product, 35% report vaping THC only, and only 16% report not vaping THC. THC products are legal in some but not all US states. There is a global market in illicit drugs including unregulated vaping products which can contain cannabis and Spice. The majority of the cases have involved a cannabis product.

Is the situation different in the UK?

Yes, the situation is very different in the UK.  Unlike the US, ecigarettes containing nicotine on sale in the UK are regulated by the medicines regulator the Medicines and Healthcare products Regulatory Agency (MHRA) and are not allowed to contain cannabis or ingredients derived from cannabis, or Vitamin E acetate oil which has also been linked to the disease and deaths in the US.[2]

In the UK according to the ASH annual survey[3], some 3.6 million people vape, of whom 54% have given up smoking, 40% both smoke and vape, and 6% have never smoked. Just under 40% reported they’d vaped for 1-3 years and around the same proportion over 3 years. No deaths or cases of lung disease have been reported to the European body (EMCDDA) that collects that information.

Is using ecigarettes safer than smoking?

Smoking is still the biggest single killer in the UK, causing 77,800 deaths in England alone in 2017, and 489,300 hospital admissions.  Smokers who start smoking at around the start of adult life lose an average of 10 years of life expectancy, or around 1 year for every 4 years of smoking after the age of 30.[4]

The RCP’s first report on tobacco, Smoking and Health in 1962[5] was the first to alert the public to the dangers of smoking. Since 2000 it has produced a series of detailed reports focusing on how to reduce the amount of death and disease from smoking, and lobbies government to introduce more harm reduction policies and support for smokers who want to give up.

The RCP’s 2016 report Nicotine without smoke: tobacco harm reduction[6] underlined that people smoke because they are addicted to nicotine, but are harmed by the other constituents of tobacco smoke, and that provision of the nicotine without the other harmful components can prevent most of the harm from smoking. The report noted that the hazard to health arising from long-term vapour inhalation was unlikely to exceed 5% of the harm from smoking tobacco.

The report also noted that health risks were likely to arise from contaminants and components generated by the vaporisation process, which could be reduced as better technology and purer products became available, but these risks were still likely to be substantially lower than those of smoking. It recommended that regulation of ecigarettes should aim to minimise potential exposure to harmful vapour constituents.

Ecigarettes are proving much more popular than pre-existing nicotine replacement therapies and the latest evidence is that in 2017 around 50,700 to 69,930 smokers used vaping as an aid to giving up — they would otherwise have carried on smoking.[7]

What about children taking up vaping?

We must make every effort to prevent children from starting to smoke or vape. There have been concerns about the number of children taking up vaping, but this has been very low.  While children, particularly older teenagers, do try ecigarettes, there is little evidence that this translates to regular use of ecigarettes. Regular use of ecigarettes remains largely confined to current or ex-smokers. The overwhelming majority, 93.8% in total, of 11-18 year olds who have never smoked have either never used an ecigarette (87.8%) or are not aware of them (6.0%). Of 11-15 year olds only 1.1% use ecigarettes more than weekly compared to 2.5% of 16-18 year olds; and 64.7% of 11-15 year olds who have tried ecigarettes say they have not used them in the last month.[3]  A 2019 study commissioned by Public Health England stated that regular use remains low, with 1.7% of 11 to 18 year olds in Great Britain reporting at least weekly use in 2018 (it was 0.4% among 11 year olds and 2.6% among 18 year olds).[8]

Overall the evidence suggests that despite more young people experimenting with ecigarettes, and an increasing proportion using ecigarettes before tobacco cigarettes, the overall trend in tobacco use over time is downwards.[3] However, we cannot be complacent — we should remain extremely vigilant, monitor the situation diligently and should increase our efforts to prevent children from taking up smoking.

Our advice

• Our advice on ecigarettes remains unchanged — vaping isn't completely risk-free but is far less harmful than smoking tobacco.
• If you’ve switched to vaping and are finding it helpful to stop you smoking, and are not suffering any adverse effects, then carry on, don’t go back to smoking.
• Vapers should only be buying from mainstream suppliers who are selling regulated products, to use black market products may carry potentially lethal risks.
• When you’re buying ecigs you can check with the retailer whether their vaping products are notified/regulated products — if the retailer doesn’t know, then go somewhere where the retailer can confirm their products are regulated.
• Anyone concerned about adverse effects from an ecigarette they’re using should immediately report this to the MHRA, using the yellow card scheme. Information about this is available here.
• If you’re experiencing serious adverse effects which you think are due to vaping, then stop vaping and get advice from your doctor
• We must continue to monitor the use of vaping, particularly in younger people, including the marketing approaches of big tobacco to this group.

References

1  Outbreak of lung injury associated with the use of e-cigarette, or vaping, products (Accessed 18 October 2019)

2  E-cigarettes: regulations for consumer products (Accessed 18 October 2019)

3  Use of e-cigarettes among young people in Great Britain (Accessed 18 October 2019)

4  Statistics on Smoking, England - 2019 (Accessed 18 October 2019)

5  Royal College of Physicians.  Smoking and health.  A report on smoking in relation to lung cancer and other diseases. London: RCP,1962.

6  Tobacco Advisory Group of the Royal College of Physicians.  Nicotine without smoke – tobacco harm reduction. London: RCP, 2016.

7  E-cigarettes may help over 50,000 smokers to quit in England each year​​​​​​​ (Accessed 18 October 2019)

8  McNeill A, Brose LS, Calder R, Bauld L & Robson D (2019). Vaping in England: an evidence update February 2019. A report commissioned by Public Health England. London: Public Health England. (Accessed 22 October 2019)