The first major public health body to endorse e-cigarettes as a means of quitting smoking was the Royal College of Physicians (RCP), which published a report in 2007. Three years later, it remains the only reliable source of information about relative safety. The RCP published Smoke-Free Nicotine in 2016 , concluding that e-cigarettes are an effective way to quit smoking. Now, in 2024, it has published E-cigarettes and
Harm reduction – a review of the evidence.
Electronic cigarettes and harm reduction: a review of the evidence is a new report that examines how electronic cigarettes can help prevent smoking-related death, disability and inequalities in tobacco use. It builds on the 2007 report Harm Reduction in Nicotine Addiction and the 2016 report Smoke-free Nicotine .
So what does the new review tell us about what we know about the science of e-cigarettes now? And does the RCP’s advice to government ministers tell us where e-cigarettes are headed in the future?
nicotine
The RCP said: “ Smokers are primarily addicted to the nicotine in tobacco, which leads to continued use of tobacco products and the subsequent devastating health damage caused by non-nicotine components of tobacco smoke, including tar particles and carbon monoxide .”
Experts reiterated that based on all the current evidence, nicotine " poses little to no harm to health ". In the short time after inhaling nicotine, people may feel " enhanced cognitive effects ", such as being able to concentrate better. Their heart rate and blood pressure will also be slightly elevated, but these will return to normal as the nicotine breaks down and leaves the blood system.
Because cigarettes and e-cigarettes are on a continuum of risk, the RCP said the two products are at opposite ends of the graph – with tobacco at the very harmful end, “ while e-cigarettes and oral nicotine products are likely to be towards the lower end of this range ”.
Smoking and vaping trends
The number of smokers had been falling, but the trend reversed during the coronavirus pandemic as lockdown measures pushed up smoking rates, especially among 18-24 year olds.
Despite widespread concerns about a youth vaping “epidemic,” the RCP makes it clear that “ vaping remains primarily an activity of smokers and ex-smokers, who account for around 93% of all people who use e-cigarette products .”
How effective are e-cigarettes for quitting smoking?
Despite arguments from opponents of e-cigarettes to the contrary, the evidence is strong. The RCP noted that results gathered from multiple randomised controlled trials and the Cochrane Living Review clearly show that e-cigarettes are “ more effective than nicotine replacement therapy in helping people to quit smoking ”.
They say e-cigarettes are useful for those social groups who have the most difficulty quitting smoking:
- Pregnant women
- People with mental health issues
- Smokers who are not motivated to quit
- Homeless people
- Prison population
They point out that free e-cigarette starter kits have been offered to smokers in NHS emergency departments and social housing to good effect.
Health effects of e-cigarettes
The RCP said cigarettes were clearly extremely dangerous and could kill.
Studies have shown that e-cigarettes:
- Delivers similar concentrations of nicotine to the blood compared to smoking
- Produces fewer toxins and at lower concentrations
- Smokers have lower levels of oxidative stress and inflammatory markers
Research on heavy metals and secondhand smoke exposure is still too limited to prove harms.
legislation
At the time of the report’s publication, the UK government had already voted to pass the Tobacco and Electronic Cigarettes Bill.
Encouraging people to use e-cigarettes to quit smoking
The RCP said the government needed to do more to encourage smokers to switch to e-cigarettes, echoing a call made by the Strauss-Kahn inquiry two years ago.
The group said accurate information should be printed on or inside cigarette packets and that attention needed to be paid to cost: " The price of e-cigarettes may be an important factor in determining their consumption; the higher the price, the lower the use ."
In summary
Professor Sanjay Agrawal, special adviser on tobacco at the RCP, said: “ We know that e-cigarettes are at least twice as effective as smoking alone in helping people quit smoking. So it’s vital that adults can use e-cigarettes to quit smoking so that they can successfully quit for good.”
“But we can’t ignore the huge increase in vaping among children and young people, or the impacts they are having on the environment. E-cigarettes may be safer than tobacco, but they come with their own risks. We recommend regulations that create a much-needed safety net – protecting young people from vaping, but allowing people to use them to quit smoking .”
The RCP report states that e-cigarettes are not harmless, but are " significantly less harmful than smoking" for users and bystanders .
The RCP reiterated its position that it supports a risk-based harm reduction approach by promoting e-cigarettes. It said this was " more ethically and scientifically sound than a precautionary approach " which supports a ban on e-cigarettes but ignores the harms of smoking.
RCP Recommendations
The RCP sets out a series of recommendations for the government to consider, aimed at maximising the benefits of e-cigarettes as part of measures to reduce harm to public health.
These recommendations include:
- More research should be done to explore the long-term effects of nicotine use
- Laws should be enacted to prevent e-cigarettes from producing dry burns or operating at extremely high temperatures
- E-cigarette users should be told about the benefits of using a cooler - just like inhaling directly into the lungs
- We need to understand more about how people transition from vaping to e-cigarettes
- The UK should combine findings from other countries
- Electronic cigarettes should be vigorously promoted to smokers
- E-cigarettes should be vigorously promoted to groups that have difficulty quitting smoking
- NHS should provide e-cigarettes to smoking patients
- More research is needed to determine which e-cigarette liquids work best
- Methods for studying e-cigarette health risks need to be standardized
- People need to be educated about the real risks of vaping to counter the misinformation they read and hear in the media
- E-liquid flavors must continue to be available to adults
- Cigarette packs should include pro-e-cigarette information