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Mr Ari Manuel, consultant in respiratory, sleep and ventilation, discusses e-cigarettes

Who's right on vaping – us or America?

They're banned in some states in America, now the NHS is set to prescribe e-cigarettes – should we be worried?

When Ravi gave up smoking in 2015, he thought vaping would help him quit. "It didn't smell and I could reduce my nicotine dosage gradually," says the digital marketing executive. "The problem was that because I didn't have to go outside to smoke I was actually taking in more nicotine. I vaped when I was lying in bed, and was constantly smoking e-cigarettes when watching a movie indoors."

Ravi is one of the 2.7 million people who vape – with e-cigarettes widely seen as a healthier alternative to the traditional, tobacco-filled variety. Now, they are set to be prescribed on the NHS, following guidance published last week by the Medicines and Healthcare Products Regulatory Agency, as part of radical Government plans to cut levels of smoking. The MHRA invited manufacturers of e-cigarettes to apply for regulatory approval, which would make England the first country in the world to prescribe e-cigarettes licensed as a medical product.

According to Health Secretary Sajid Javid, the move reflected England's status as a "global leader on healthcare", with talk of England becoming smoke-free by 2030. 

But not all experts are so enthusiastic about the benefits of vaping – and the announcement puts us at odds with many other nations. Because of a growing concern about young people being introduced to vaping, the World Health Organisation (WHO) has branded e-cigarettes as "harmful", saying that there is "scant" evidence to show that they can actually help people give up smoking. They are banned in Australia, while in America growing concerns over their health risks have also seen some states banning their sale. The products were only formally authorised by the Food and Drug Administration (FDA) for the first time in October. The decision had been delayed due to concerns over their appeal to use by teenagers, particularly with 'flavoured' brands. The FDA also set down strict marketing restrictions. 

Their reticence follows research such as a 2018 report by the National Academies of Science, Engineering and Medicine, which found e-cigarettes both contain and emit a number of potentially toxic substances. The Academies' report also states there is moderate evidence that youths who use e-cigarettes are at increased risk for coughing and wheezing and an increase in asthma exacerbations. 

E-cigarettes contain nicotine and are not risk-free, but other expert reviews from the UK and US have been clear that regulated products are less harmful than smoking. 

An e-cigarette would have to pass even more rigorous safety checks to be approved by the MHRA. Clinicians could then decide on a case-by-case basis whether it would be appropriate to prescribe an e-cigarette to NHS patients to help them quit smoking. It remains the case that non-smokers and children are strongly advised against using e-cigarettes.

Dr Ari Manuel is a consultant in respiratory, sleep and ventilation at Liverpool University Foundation Trust NHS hospital and a lecturer at the University of Liverpool. "My first response is that 15 per cent of Britons still smoke – especially among young people and those from low-socio-economic backgrounds. Smoking is the highest cause of premature death, as well as the most preventable. Anything that can help people quit tobacco has to be a good thing. And vaping has risen so much in the past 10 years, it's impossible to ignore."

E-cigarettes work by heating a liquid that typically contains a range of propylene, glycol and/or vegetable glycerine – and nicotine, but at a much lower level than in traditional cigarettes. The area isn't officially regulated, but the maximum volume of nicotine permitted in an e-liquid is 20mg per ml. The user inhales it in a vapour, rather than smoke, and vapes are often fruit-flavoured. They do not burn tobacco, nor produce tar or carbon monoxide, two of the most damaging elements in tobacco smoke. Devices come either as vape pens, pod systems (shaped like pebbles with liquid capsules), or larger 'mods'.

Manuel says health risks have been linked to unregulated products found online. "Approved e-cigarettes are generally controlled and safe," he says. "The best types have the lowest nicotine levels, and burn at the lowest temperature. If people use these to stop smoking, that can only be a good thing."  

Many vapers say they have helped them reduce or stop smoking. 

Sally-Ann Semple, 45, recently decided to try vaping to break her 40 a day habit. She had been trying to quit ever since having a stroke in 2011. "The doctor strongly advised me to give up smoking and put me on Champix [a medication that reduces nicotine cravings]," she says. "Within a week, I had stopped the cigarettes completely. Then my GP said he could no longer prescribe it." (Champix was discontinued altogether over safety concerns in June 2021.)

She ended up smoking again, until September this year when she saw an online advert for a 30-day free e-cigarette trial with e-liquids.com. 

"It's now been almost a month since I had a cigarette," she says. "My skin looks better, I can breathe more easily, I smell of cherries, not tobacco. And I'm definitely inhaling less nicotine, smoking the equivalent of five cigarettes a day: a quarter of what I was smoking this summer." Semple plans to lower the concentration of her vapes continually, eventually coming off altogether before the end of the year.

Others, however, believe vaping can ultimately lead to maintaining a nicotine addiction – or even make it worse. 

Ravi felt this was the case for him. "When I used to smoke actual cigarettes, I'd have them at set times, walking to work, or after a meal," he says. "But I'd find myself vaping more and more. I'd smoke them at my desk – as often as one every half an hour, especially when I was under stress." While Ravi wasn't coughing as much, he also found himself more short of breath. "Which, let's face it, was counter-productive."

After the lockdowns, Ravi redoubled his efforts to cut down, having an e-cigarette every couple of days, before eventually stopping altogether. "But vapes are an easy habit to fall into," he says.

Manuel agrees that when smokers use their vapes as a replacement for old-fashioned cigarettes, they can potentially take in as much – if not more – nicotine than they did before.

He thinks e-cigarettes have a place, but the challenge lies in ensuring they are used in the right way. "If you are just changing the mechanism for the delivery of nicotine, that's no good," he says. "Vapes need to be used as part of a wider programme of smoking cessation – with counselling and an attempt to modify people's behaviour around smoking. Research into this area needs to continue."

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The Sefton Suite
Liverpool University Hospitals NHS Foundation Trust
Lower Lane
Liverpool
Merseyside
L9 7AL
Telephone: 0151 257 6700