E - cigarettes (ECs)

Last edited 11/2022

E-cigarettes (ECs)

E-cigarettes, also known as vapourisers or ENDS (electronic nicotine delivery systems), are handheld battery-operated devices which can deliver nicotine containing vapour

  • devices can come in a variety of forms, and generally consist of a cartridge containing liquid nicotine (or 'e-liquid'), an atomiser (heating device) and a mouthpiece
    • solutions of e-liquid typically contain nicotine, propylene glycol and/or glycerol, as well as flavourings

  • increasing numbers of smokers are using e-cigarettes, with many people finding them helpful in cutting down or quitting cigarette use
    • in 2017, there were 2.9 million adults in Great Britain using ECs. There were more ex-smokers (52%) in Great Britain using ECs than dual users of both cigarettes and ECs (45%) (2)

  • a review of the latest available evidence suggests that e-cigarettes are at least 95% less harmful to health than tobacco smoking (1)
    • evidence so far shows that e-cigarettes have significantly reduced levels of key toxicants compared to cigarettes, with average levels of exposure falling well below the thresholds for concern. (2)
      • study evidence showed that long-term e-cigarette users (who had been using their product for 17 months on average) had significantly lower levels of key toxicants in their urine than those that still smoked - with levels in e-cigarette users similar to exclusive Nicotine Replacement Therapy (NRT) users (2)
      • no good evidence to suggest that passively breathing vapour from e-cigarettes is likely to be harmful (2)

  • E-cigarettes have become the most popular aid to quitting smoking in the UK (1)
    • RCGP position statement suggests that "..Using their clinical judgement on an individual patient basis, Primary Care Clinicians (PCCs) may wish to promote EC use as a means to stopping. Patients choosing to use an e-cigarette in a quit attempt should be advised that seeking behavioural support alongside e-cigarette use increases the chances of quit success further.." (2)

MHRA state that (3):

As part of routine clinical practice, clinicians are advised to document use of e-cigarettes or vaping devices in medical records for all patients as they would with smoking.

Clinicians should routinely document:

  • Name or brand of product used
  • Type of product (if known)
  • Duration and frequency used
  • Substances vaped (for example, nicotine or recreational substances)
  • Strengths of substances

MHRA have issued guidance regarding E-cigarette use or vaping associated lung injury (EVALI) (3).

NICE state (4):

  • give clear, consistent and up-to-date information about nicotine-containing e-cigarettes to adults who are interested in using them to stop smoking (for example, see the NCSCT e-cigarette guide and Public Health England's information on e-cigarettes and vaping)
  • advise adults how to use nicotine-containing e-cigarettes. This includes explaining that:
    • e-cigarettes are not licensed medicines but are regulated by the Tobacco and Related Products Regulations (2016)
    • there is not enough evidence to know whether there are long-term harms from e-cigarette use
    • use of e-cigarettes is likely to be substantially less harmful than smoking
    • any smoking is harmful, so people using e-cigarettes should stop smoking tobacco completely.
  • Discuss:
    • how long the person intends to use nicotine-containing e-cigarettes for
    • using them for long enough to prevent a return to smoking and
    • how to stop using them when they are ready to do so

  • Ask adults using nicotine-containing e-cigarettes about any side effects or safety concerns that they may experience. Report these to the MHRA Yellow Card scheme, and let people know they can report side effects directly

  • Explain to adults who choose to use nicotine-containing e-cigarettes the importance of getting enough nicotine to overcome withdrawal symptoms, and explain how to get enough nicotine.

Effectiveness of E-cigarettes versus nicotine replacement therapy

  • E-cigarettes versus nicotine replacement treatment (6)
    • review (78 studies; n=22,052) found high-certainty evidence that use of nicotine electronic cigarettes was associated with higher quit rates than nicotine replacement therapy (an additional 4 quitters [95% CI 2 to 6] per 100), with a similar rate of adverse events
    • also found quit rates with nicotine e-cigarettes were higher than those seen with non-nicotine e-cigarettes (RR 1.94; 95% CI 1.21 to 3.13) and with behavioural support or no support at all (RR 2.66, 95% CI 1.52 to 4.65)

A review suggests with respect to acquiring a vaping history (7):

  • be empathetic:
    • young adults may be reluctant to share history of vaping use. Familiarity with vaping terminology, asking in a non-judgmental manner, and asking in a confidential space may help
  • enquire about what vape products and where the patients sources them from:
    • vape products - vape pens commonly contain nicotine or an alternative active ingredient, such as THC (tetrahydrocannabinol) or CBD (cannabidiol)
      • may also inquire about flavorants, or other vape solution additives, that their patient is consuming, particularly if vaping related lung injury is suspected
    • source
      • ask where they source their product from. Sources may include commercially available products, third party distributors, or friends or local contacts.
  • enquire about details of vaping:
    • device
      • what style of device are they using?
    • frequency
      • how many times a day do they use their vape pen (with frequent use considered >5 times a day)? Alternatively, providers may inquire how long it takes to deplete a vape solution cartridge (with use of one or more pods a day considered heavy use)
    • nicotine concentration
      • for individuals consuming nicotine-containing products, clinicians may inquire about concentration and frequency of use, as this may allow for development of a nicotine replacement therapy plan
  • is the patient using other inhaled produced in his/her vaping device?
    • clinicians should ask patients who vape about use of other inhaled products, particularly cigarettes. Further, clinicians may ask about use of water pipes, heat-not-burn devices, THC-containing products, or dabbing
      • concurrent smoking
        • simultaneous use of multiple inhaled products is common among vape users, including concurrent use of conventional cigarettes, water pipes, heat-not-burn devices, and THC-containing or CBD-containing products (6)
          • among those using marijuana products, gathering a history regarding the type of product use, the device, and the modality of aerosol generation may be warranted
        • "dabbing" is the practice of inhaling heated butane hash oil, a concentrated THC wax - which may also be associated with lung injury

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