This is the beginning of a series of “THR 101 Reviews,” which examine studies and data on electronic cigarettes and vaping devices.

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Public Health England (PHE) is an executive agency within the Department of Health and Social Care in the United Kingdom. The agency “exist[s] to protect and improve the nation’s health and wellbeing, and reduce health inequalities.” In this sense, PHE operates similarly to the US Food and Drug Administration.

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Since 2015, PHE has been a leading agency in providing information on electronic cigarettes and vaping devices. In its landmark 2015 report, E-cigarettes: an evidence update, PHE concluded “that e-cigarettes are around 95% safer than smoked tobacco and they can help smokers to quit.” Since then, PHE has given annual updates to the 2015 report.

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In March, 2018, PHE provided an evidence update to its 2015 report. The 2018 report examines the role of nicotine and its health effects, e-cigarette product use and effectiveness as a cessation tool, the health risks of vapor products and perceptions of harm. The report is a comprehensive tool that can help policymakers understand adult use of e-cigarettes and their role in tobacco harm reduction.

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PHE identified over “32,000 e-cigarette and nicotine containing e-liquid products,” noting that there appears to be “a level of compliance with the regulations” in England. E-cigarettes are regulated by the UK Tobacco and Related Products Regulations 2016, with regulations including notification of products, “minimum standards for safety and quality of e-cigarette products, standards for information provision (including a nicotine health warning) and advertising restrictions and updated standards.”

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The harms of nicotine have not been extensively studied, with the agency noting that combustible cigarettes’ addictiveness “may be enhanced by compounds in the smoke other than nicotine.” PHE also remarks that although nicotine “has effects on physiological systems that could theoretically lead to health harms,” there have been no increases in health risks among users of snus – a “low nitrosamine form of smokeless tobacco” – or any detrimental effects to fetuses of pregnant women who use nicotine replacement therapy. Understandably, PHE implores policymakers to further examine possible harms of nicotine, as well as the benefits from its use in products other than combustible cigarettes.

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Among adult e-cigarette use in England, less than one percent of users were never smokers, which is similar to adult use of nicotine replacement therapy. In Great Britain, nicotine concentrations in e-liquids are restricted to “a maximum of 20mg/mL.” According to PHE, in March, 2017, approximately 6 percent of “e-cigarette users reported using higher nicotine concentrations.” The most popular flavors among e-cigarette users were fruit, tobacco, menthol and/or mint. More than 40 percent of e-cigarette users reported purchasing products in “specialist vape shops.”

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PHE notes that e-cigarettes may have played large role in England’s quit smoking success rates, as in the beginning of 2017, “quit success rates were at their highest rates so far observed and for the first time, parity across different socio-economic groups was observed.” PHE estimates that between 22,000 and 57,000 adults have quit smoking due to the use of e-cigarettes.

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PHE assesses e-cigarettes health risks by examining several risk factors that have long been associated with combustible cigarette use. Regarding lifetime cancer risks, one study noted that the “cancer potencies of e-cigarettes were largely under 0.5% of the risk of smoking.”

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E-cigarettes appear to help smokers reduce the risks of cardiovascular disease and lung disease as indicated in studies comparing smokers and e-cigarette users. Two studies examining “biomarker data for acrolein, a potent respiratory irritant, found levels consistent with non-smoking levels” among e-cigarette users.

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PHE also examines whether flavors can contribute to adverse health outcomes finding that “there is no clear evidence that specific [flavorings] pose health risks.” Moreover, although vaping devices “can release aldehydes if e-liquids are overheated … overheating generates an aversive taste” and many e-cigarette users are at no risk due to the lack of palatability.

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Further, PHE notes that “[b]iomarkers of exposure assessed to date are consistent with significant reductions in harmful constituents … similar levels to smokers abstaining from smoking or non-smokers were observed.” This indicates that certain biomarkers in former smokers could return to levels as if they had never smoked, while simultaneously using vaping devices.

PHE concludes that “stating that vaping is at least 95% less harmful than smoking remains a good way to communicate the large difference in relative risk” of electronic cigarettes and vapor products.

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Deeply troublesome in PHE’s evidence update is that more adults in Great Britain – similar to the United States – believe that e-cigarettes are more harmful than combustible cigarettes. PHE notes that “nicotine replacement therapy is subject to similar misperceptions.” PHE attributes this to misperceptions about nicotine’s relative harm. For example, when asked, only 8 to 9 percent of adults in Great Britain can accurately describe “what proportion of the health harms of smoking is due to nicotine.” The correct answer being that “most health harms are not caused by nicotine.”

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The 2018 evidence update expands from PHE’s 2015 review of e-cigarettes and offers new evidence that vapor products are significantly less harmful that combustible cigarettes. Further, these are an effective smoking cessation tool and have helped tens of thousands of adults in Great Britain quit smoking. Rather than hinder adult access to tobacco harm reduction products, policymakers should promote their use and look for ways to help adults quit smoking.

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Nothing in this analysis is intended to is intended to influence the passage of legislation, and it does not necessarily represent the views of Tobacco Harm Reduction 101. For more information on tobacco and vapor products, please visit https://www.thr101.org.