Time to end e-cigarette naivety

It is with reluctance and a heavy heart that I lift the pen to once more address the vexed issue of electronic cigarettes and public health. The last time I did this was in 2014, when, as President of the Faculty of Public Health, I publicly supported the World Health Organisation policy position to treat the Pandora’s box of a proposed panacea for tobacco addiction with an appropriate level of caution. The immediate outcome was an abusive twitter firestorm from a dedicated band of electronic cigarette enthusiasts that I was foolish enough to respond to. This resulted in my self-referring to the GMC for the possibly unprofessional use of the English language and a great deal of personal stress (the referral went no further).

In the ensuing five years the global growth in the market for these new nicotine delivery systems has been enormous. According to the Business section of the Sunday Times, global annual sales of nicotine devices has reached £15.7 billion, with over 3000 dedicated vaping stores in Britain alone.1 A coalition of proponents of the new product include Public Health England (PHE) and the Royal College of Physicians, who have sought to develop a consensus that nicotine devices, accompanied by seductive premises with barely a nod to smoking cessation, are the best thing since sliced bread. This is despite a growing body of research from the United States that indicates the hazard of e-cigarettes (especially those containing sweet flavourings) for hooking a significant proportion of adolescents into nicotine addiction. The advent of stronger doses through a new generation of devices, in particular that marketed as JuuL, over the past two years has raised the stakes. During the last two months a series of deaths from respiratory conditions, and large numbers of hospital admissions attributed to the use of these products, has brought panic to the companies invested in their sale and distribution.

Despite all this, PHE and its select group of advisers continue to claim that these products are 95% safer than traditional cigarettes.2,3 However, a comprehensive review on the impact of e-cigarettes, recently published in the BMJ by Jeffrey Gotts,4 has concluded that these pharmacologically active devices were marketed without the extensive preclinical toxicology testing or long term safety trials required of conventional therapeutic or medical devices; and that current knowledge of their effectiveness is insufficient to determine whether the respiratory health effects of e-cigarettes are less than those of combustible tobacco products. The 95% figure proposed by PHE advisers has been described by the highly respected commentator Professor Martin McKee, from the London School of Hygiene and Tropical Medicine, as ‘astonishing’ – since the only attempt to quantify the risk used a five year follow up, and the authors conceded that they had almost no evidence to go on.5 Mckee also points out that many of the studies that conclude that there is little risk in nicotine devices are often funded by groups that have potential conflicts of interest. This claim is supported by Gotts, who draws attention to his finding that industry funded research is strongly associated with results that indicate no harm of e-cigarettes compared with studies without a potential conflict of interest.

Sadly, this is not the only issue on which PHE finds itself at variance with the views of senior and respected public health opinion. Other examples include its position on health checks, the public health case against fracking, engagement with the alcohol industry through ‘Drinkaware’ and the confectionary industry with the so-called ‘responsibility deal’. As the organisation responsible for public health in England it should not go unnoticed that, since the inception of PHE in 2013, immunisation and cancer screening coverage have deteriorated and there have been increases in sexual transmitted infection rates, drug related deaths and overall mortality rates. If PHE is to fulfil its initial promise and become the relevant national institution that the public needs then something needs to change urgently. A new board is currently being recruited, let us hope that the opportunity is taken to appoint one that can put this important institution back on track.

Click here to read the news story about the recent BMJ review into e-cigarette use. 

What are your thoughts on the public health concerns over vaping? Has enough research been done? Feel free to add your thoughts to the comment section below. 


  1. Luke Johnson. The future of vaping seems uncertain, the future for smokers is a dead end. The Sunday Times, 6 October 2019 (https://www.thetimes.co.uk/article/the-future-of-vaping-seems-uncertain-the-future-for-smokers-is-a-dead-end-fkw5p6s5k; accessed 8 October 2019).
  2. Public Health England. ‘E-cigarettes around 95% less harmful than tobacco estimates landmark review’. Public Health England, 19 August 2015 (https://www.gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review; accessed 8 October 2019).
  3. Professor John Britton. ‘Switch to vaping’ in ‘Letters to the Editor’, The Times 3 October 2019 (https://www.thetimes.co.uk/article/times-letters-wallace-collection-and-making-art-accessible-0250wpcqc; accessed 8 October 2019).
  4. Gotts J, Jordt SE, Tarran R. What are the respiratory effects of e-cigarettes?. British Medical Journal 2019;366:15275.
  5. Martin McKee. ‘Vaping safety fears’ in ‘Letters to the Editor’, The Times 7 October 2019.
Comments (13) Add yours ↓
  1. Culley C Carson MD, FACS, FRCS Rhodes Distinguished Professor

    This blog is timely as there have now been 18 documented deaths in the US attributed to vaping. Most of the deaths and severe illnesses are from vaping THC and are in young people. In addition to the deaths, there have \been countless severe reactions and hospitalizations from these products. The original message to the US FDA was that vaping was less addictive and safer than cigarettes but the nicotine levels from these products can be as much as 200 times a cigarette! While Juul and other companies are making millions, many adolescents and young adults are causing permanent harm to their lungs. Several states have banned the sales of these products and many more are considering the bans. There is a movement to ban vaping products, at least for those under 21 years of age.

    This is a true public health emergency and must be dealt with aggressively before more people are permanently harmed. The blog is great and appropriately raises awareness of a true impending disaster in the US, Europe and throughout the world

    October 9, 2019 Reply
  2. Roger Kirby Professor of Urology

    The outbreak of lung illnesses linked to vaping grew by more than 200 cases in a week, now totaling 1299, , the Centers for Disease Control and Prevention reported on Thursday.

    Twenty-seven people have died from vaping-related illnesses, health officials said.

    The figures mean that 219 new cases and seven new deaths were reported. Cases have occurred in 49 states, the District of Columbia and the United States Virgin Islands.

    A 17-year-old boy died in the Bronx last week, the youngest death so far linked to vaping. Utah and Massachusetts officials confirmed their states’ first vaping deaths this week.

    October 10, 2019 Reply
  3. Roger Kirby Professor of Urology

    It is becoming increasingly clear that young men who vape THC are at particular risk, although cases have been reported among women and those who say they only vape nicotine.
    70 percent of patients are male
    80 percent of patients are under age 35
    76 percent of patients report vaping THC.
    THC is marijuana’s active ingredient that gives users a high. The Food and Drug Administration has tested more than 440 vape product samples obtained from patients, though no single product or substance has been linked to all of the cases. In addition, some products sent to the FDA for testing contained little to no e-liquid.

    The surge in cases has prompted several states to enact various e-cigarette bans. The Washington State Board of Health, for example, approved an emergency stoppage on the sale of flavored vaping products, including mint and menthol, effective from Thursday.

    October 11, 2019 Reply
  4. Dr Nicola Stingelin Medical Ethics Consultant

    Excellent that light is being shone on the facts and repercussions surrounding vaping. It is accordingly especially distressing that vaping is taking a position – and is even being marketed? – as an acceptable new cool starter- addiction – even as an end in itself.

    As a long time ex heavy smoker, I admit to having initially hoped that vaping could help people kick the habit (I achieved it by using nicotine plasters and smoking herbal cigarettes in the days when one could smoke pretty much anywhere). And I have to admit that if ‘the bomb’ goes up, I plan to smoke and drink myself into oblivion.

    The freedom as adults to use our autonomy to decide to be hopeless imprudent is one of the most vital freedoms (unless we harm others thereby).

    Even such a position does not however justify inaccurate or careless information being communicated on the risks of vaping; nor does it detract from our responsibilities towards the young.

    October 11, 2019 Reply
  5. Roger Kirby Professor of Urology

    A new study suggests that vaping e-liquids, specifically propylene glycol and glycerin, may lead to some inflammation in the lungs — but more research is needed to determine just how much inflammation may occur over a prolonged period of time.
    The study, published in the journal Cancer Prevention Research on Wednesday, found that in people who had never smoked, after using e-cigarettes just twice daily for a month, levels of propylene glycol in their system was linked with changes in inflammatory cell counts in their lungs, although the magnitude of changes was small.
    The study is a significant demonstration of the impact that e-cigarette use may have on inflammation in human lungs.

    October 17, 2019 Reply
  6. Nicola Stingelin Dr of Medical Ethics

    Thank you, Roger

    This is further evidence that legal action must be taken to limit access to vaping e-liquids; I suggest ‘legal action’ with some with regret [responsible self-regulation preferable], but the cohort of non smoking minors must especially be protected.

    I live in the rather run-down town of Maidenhead [Theresa May’s constituency] where even charity shops are shutting [although an excting program of redevelopment is underway].

    It is very worrying to see that vacated commercial spaces are being take-up by eye-catching shop fronts that on closer inspection are not discount perfume shops or some such but vaping shops.

    October 17, 2019 Reply
  7. Nicola Stingelin Ethicist


    I note that there is an All-Party Parliamentary Group on Vaping


    Their purpose is

    “To explore the most appropriate parliamentary and regulatory response to e-cigarettes and to raise education and literacy amongst policy makers regarding e-cigarettes and related public policy questions.”

    Should the contents of this blog be brought to their attention as a matter of urgency?

    October 17, 2019 Reply
  8. Roger Kirby Professor of Urology

    The head of the agency that regulates tobacco products In the USA said on Wednesday during questioning on Capitol Hill that the federal government should have acted sooner on e-cigarettes.

    Ned Sharpless, acting commissioner of the Food and Drug Administration, was pressed by members of a House Energy and Commerce subcommittee on why the agency hadn’t acted sooner to regulate e-cigarettes as youth consumption has skyrocketed.

    “In retrospect,” he stated, “the FDA should have acted sooner — we should have begun regulating these devices sooner.”

    November 1, 2019 Reply
  9. Roger Kirby Professor of Urology

    Read John Ashton’s recent article:

    November 12, 2019 Reply
  10. Dr Nicola Stingelin Ethicist

    Thanks Roger

    I imagine that many of us saw the BBC report yesterday:


    As soon as the election is behind us I will get in touch with the All-Party Parliamentary Group on Vaping,
    seeking assurance that they have access to the best science on the subject.

    November 13, 2019 Reply
  11. Roger Kirby Professor of Urology

    Cardiologists have issued a warning about the dangers of e-cigarettes, after research suggested vaping could damage key blood vessels.

    A new study, published in the European Heart Journal today, examined the effects on 20 healthy smokers before and after they vaped an e-cigarette. It looked at blood flow in the brachial artery in the upper arm and measured how stiff the artery became.

    The research found that a single vaping episode increased the subjects’ heart rates and caused the arteries to stiffen, while the inner lining of the arteries – the endothelium – also stopped working properly. The endothelium is responsible for maintaining the contraction of blood vessels as well as regulating inflammation and blood clotting. It has been linked with heart disease.

    Professor Thomas Munzel, from the department of cardiology at the University Medical Centre in Mainz, Germany, said he believed e-cigarettes were especially dangerous for young people who were taking up the habit and argued that countries should consider banning them.

    November 13, 2019 Reply
  12. Roger Kirby Professor of Urology

    The case of an e-cigarette user with a rare form of lung scarring typically found in metal workers has prompted more warnings about the dangers of vaping.

    A report in the European Respiratory Journal said that an e-cigarette user in California was diagnosed with a condition known as hard-metal pneumoconiosis despite having had no known exposure to working with hard metals such as cobalt or tungsten.

    The condition causes a distinctive pattern of scarring and damage to the lung tissues. The case represents the first known example linked to vaping.

    Professor Kirk Jones, from the University of California, San Francisco, said: “This patient did not have any known exposure to hard metal, so we identified the use of an e-cigarette as a possible cause.”

    When researchers tested the patient’s e-cigarette, which was used with cannabis oil, they found cobalt in the vapour it released, as well as other toxic metals: nickel, aluminium, manganese, lead and chromium.

    It is thought the metals come from the heating coils found in vaping devices.

    Dr Rupal Shah, part of the research team, said: “This is the first known case of a metal-induced toxicity in the lung that has followed from vaping and it has resulted in long-term, probably permanent, scarring of the patient’s lungs.

    December 5, 2019 Reply
  13. Roger Kirby Professor of Urology

    British America Tobacco (BAT) and three other e-cigarette firms have been been told to stop promoting their products on public Instagram pages.
    Health campaigners described it as a ‘major step forward’ in preventing teenagers and children getting hooked on vaping.
    But BAT, Ama Cape Lab, Attitude Vapes and Mylo Vapes all argue their Instagram posts simply provided factual information like the name, content and price of their products.
    The Advertising Standards Authority (ASA) disagreed and said they ‘clearly went beyond the provision of factual information’ and were promotional in nature.
    Its ruling followed pressure from a number of anti-smoking campaigners who said the firms were breaking advertising rules by promoting unlicensed products containing nicotine on social media.

    December 18, 2019 Reply

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