letter from 2019-09-20

I'd like to feed in some observations from my UK/Scotland perspective. In the UK there is no one position but different approaches are being taken in each of the four UK nations. In Scotland we work to an agreed e-cigarette consensus statement from 2017, brokered by the national health agency NHS Health Scotland in the light of available research evidence considered at the time.


Scotland's statement recognises the importance of stopping smoking as the main aim, with expert support and (prescription) medicinal treatments being the strongest recommendation.

 To date the research I have seen comparing e-cigs vs NRT for cessation places e-cigs as only a little more effective than NRT for quitting but with a much longer persistence of use. Effective for some individuals but not a population level game-changer, and less effective than some other current on-prescription medicinal treatments (eg Varenicline). Also with the caveat that research conditions do not necessarily match wider real-population conditions and use.

 E-cigarettes are certainly popular amongst smokers here in the UK, but cessation efficacy is a question not yet resolved. I believe Australia has seen similar declines in adult smoking rates without e-cigs. As e-cigs became popular amongst smokers in Scotland, the national rate of decline in adult smoking rates became shallower. Prof Simon Chapman in Australia recently critiqued the ‘e-cigs as cessation’ arguments:


 The NASEM independent international evidence review in 2018 found substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults, but limited evidence that e-cigarettes may be effective aids to promote smoking cessation.

NASEM Summary by outcomes https://www.nap.edu/resource/24952/012318ecigaretteConclusionsbyOutcome.pdf

full report: http://nationalacademies.org/hmd/reports/2018/public-health-consequences-of-e-cigarettes.aspx

 The question of health harm reduction/additional health harms is also not resolved. Scotland's consensus statement notes that vaping e-cigarettes is 'less harmful' than smoking tobacco, qualified with 'based on the current evidence', which related to a short timeframe in robust research (up to 4 years use at the time of consensus discussions) and research comparing carcinogenic substances in tobacco with the same substances in e-liquids. It takes time for some serious health effects to manifest (typically 10-30 years for smoking). And we are not talking about a standard established product, but rapidly changing markets and a plethora of delivery devices, methods of use, liquids, flavourings ...

The UK has some advantages in terms of regulation (mainly Westminster legislation enacting the European Tobacco Products Directive). We have a limit on nicotine content in e-liquids, a requirement to notify nicotine containing e-liquids to the Westminster Dept of Health, and limits on cross-border advertising. In addition the Scottish Government plans to consult towards the end of this year on further regulations to restrict domestic (Scottish) e-cigs advertising (eg billboards and free samples). Non-nicotine containing e-liquids however currently fall under general consumer (ie food) regulations.

 There has been much publicity here about the reports from the United States and recently Canada on respiratory diseases and deaths linked with vaping. While THC related oils, illicit or self-mixed liquids and vitamin E acetate have been suggested as causes, investigations are ongoing. According to CDC, 'no single substance or e-cigarette product has been consistently associated with illness'. The current statements from FDA, CDC and Health Canada seem measured and are worth reading.

 FDA Statement

Statement on federal and state collaboration to investigate respiratory illnesses reported after use of e-cigarette products


CDC Severe Pulmonary Disease Associated with Using E-Cigarette Products


Information Update - Health Canada warns of potential risk of pulmonary illness associated with vaping products



I believe there are serious gaps in analysis on the part of some commentators with regards to a) the effects of use of e-cigs at whole-population level and b) how commercial multi-nationals operate to drive and protect their profits. I would add from a Scotland/UK perspective also c) ambient vapour.

Finally, it is perhaps telling that Hon Lik - the inventor of the original e-cigarette in 2002/3, who intended it as a method to quit smoking – went on as the Guardian reported in 2015 to work for a multinational tobacco company and be a dual user of combustible tobacco.


Scotland’s e-cigarette consensus statement states (again on research available at the time) ‘Using e-cigarettes without stopping smoking (dual use) does not provide health benefits.’

Best wishes

Sheila Duffy

Chief Executive

 ASH Scotland, Edinburgh 


  ASH Scotland’s vision is of a healthier Scotland, free from the harm and inequality caused by tobacco. See our 2018-2021 strategy