Horizon: E-Cigarettes: Miracle or Menace?

BBC Two – 9.30pm on Sunday 22nd May 2016 

When the editor of the BBC science series Horizon asked me if I fancied making a programme about e-cigarettes that would involve “vaping” (inhaling nicotine-laden vapour) for a month my initial reaction was: “Hell, no.”

Then I thought about it a bit. I was worried that if I took it up I might get addicted (I’d never smoked), but I was also curious. What would it be like? What effect would it have on me? There has been a huge surge in the use of e-cigarettes over the past couple of years, yet very few studies on the effects of vaping on non-smokers. Time, I decided, to do one, with me as the subject.

I hate cigarettes, really hate them. I’ve never smoked, partly because when I was young I didn’t see the point, but mainly because when I was about 12 my dad offered me £100 if I didn’t smoke before the age of 18. I can’t remember if he ever paid me.

If I was even a little tempted to smoke, going to medical school put me off. One of the first patients I saw was Sarah, a 65-year-old woman who was dying of emphysema, a very common disease of the lungs caused by smoking. Even with an oxygen mask she struggled for breath. She’d been smoking 40 a day since she was 15 and she reckoned that she’d spent about £90,000 on cigarettes (at today’s prices it would be more like £290,000).

I also remember a young man called Alex with Buerger’s disease, a relatively rare condition where you get inflammation and clotting in your arteries and veins. Almost everyone who has Buerger’s smokes, and quitting smoking is the only way to stop it progressing. Despite knowing the risks Alex just couldn’t stop. He eventually developed gangrene and had to have a limb amputated.

Fans of e-cigarettes claim that vaping could help people like Alex and Sarah, either by making it easier for them to quit or by providing a safer way for them to get a nicotine hit. It is said that smokers smoke for the nicotine but die from the tar, so why not give them one and not the other?

Critics, however, say that we are gambling with a technology we don’t understand and that there is no convincing evidence that e-cigarettes help people to quit smoking. It may even encourage non-smokers to start.

There is a huge amount at stake. A billion people worldwide spend about £500 billion a year on cigarettes and about half will die of smoking-related diseases. In the UK alone smoking kills about 100,000 a year. If e-cigarettes take even a small fraction of the cigarette market, that is a lot of money and a lot of lives.

Some countries have warily embraced e-cigarettes, while others have effectively banned them. The UK has so far adopted a liberal approach, but in a few days’ time there will come into force European legislation that will limit the size of refills and the nicotine content of the fluids. Vaping will become more restricted.

So who’s right? Are e-cigarettes one of the greatest public health measures invented, with the potential to save millions of lives, or are they just another cunning way to keep us hooked on nicotine? I was keen to find out.

I started by having a range of physical and mental tests, including cognitive tests such as reaction times, then headed for my nearest e-cigarette shop. They come in lots of different shapes and sizes but all work on the same principle: there’s a battery that powers a heating element, a coil. There’s a chamber into which you pour your “e-liquid” which usually, but not always, contains nicotine. The heat from the coil turns the liquid into vapour, which you then inhale. There’s no burning and therefore fewer noxious chemicals involved. The e-liquids come in many flavours, from pina colada to menthol. I went for mint.

I bought a nice, geeky-looking device, with a big, shiny canister and lots of buttons. Then I went home to start vaping. I’d been given a schedule that began gently, then rapidly built to the point where I was taking about 120 puffs a day at a moderately high nicotine dose (the equivalent of a heavy smoker trying to give up). The plan was to do this for a month.

Initially I did a lot of coughing and found the head rush unpleasant, but after a while I started to enjoy the experience. It was a bit like having a very strong cup of coffee, except the effects were almost instantaneous. Blowing smoke was also fun, in an adolescent sort of way, though my friends and family were not impressed.

What was vaping doing to my body, though? According to some scientists, quite a lot of damage. In a recent widely reported study ominously titled Electronic cigarettes induce DNA strand breaks and cell death, researchers found evidence that e-cigarettes are “as harmful as tobacco”.

Addictive or not, it seems nicotine by itself is not that bad for you They took human epithelial cells, the sort that line your mouth, trachea and lungs, and exposed them to vapour from e-cigarettes. Some of this vapour had nicotine in it, some didn’t. When they examined the cells afterwards they found DNA damage and cell death. Although there was more damage in the cells exposed to nicotine-laden vapour, it was still detectable in the nicotine-free vapour. This was the sort of damage that, according to the report, can “set the stage for cancer”. Scary stuff. The lead researcher was quoted as saying that e-cigarettes “are no better than smoking regular cigarettes”.

What the press release that promoted this study didn’t mention, and what most of the headlines missed, was that the researchers had also exposed some cells to tobacco smoke. The results of this were nothing short of cataclysmic. Most of the cells exposed to tobacco smoke died within 24 hours. By contrast, the cells exposed to e-cigarette vapour survived for up to eight weeks.

As a cancer charity researcher quickly tweeted, instead of the headline “Vaping no better than smoking regular cigarettes”, they could have said “Cells can survive for eight weeks in e-cig liquid but only 24 hours in cigarette extract”. Not, perhaps, quite as catchy.

To be honest, when I took up vaping I wasn’t that worried about the short-term health effects. There have been a number of major reports, such as the one from Public Health England, that state that e-cigarrettes are “around 95 per cent safer than tobacco”.

What I was far more concerned about was getting hooked on nicotine. Yet as the weeks went by and I puffed away, nothing happened. When I leapt out of bed I didn’t feel a longing to reach for my machine. If anything I struggled to keep up with my schedule. Once the novelty had worn off it became a bit of a chore.

Chatting to experts, I discovered to my considerable surprise that although cigarettes are highly addictive, nicotine alone may not be. Although no one knows for sure, research in animals suggests that nicotine is far more addictive when delivered in combination with the other chemicals found in regular cigarettes.

Addictive or not, it seems that nicotine by itself is not that bad for you. A report put out by the Royal Society for Public Health last year said that though 90 per cent of the public think that nicotine is harmful, in fact it is “no more harmful to health than caffeine”. And, like caffeine, nicotine has potential health benefits. A natural plant alkaloid, it binds to and stimulates receptors in the brain that are important for thinking and memory. Dr Lynne Dawkins, an addiction expert, tells me: “There is emerging evidence that in certain conditions, such as Alzheimer’s and Parkinson’s disease, nicotine may have a cognitive-enhancing effect.”

To test this claim the National Institute on Aging in the US has funded a trial of 300 patients with mild cognitive impairment (a precursor to Alzheimer’s). The patients, none of whom are smokers, will be randomly allocated to nicotine patches or placebo patches that they will have to wear for 16 hours a day. Over the next few years they will have regular health checks as well as memory and cognition tests. A similar, smaller study, published in 2012, found that non-smokers given nicotine patches saw improvements in memory, attention and reaction times.

Yet before you start slapping on the patches or firing up an e-cig you should be aware that though nicotine may help people who already have impaired memory, there’s no evidence it will help the rest of us. Although I was tested before and after a month of heavy vaping, the nicotine didn’t enhance my brain, apart from a small improvement in my fine motor skills that could apparently make me slightly better at sewing.

The main health justification for e-cigarettes is not that they can help to improve your memory but that they can help those who are keen to quit smoking tobacco — but do they? A recent meta-analysis (comparing lots of different studies) concluded that they don’t. Surprisingly enough this paper concluded that vapers are less likely to give up smoking than those who try other methods. It led to headlines along the lines of “E-cigarettes don’t help smokers quit — they may actually have the opposite effect”.

Like so much of the evidence used to attack or justify vaping, this finding was hugely contentious. Critics, such as Professor Peter Hajek from Queen Mary University of London, described it as “grossly misleading”. Professor Robert West of University College London pointed out that if this were true then quit rates would be falling in countries such as the UK where e-cigarettes are taking off. This isn’t happening. If anything we are seeing the reverse.

When Horizon conducted a small study in which a group of hardcore smokers were randomly allocated e-cigs, nicotine patches or going cold turkey, we found the vapers and those who slapped on the patches were far more successful at abandoning their fags.

E-cigs are not risk-free, and after a month of heavy vaping there were signs of increased inflammation in my lungs (which reversed rapidly when I stopped). Nonetheless I think that e-cigarettes could prove to be a game-changer, one of the great inventions of the age. That said, I have no desire to ever take another puff again.

Horizon: E-Cigarettes: Miracle or Menace? is at 9.30pm on Sunday, BBC Two

Smokers should be offered and encouraged to use e-cigarettes to help them quit, says a leading medical body.

The UK’s Royal College of Physicians says there is resounding evidence that e-cigarettes are “much safer” than smoking and aid quitting.

With the right checks and measures, vaping could improve the lives of millions of people, it says in a new, 200-page report.

It says fears that e-cigarettes are a gateway to smoking are unfounded.

But, by and large, people who want to use electronic cigarettes will still need to buy them rather than get them on the NHS.

Do e-cigarettes make it harder to stop smoking?

Are e-cigarettes safe?

Should we switch from tobacco to e-cigarettes?

UK doctors can only prescribe e-cigarettes if they have been licensed as a “quit smoking aid” – something that requires strict regulation.

Few manufacturers go down this route and instead sell products to satisfy users’ desire for nicotine without the harmful chemicals produced by tobacco.

Best way to quit?

Sales of e-cigarettes have been rising steadily since the first went on sale in 2007 in the UK.

Since 2012, they have replaced nicotine patches and gum to become the most popular choice of smoking cessation aid in England.

Around one in 20 adults in England uses e-cigarettes, and nearly all of these are ex-smokers or current smokers who are trying to cut down or quit.

E-cigarettes have remained controversial and this year ministers in Walesattempted to ban them from public places.

The Royal College of Physicians says smokers who use e-cigarettes or prescribed medications – with support from their doctor – are more likely to quit permanently.

1. On some e-cigarettes, inhalation activates the battery-powered atomiser. Other types are manually switched on

2. A heating coil inside the atomiser heats liquid nicotine contained in a cartridge

3. The mixture becomes vapour and is inhaled. Many e-cigarettes have an LED light as a cosmetic feature to simulate traditional cigarette glow.

Different brands of e-cigarettes contain different chemical concentrations.

And in terms of long-term health hazards, e-cigarettes are at least 95% safer than regular cigarettes – something Public Health England has also said.

But that does not mean they are entirely risk-free.

Prof Simon Capewell, of the Faculty of Public Health, said there were still many unknown factors.

“We don’t know enough yet about the long-term effects of vaping on people’s health, which is why we need more research.

“The best thing anyone can do if they want to quit smoking is talk to their GP: there’s solid evidence that NHS quit-smoking services help people kick the habit for good.”

But Prof John Britton, who co-authored the RCP report, says e-cigarettes are extremely positive for public health and should be “encouraged and endorsed”.

He said: “The public need to be reassured this is not a new nicotine epidemic in the making. E-cigarettes have very little downside and a lot of potential benefit.”

According to Public Health England, smokers should consider using e-cigarettes alongside NHS quit-smoking services.

Around a third of UK smokers try to quit each year, but only one in every six of those succeeds.

New EU laws are due to come into force in May that will set safety and quality standards for all e-cigarettes and refills. Manufacturers will be required to disclose the purity of their products to consumers.

Dr Tim Ballard, from the Royal College of GPs, said: “Moving forward we would be looking for clear evidence that making e-cigarettes available on prescription as part of a wider smoking cessation scheme is a wise use of both scant NHS funds and GP practice resources, before the College could get behind it.

“It is not just the cost of the product that needs taking into account, but the time and resources that are involved in assessing patients, and monitoring their progress over a prolonged period of time.

“We reiterate our calls for NICE to take a leading role in establishing whether making e-cigarettes available on prescription is the best way forward.”

A Department of Health spokesperson said: “The best thing a smoker can do for their health is to quit smoking.

“We know that there are now over a million people who have completely replaced smoking with e-cigarettes and that the evidence indicates that they are significantly less harmful to health than smoking tobacco.

“We want to see a wide range of good quality e-cigarettes on the market including licensed products whose safety, quality and effectiveness are independently assured.”