The United Kingdom’s Royal College of Physicians issued a groundbreaking report this morning on electronic cigarettes which concludes that encouraging smokers to switch to e-cigarettes is likely to be beneficial to U.K. public health. Smokers can therefore be reassured and encouraged to use them, and the public can be reassured that e-cigarettes are much safer than smoking.

The 200-page report reviewed recent evidence on e-cigarettes and came to the following conclusions:

  • E-cigarettes are not a gateway to smoking– In the United Kingdom, use of e-cigarettes is limited almost entirely to those who already use, or have used, tobacco.
  • E-cigarettes do not result in normalization of smoking– There is no evidence that either nicotine replacement therapy (NRT) or e-cigarette use has resulted in renormalization of smoking. None of these products has to date attracted significant use among adult never-smokers, or demonstrated evidence of significant gateway progression into smoking among young people.
  • E-cigarettes help smokers to quit– Among smokers, e-cigarette use is likely to lead to quit attempts that would not otherwise have happened, and in a proportion of these to successful cessation. In this way, e-cigarettes can act as a gateway from smoking.
  • E-cigarettes cause much less long-term harm– The possibility of some harm from long-term e-cigarette use cannot be dismissed, due to inhalation of the ingredients other than nicotine, but is likely to be very small, and substantially smaller than that arising from tobacco smoking. With appropriate product standards to minimize exposure to the other ingredients, it should be possible to reduce risks of physical health still further. Although it is not possible to estimate the long-term health risks associated with e-cigarettes precisely, the available data suggest that they are unlikely to exceed 5 percent of those associated with smoked tobacco products, and may well be substantially lower than this figure.

While the report acknowledges the need for regulation of e-cigarettes, they suggested that regulation should not be allowed to inhibit significantly the development and use of harm-reduction products by smokers. A regulatory strategy should take a balanced approach to ensure product safety, enable and encourage smokers to use these product instead of tobacco, and to detect and prevent effects that counter the overall goals of tobacco-control policy.

The early response from the U.S. Centers for Disease Control and Prevention and other public health authorities in the United States has been muted. They already have staked out a position that opposes adopting unregulated e-cigarettes as a harm-reduction strategy. From their point of view, the unintended consequences of e-cigarettes, in terms of youth adoption and unknown hazards associated with vapor, supersede any potential benefit to current adult smokers. They arrive at these positions from the same data summarized in the RCP report.

In an article that appeared earlier this month in the New England Journal of Medicine, Sharon H. Green and her co-authors explain that the framing for harm-reduction interventions is the key distinction: England has a long tradition of helping people with addictions (e.g., providing heroin and needles for heroin addicts) while the United States has been more critical of methadone maintenance, needle exchange and other similar programs.

When framed in the context of reducing the burden of tobacco-related illness, the evidence clearly favors use of e-cigarettes. When framed in the context of youth utilization, unknown harms, uncertainties regarding content and unintended consequences, use of e-cigarettes appears to generate red flags for U.S. regulators. For public-health officials steeped in a precautionary principle, the presumption becomes that no action can be taken until e-cigarettes are shown to be absolutely safe.

There can be little question that a subset of adult smokers in both the United Kingdom and the United States are able to quit smoking or reduce their smoking substantially by using e-cigarettes.

At the Oct. 20, 2015, CDC Public Health Grand Rounds on E-cigarettes, CDC Director Tom Frieden was quoted saying: “For the individual smoker, there is no question that e-cigarettes are safer.” While the debate about the RCP report is sure to continue, an increasing fraction of smokers and their doctors will be framing the question from a perspective of the benefits switching to e-cigarettes can convey.