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Research review

Are e-cigarettes a safer alternative to smoking?


E-cigarettes are becoming an increasingly popular alternative to smoking. However, it is still not clear whether they are a safe and effective way of quitting


Smokers appear to be using electronic cigarettes in attempts to quit but the products are currently unregulated. This article explores evidence regarding electronic nicotine delivery devices - usually known as e-cigarettes - and how this relates to clinical practice. It also discusses secondary care smoking cessation services in the light of NICE guidance.

Citation: Preston W, Ayre S (2014) Are e-cigarettes a safer alternative to smoking? Nursing Times; 110: 7, 20-21.

Authors: Wendy Preston is nurse consultant, George Eliot Hospital, Nuneaton, Warwickshire, and senior lecturer, Coventry University; Stephen Ayre is library services manager, George Eliot Hospital.


The safety of electronic cigarettes has received considerable attention (Hogenboom, 2013; Traynor, 2013), as people appear to be increasingly using them as an alternative to tobacco (Action on Smoking and Health, 2014).

Electronic nicotine delivery devices (ENDDs) - commonly called e-cigarettes - are electronic devices that mimic real cigarettes. Operated using chargeable batteries, they deliver nicotine through vapour rather than smoke. They usually look like cigarettes, and reproduce the glowing light at the end of a cigarette when it is inhaled, and steam that mimics smoke when it is exhaled. The nicotine content varies and they are made in several strengths.

There are also devices that deliver vapour with nicotine, in a process known as “vaping”. These also come in a variety of strengths and flavours, and can contain shisha, which is predominately a fruit-based tobacco mix.

E-cigarettes: product variety

Tobacco is smoked to obtain nicotine, mainly to relieve nicotine withdrawal symptoms. Although nicotine has few serious adverse effects, smokers expose themselves to serious harm from tar and gases, including oxidant gases and carbon monoxide, from cigarettes (National Institute for Health and Care Excellence, 2012).

Replacing conventional cigarettes with e-cigarettes and similar devices could appear to be reducing harm from cigarettes, and a body of evidence is developing to support this (ASH, 2014). However, currently, the evidence for smoking cessation is stronger, and NICE recommends a programme of behavioural support and a licensed nicotine replacement product or medication (NICE, 2012).

E-cigarettes are not regulated medicines so the ingredients and amount of nicotine contained in each e-cigarette may vary. In response to this, the Medicines and Healthcare Products Regulatory Agency is planning to introduce regulation from 2016.

The difficulty when looking at the effectiveness of e-cigarettes in helping smokers quit is that the range of devices is vast and they work in different ways. There are many formulas and flavours; these are tested as food products for oral consumption - their effects on airways when inhaled have not been studied.

These issues were discussed at the E-Cigarette Summit held in November 2013 in London, which was attended by health professionals and policy makers. Discussions highlighted the range of flavours, that the long-term effect on airways is unknown and that the products have the potential to be an irritant.

Recent research on e-cigarettes

Last year, two studies were published looking at the effectiveness of e-cigarettes in cessation.

The first was a randomised control trial studying 697 adults who wanted to stop smoking (Bullen et al, 2013). The study investigated whether e-cigarettes were more effective than nicotine patches at helping smokers to quit. Participants were given electronic cigarettes with 16mg of nicotine, a daily 21mg nicotine patch or placebo electronic cigarettes. They were studied from the week before they intended to stop smoking until 12 weeks after their designated quit day.

The study found that e-cigarettes, with or without nicotine, were moderately effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches. However, the researchers said more studies were urgently needed to establish the benefits and harms of e-cigarettes as they were unable to follow up the results of 22% of participants.

The second 12-month randomised control trial looked at the efficiency and safety of e-cigarettes (Caponetto et al, 2013). Three hundred smokers, aged 18-60 years, who did not intend to quit were divided into three groups. One group was given up to four 7.2mg nicotine cartridges per day, the second 7.2mg nicotine cartridges for six weeks followed by up to four 5.4mg nicotine cartridges per day for six weeks, and the third group up to four placebo cartridges per day.

While all three groups smoked fewer cigarettes at the end than at the start of the study, after 52 weeks there were no significant differences between them in terms of the number of cigarettes smoked or quit rates. The study also found that, for smokers not intending to quit, the use of e-cigarettes, with or without nicotine, decreased cigarette consumption and resulted in their being able to stop smoking without significant side-effects.

Again, because of the high drop-out rate (39%), researchers recommended that more studies were needed to establish the safety and effectiveness of e-cigarettes.

Using e-cigarettes in practice

In clinical practice, the lack of robust evidence makes it difficult for health professionals to recommend e-cigarettes or related devices. However, patients are using e-cigarettes to help them quit and practitioners need to respond to this development.

People using e-cigarettes should still be offered smoking cessation referrals because quitting is thought to have better outcomes than harm reduction. Patients should be informed of the lack of robust evidence supporting the use of e-cigarettes to stop smoking, but it is important to be non-judgemental if they are using them. If patients are not ready to try quitting, this may be a harm reduction opportunity and, in time, may lead to cessation.

Advice on cessation services is outlined in Box 1 and use of e-cigarettes in Box 2.

Box 1. Stop-smoking service

Smoking cessation services should be available in a range of locations that are accessible to the public, including hospitals.

National Institute for Health and Care Excellence (2013a) guidelines describe how stopping smoking at any time has considerable health benefits for people who smoke and for those around them.

In hospitals, there are additional advantages, including shorter hospital stays, lower drug doses, fewer complications, higher survival rates, better wound healing, fewer infections and fewer readmissions after surgery. NICE (2013a) recommends that smoking should be banned on hospital premises. Secondary care providers have a duty of care to protect the health of and promote healthy behaviour among people who use or work in their services.

The British Thoracic Society has published a recommendation paper for services. It also has a range of resources to help clinicians develop services, such as the Case for Change paper and the Return on Investment calculator (BTS, 2013).

Box 2. E-cigarettes and clinical practice

  • E-cigarettes are not licensed so health professionals should not recommend them
  • Devices vary significantly and offer a wide range of nicotine doses
  • Abrupt cessation is the most effective method of smoking cessation. Support is available from NHS stop smoking services in a range of locations
  • Health professionals should suggest to patients that advice can be sought from smoking cessation services for support to cut down to quit
  • Health professionals should consult hospital smoke-free policies to check whether e-cigarettes are allowed

E-cigarettes: the future

Once regulated, e-cigarettes and related devices may become useful in smoking cessation as part of a treatment plan that includes behavioural support.

However, more research is required to provide evidence on how effective this approach would be in helping people to quit, and this research needs to compare like with like. For example, it could compare: behavioural support; nicotine patch and e-cigarettes with behavioural support; nicotine patches; and a short-acting nicotine replacement product.

Smokers have the best chance at quitting if they have medication combined with behavioural support for at least 12 weeks, and a combination approach to nicotine replacement therapy is more effective than a single therapy (NICE, 2008). This means future research needs to compare e-cigarettes or similar devices with a combination approach (NICE, 2013a; 2013b).

More research is also needed to establish how e-cigarettes work and their effect on the body.

Key points

  • E-cigarettes are electronic devices that mimic real cigarettes
  • The nicotine content of e-cigarettes is variable and they can be purchased in several strengths
  • Regulation of e-cigarettes and related devices may help to develop this potential treatment
  • Patients should be encouraged to attend smoking cessation services
  • More research on e-cigarettes is required

Readers' comments (9)

  • tinkerbell

    The fact that they mimic the hand to mouth behaviour and vapours come out of your mouth I think just reinforces the 'paraphernalia' aspect of the smoking habit. Just saying I don't think it is the best way to get nicotine replacement whilst trying to give up the habit of smoking when to all intents and purposes you are still going through the 'ritual' and 'gear' of smoking which is also part of the addictive behaviour.

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  • I think we need to be clear about the purpose o e cigarettes.

    Its about Harm Minimisation (Reductiom) which is about reducing the amount of harmful chemicals in both active and passive smoke.

    Using something that reduces this risk to almost zero while accepting that it is stil maintaining a nicotine addiction and reinforcing the smoking habit is a lessor consideration.

    We are now considering a ban on smoking in vehicles where children are present. Good thing I say but how can we police and enforce it??

    To offer this as an alternative considerably protects children but does not alienate smokers and may be even will persuade them to consider a(nother) quit attempt.

    But they are not regulated some people cry - well lets get them regulated and made safer so we can use them effectively.

    (For qualification - I have practised in and managed addictions services for over 30 years including 2 years as an NHS Stop Smoking Services Manager and am a lifetime non smoker).

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  • michael stone

    'tinkerbell | 9-Feb-2014 10:30 pm

    The fact that they mimic the hand to mouth behaviour and vapours come out of your mouth I think just reinforces the 'paraphernalia' aspect of the smoking habit.'

    Exactly the point - almost word-for-word - made by someone during a discussion of e-cigs on Radio 4 a couple of weeks ago. I admit that it hadn't occurred to me, but it falls in to the 'blindingly obvious as soon as you do think about it' category.

    I'm not so sure about any idea that nicotine isn't potentially harmful: my instinct is that nicotine vapour is probably less harmful than burnt tobacco smoke, but inhaling a lot of nicotine is [I suspect] likely to be bad for you (although perhaps e-cigs would not reach that level).

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  • beats going of the ward for a fag

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  • To further state the blindingly obvious - there is no rational argument to the facts that smoking tobocco (or anything else for that matter) is damaging to your health and to others who do not diectly smoke via passive smoking.

    Any attempt to reduce this threat to our nations health should be pursued - but - up to now - all we have had is NRT products and some other meds that require the smoker to quit.

    The biggest cause of relapse is not nicotine withdrawal - NRT products are freely avaialble on prescription and to buy - its that people miss the 'habit' of smoking.

    If we agree that the Stop Smoking Movement is about reducing the health burden caused by the other noxious and carcingenic elements in tobacco smoke, then providing a system where people can indulge in their pleasurable habit of puffing on something that looks like a cigarette or pipe while greatly reducing their own and families risk of developing serious illnesses is another 'no brainer' and I just can't see why the Dept of Health / NICE etc is'nt embracing the opportunity, investing in some development and producing a product that IS regulated and safe - as an alternative to being able to continue to buy tobacco which IS regulated by our Government and clearly UNSAFE.

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  • Basically I'm saying - so it reinforces the hand to mouth behaviour - SO WHAT - if thats what people want to do - but they are not inhaling a cocktail of industrial gasses it has surely got to be better for them and the people they live with??????

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  • My husband uses e cigs, as does my friend. She has had a complete recovery from precancerous cells found in a smear test, this is after two years of repeated tests and laser treatment that failed.

    My husband has no problems with the smoker's cough, and has finally managed to quit after years of failed attempts with patches. It still involves a lot of willpower, but the reduction in toxic chemicals has got to be a good thing!

    Perform studies on vaping, regulate it if needs be, and then accept the fact that it is surely healthier than smoking. The reduction in lung cancers, emphysema and heart diseases in the future will be worth it.

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  • Anonymous -- It was great to read your listing. Unfortunately, the debate around Electronic Cigarettes has turned into a comparison of ECigarettes vs Tobacco Cigarettes. It's likely due to the use of the word Alternative. ECigarettes are not at all like Traditional Tobacco Cigarettes other then Look, Feel and Nicotine; without carcinogens and tar.

    I will cite the FDA; Nicotine causes the addiction not cancer. The tar and carbon cause the Cancer.

    Where I will slightly disagree is, Nicotine does restrict the Arteries, potential for heart disease, and increase blood pressure / heart rate.

    I couldn't agree more with your stance though.


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  • E-cigarettes are a great way to quit smoking, without 'really' quiting smoking because they don't contain tobacco. Instead, there's a mechanism that heats up liquid nicotine, which turns into a vapor that smokers inhale and exhale. Users of the e-cigarette say they feel better using the device than they did when they were smoking tobacco cigarettes, and that because the e-cigarette is reusable, it saves them money.

    We will provide you with free info, tips and recommendations via email. Thus together they will be a great accessory if you want to follow e-cigarettes and stay healthy. All these recommendations are hand picked and have been tested by several people so be convinced that they are trustworthy. Check it out at and let us know how quiting smoking goes for you.

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