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7 <br />3 What are critics concerned about? <br />Opponents of e-cigarettes focus on two main arguments: risks to users and bystanders arising from <br />exposure to vapour, population risks arising from changes in smoking or nicotine-using behaviour <br />caused by e-cigarettes. <br />3.1 Risks arising from exposure to vapour <br />No-one should claim that vaping is entirely benign. It may prove to be, but that cannot be <br />established without many years of data. However, vaping does not need to be harmless or <br />completely safe to make deep inroads into the risks of disease if people switch from smoking. <br />Studies of liquids and vapour chemistry reveal traces of contaminants and thermal breakdown <br />products that are potentially harmful, but at levels generally two orders of magnitude lower than in <br />cigarette smoke and unlikely to pose a material threat. Critics of e-cigarettes routinely cite studies <br />suggesting presence of harmful substances, but risk is determined by exposure, not merely by the <br />presence of a hazardous substance – which are present in just about everything we consume at low <br />levels. The most comprehensive literature review so far concluded 16: <br />Current state of knowledge about chemistry of liquids and aerosols associated with <br />electronic cigarettes indicates that there is no evidence that vaping produces inhalable <br />exposures to contaminants of the aerosol that would warrant health concerns by the <br />standards that are used to ensure safety of workplaces. … Exposures of bystanders are likely <br />to be orders of magnitude less, and thus pose no apparent concern. <br />Some commentators draw attention to the following to make the case that e-cigarettes are harmful. <br />3.1.1 Nicotine <br />The active drug in tobacco is not the primary cause of harm in smoking and would not be in vaping. <br />It has been understood for four decades that: “people smoke for the nicotine but die from the tar”17. <br />Nicotine is not a cause of cancer, cardiovascular disease or the respiratory conditions that dominate <br />the ill health from smoking 18. Pure nicotine is not completely benign, but it is widely sold in <br />medicinal form and does not cause any serious illness 19. The US Surgeon General has made a <br />detailed assessment of nicotine risks 20, and though it is possible to measure many effects on the <br />body, these are trivial compared to smoking: for health, it is always better to vape than to smoke. <br />3.1.2 Nicotine poisoning <br />There have been a small number of incidents of people or pets swallowing nicotine liquids and some <br />have tried to characterise this risk by reference to the number of calls to poison centres. However, <br /> <br />16 Burstyn I. Peering through the mist: systematic review of what the chemistry of contaminants in electronic cigarettes <br />tells us about health risks, BMC Public Health 2014;14:18. doi:10.1186/1471-2458-14-18 [Link] <br />17 Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:1430–3. [link] <br />18 In England in 2013, smoking caused 79,700 deaths of which 37,200 were from cancer, 24,300 respiratory diseases, <br />17,300 circulatory diseases, 900 digestive diseases. Health and Social Care Information Centre, Statistics on Smoking in <br />England, October 2014 [link]. No deaths have been attributed to pure nicotine use. <br />19 Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: <br />a systematic review. Ther Adv Drug Saf 2014;5:67–86. [Link ] <br />20 US. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of <br />the Surgeon General. 2014. P.116 [link]