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9 risk. Where toxicants are found in e-cigarette vapour, they are found at much lower levels than tobacco smoke. The biggest study on toxicants in vapour 31 concluded: “The levels of the toxicants were 9-450 times lower than in cigarette smoke and were, in many cases, comparable with trace amounts found in the reference product”. Many of the more important toxins in cigarette smoke are simply not present at all in measurable quantities in vapour. The data on toxicity and carcinogenicity are consistent with the claim that vaping is at least 95% safer than smoking. 3.1.6 Heavy metals Traces of metals can be found in some e-cigarette vapour, but at very low levels that do not pose a material risk – equivalent to or lower than levels found and permitted in medicines 32: “an average user would be exposed to 4–40 times lower amounts for most metals than the maximum daily dose allowance from impurities in medicinal products”. Some regulations covering the materials used in device construction would reduce this still further. 3.1.7 Lung irritation A February 2015 study exposed mice to e-cigarette vapour and concluded it demonstrates “that e- cig exposure elicits impaired pulmonary anti-microbial defences” (in mice)33. In fact, the study greatly over-interpreted the applicability of a mouse study to humans 34, failed to measure impacts for tobacco smoke for comparative purposes and failed to note that free radical exposure was 150 times lower than is typically found for smoking 35. 3.2 Risks to the population As it becomes clearer that e-cigarettes offer smokers a 95-100% reduction in risk, the critics of e- cigarettes have moved their focus onto ‘population’ arguments. This is the idea that though vaping is very much less hazardous than smoking for an individual, at population level it could be more dangerous because it somehow causes changes in the way people smoke. For example: • By visible displays of smoking-like behaviour or marketing it might ‘renormalise’ smoking. • It might divert people from quitting smoking because they don’t feel discomfort of temporary withdrawal or under so much social pressure. • It could be a ‘gateway’ to smoking for adolescents, and ‘kiddie flavours’ may be used to lure children into nicotine addiction and ultimately on to smoking. There is no basis to believe any of these effects are real rather than tactical campaign arguments. 3.2.1 Renormalising smoking The UK’s foremost experts in smoking cessation who also manage the surveillance of the market in 31 Goniewicz M., Knysak J., Gawron M., Kosmider L., Sobczak A., Kurek J., et al. . (2013) Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014 Mar;23(2):133-9 [abstract][paper from March 2015] 32 Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf 2014;5:67–86. [link] 33 Sussan TE, Gajghate S, Thimmulappa RK, et al. Exposure to electronic cigarettes impairs pulmonary anti-bacterial and anti-viral defenses in a mouse model. PLoS One 2015; [link] 34 Explained by Mike Siegel, New Study Reports Adverse Effects of E-Cigarette Aerosol on Mouse Respiratory Epithelial Cells, The Rest of the Story, 5 February 2015. [link] 35 Farsalinos K. A new study in mice provides no information for smokers but verifies e-cigarettes are less harmful, E- cigarette Research. 5 February 2015 [link]