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E-cigarettes: an evidence update <br /> <br />14 <br />1. Introduction <br />Despite the decline in smoking prevalence observed over the last few decades, there <br />remain over eight million smokers in England. Most of these are from manual and more <br />disadvantaged groups in society, including those with mental health problems, on low <br />income, the unemployed and offenders. In some such population groups, the proportion <br />who smoke is over two or three times higher than that in the general population, a level <br />of smoking observed in the general population over 40 years ago. For those who <br />continue to smoke regularly, much of their lives will be of lower quality and spent in <br />poorer health than those who don’t smoke, and they will have a one in two chance of <br />dying prematurely, by an average of 10 years, as a direct result of their smoking. <br />Smoking is therefore the largest single contributor to health inequalities as well as <br />remaining the largest single cause of preventable mortality and morbidity in England. <br /> <br />Moving forward, it is therefore important to maintain and enhance England’s <br />comprehensive tobacco control strategy in order to motivate and support all smokers in <br />society to stop smoking as quickly as possible, and prevent the recruitment of new <br />smokers. Harm reduction guidance, published by the National Institute for Health and <br />Care Excellence in England in 2013, recognised that some smokers struggled to quit <br />abruptly and that cigarettes were a lethal delivery system for nicotine [1]; it is widely <br />accepted that most smokers smoke for the nicotine but die from the other smoke <br />constituents. Harm reduction has been identified as one of the more promising policy <br />options to reduce smoking induced inequalities in health [2]. All experts agree that a <br />well-resourced comprehensive strategy, involving cessation, prevention and harm <br />reduction should make the goal of a smoke-free society in England quickly achievable. <br /> <br />However, the advent of electronic cigarettes (EC) over recent years has caused <br />controversy. In 1991, Professor Michael Russell, a leading English smoking cessation <br />expert from the Institute of Psychiatry, argued that ”it was not so much the efficacy of <br />new nicotine delivery systems as temporary aids to cessation, but their potential as <br />long-term alternatives to tobacco that makes the virtual elimination of tobacco a realistic <br />future target”, and he recommended that “tobacco should be rapidly replaced by <br />cleaner, less harmful, sources of nicotine” [3]. Professor Russell was one of the first to <br />recognise the critical role that nicotine played in tobacco use and he identified that <br />whilst there were good ethical and moral reasons not to promote nicotine addiction in <br />society, the harm caused by nicotine was orders of magnitude lower than the harms <br />caused by cigarette smoke. Professor Russell was also a pioneer of new treatments for <br />smoking cessation, in particular, nicotine replacement therapies (NRT). Since then, the <br />number of NRT products has proliferated such that there are now several different <br />delivery routes and modes and countless different dosages and flavours. However, <br />even with a relaxation of the licensing restrictions which increased their accessibility, <br />NRT products have never become popular as an alternative to smoking.