"Giving up smoking is the easiest thing in the world," said Mark Twain. "I know because I've done it thousands of times."
Nicotine is one of the most addictive substances consumed by humans. It takes as little as seven seconds for the drug to reach the brain once inhaled through a cigarette. Smoking-related illnesses kill around 114,000 people a year in the UK and cost the NHS an estimated £2.7bn. If only there was a reliable, cost-effective way to help smokers quit the "death stick".
To date, the options have been twofold: encourage smokers to use nicotine-replacement products such as gum and patches, or greatly limit the places where smokers can get their fix, via the introduction of smoking bans in public places. Each has been successful – it is now almost six years since a public smoking ban was introduced across the UK – but the habit is still proving hard to stub out, with one in five adults in the UK categorised as a regular smoker. However, many health campaigners are greatly excited by the sudden boom in use of e-cigarettes, which have seen sales rocket over the past two years, with as many as one million smokers now said to have tried "vaping".
E-cigarettes let smokers continue the habitual act of holding a small white stick between their fingers and then inhaling a dose of nicotine. But they do so without the tar, smoke and cocktail of other harmful compound chemicals that do the vast majority of harm in a real cigarette. Instead, the nicotine is delivered to the lungs via a spritz of water vapour – hence, the term "vaping" – from a tiny canister contained within the battery-operated plastic "cigarette".
But just as they look set to transform the health of smokers, they now face the prospect of greatly increased regulation and even a possible ban from use in public places, with some critics arguing that their health claims have been overstated. Worse, perhaps, they could act as a "gateway" to the smoking of real cigarettes if marketed at impressionable children and young adults. Although e-cigarettes are legally allowed to be sold to children, some secondary schools have banned their use.
"Any product that could potentially glamorise smoking is not welcome here," David Hill, the head teacher at Burton Borough school in Newport, Shropshire, told reporters last month.
The British Medical Association says it is concerned that there is a lack of rigorous, peer-reviewed studies to support the claim that e-cigarettes are a safe and effective form of nicotine-replacement therapy. Until such studies exist, it wants the sale of e-cigarettes regulated, as well as a ban on their use in public places – as is now being actively considered in France. Unlike tobacco products, there are very few advertising restrictions, but regulation is under discussion.
"These devices directly undermine the effects and intentions of existing legislation including the ban on smoking in enclosed public spaces," says Richard Jarvis, co-chair of the BMA's public health medicine committee. On the question of whether e-cigarettes are safe, Vivienne Nathanson, the BMA's director of professional activities, is also clear: "The simple answer is we don't know."
But other healthcare professionals strongly disagree with the BMA's precautionary stance. The potential prize, they argue, is too great to risk extinguishing. "We have such a massive opportunity here," says Robert West, professor of health psychology and director of tobacco studies, at University College London's department of epidemiology and public health. "It would be a shame to let it slip away by being overly cautious. E-cigarettes are about as safe as you can get. We know about the health risks of nicotine from studies in Sweden into the use of "Snus", a smokeless tobacco. Nicotine is not what kills you when you smoke tobacco. E-cigarettes are probably about as safe as drinking coffee. All they contain is water vapour, nicotine and propylene glycol [which is used to help vaporise the liquid nicotine]."
West says their use is likely to continue increasing rapidly as their price falls: "They are about 20% cheaper than cigarettes at the moment. As they get more popular and sales increase, they could end up being half the price, especially if they end up being regulated as a medicine and are exempted from VAT."
The one potential problem West fears is "clever marketing". Without regulation, he could see e-cigarettes being directed at teenagers through trendy product designs and celebrity endorsement. "This is a danger. Regulators should monitor this. Their sale should be restricted to 18-year-olds and over. However, the use of e-cigarettes by children and non-smokers is basically nil at the moment. Fear of normalisation shouldn't stop us transforming the health of smokers."
Deborah Arnott, chief executive of anti-smoking health charity ASH, agrees that the benefits outweigh the risks. But she, too, wants tight regulations: "There is no evidence that they get people into smoking by acting as a gateway. Behavioural psychologists tell us that substituting behaviour is easier than extinguishing behaviour. The sucking, shape, finger feel, and act of exhaling – all this helps the transition away from real cigarettes more easily than gum or patches. However, e-cigarettes aren't regulated and we would always recommend in the first instance that smokers try licensed nicotine replacement therapies."
On Wednesday, the National Institute for Health and Care Excellence (Nice) is due to publish fresh guidance on "new approaches to help reduce the harm from smoking tobacco". Many health campaigners hope and expect Nice to include the use of e-cigarettes in its guidance for the first time.
"We could see the end of tobacco use in the UK within five to 10 years if e-cigarettes are allowed to flourish," says West. "Why would smokers continue to kill themselves if they could use e-cigarettes? Smoking tobacco is so last century."
