Which is more harmful, electronic cigarettes or regular cigarettes?

Which is more harmful, electronic cigarettes or regular cigarettes?

Let me first state the conclusion. E-cigarettes are not completely harmless, but they are less harmful than cigarettes. There is still controversy as to whether e-cigarettes can help people quit smoking.
The Oxford Dictionary selects the word of the year every year. In 2013, the word of the year was selfie; in 2015, it was the emoji expression " "; and in 2014, which was in between, it was "vape", which means electronic cigarette.
From 2010 to 2014, the sales of e-cigarettes in the world skyrocketed. However, for most Chinese people, e-cigarettes are an unfamiliar product. E-cigarettes are regarded as a foreign fashion trend, popular among a small number of people, although they were invented by Chinese people and are mostly produced in China.
Most people only hear about e-cigarettes sporadically. For example, in October 2018, Carrie Lam, the Chief Executive of Hong Kong, said in her policy address that Hong Kong would completely ban the sale of e-cigarettes; for another example, e-cigarettes have become a popular entrepreneurial project in the mainland.
What exactly are e-cigarettes? Are they good or bad? Can e-cigarettes really help people quit smoking?
E-cigarettes are harmful, but better than cigarettes
If you have ever searched for introductions to e-cigarette products out of curiosity, you may have seen some domestic merchants portraying e-cigarettes as medicines, claiming that e-cigarettes are "healthy and harmless" and "clear the lungs and detoxify."
You may have also seen some other popular science articles in Chinese that list the dangers of e-cigarettes, some of which even claim that "e-cigarettes are 7 times more carcinogenic than cigarettes!"
Are e-cigarettes harmful? And, are e-cigarettes more harmful than traditional cigarettes?
To answer these two questions, we first need to have a brief understanding of the structure of electronic cigarettes. Electronic cigarettes are usually divided into two major parts: electronic atomizer and nicotine-containing liquid (e-liquid). These two parts are similar to the relationship between a pen and ink, or a syringe and medicine.
The principle of electronic cigarettes is to atomize the e-liquid to form nicotine smoke, and smokers inhale the smoke into the body like smoking. This item is also called "vape" in English, and sometimes it is also called an electronic atomizer. Of course, sometimes electronic cigarettes also refer to a low-temperature roasted tobacco type electronic cigarette, also called "IQOS", which will not be discussed here. While traditional cigarettes contain burning tobacco and produce smoke, e-cigarettes like the IGET vape use an e-liquid that gets atomized for inhalation.

Let us first draw the conclusion that e-cigarette smoking is not completely harmless to health.

The US Centers for Disease Control and Prevention (CDC)'s assessment of e-cigarettes is that e-cigarettes are a new thing, and we still don't know the health effects of long-term use.
E-cigarettes usually contain nicotine, which is harmful to the development of the fetus and the cognitive development of young people under the age of 25.
In addition to nicotine, e-cigarette aerosols are not completely harmless. They contain some tiny particles that may cause cancer, and may also contain some heavy metals and volatile compounds [15]. Some studies have also shown that e-cigarettes increase the risk of heart disease and cancer.

However, although e-cigarettes are not “completely harmless” as some businesses claim, they are much less harmful than traditional cigarettes.

After weighing the pros and cons, public institutions in both the UK and the US tend to believe that e-cigarettes are better than cigarettes for smokers.
In 2015, Public Health England (PHE) released a 113-page report that analyzed the various risks of e-cigarettes in detail. The report concluded that e-cigarettes are 95% safer than smoking, and policies should encourage smokers to use e-cigarettes as a key tobacco control strategy to reduce the harm caused by smoking.

Despite being questioned by many parties, the Public Health Agency of England still insisted in 2018 that e-cigarettes are 95% safer than smoking.
In February 2018, the American Cancer Society (ACS) also issued a position statement: Although the long-term effects of using e-cigarettes are not clear enough, it can be estimated that it is less harmful than ordinary cigarettes. The association clearly encourages people to try using e-cigarettes instead of traditional cigarettes. The association also recommends that clinicians recommend e-cigarettes to smokers instead of traditional cigarettes. Of course, e-cigarettes are only a transitional state, and quitting smoking should always be the first choice.
In November 2018, the Centers for Disease Control and Prevention (CDC) in the United States also expressed its attitude to the public. It recommended that people who are already addicted to smoking switch to e-cigarettes and try to quit smoking. However, it also reminded that e-cigarettes are not harmless, and teenagers, pregnant women, and non-smokers should not try them just because they are less harmful than cigarettes.

Electronic cigarettes may not help you quit smoking

When selling e-cigarettes, merchants will promote that e-cigarettes can help people quit smoking, and some people choose e-cigarettes for this reason; but many people also say that e-cigarettes cannot help people quit smoking, so they don’t want to pay this IQ tax. Will they not be able to save on tobacco taxes, but will they have to pay an extra IQ tax?
At first glance, e-cigarettes and nicotine replacement products appear similar.
Nicotine substitutes are a general term for some smoking cessation products, which are mainly used in nicotine replacement therapy (NRT). Nicotine in cigarettes is an addictive substance, and people will have withdrawal reactions when quitting smoking, and they will feel uncomfortable, so they give up quitting smoking.

If you use nicotine patches, nicotine gum or nicotine spray to deliver nicotine to the blood when you quit smoking, you can alleviate the withdrawal reaction and increase the success rate of quitting smoking.
In 1996, the World Health Organization (WHO) officially recommended nicotine replacement therapy to all countries[1]. The FDA has also approved at least four legal nicotine replacement products to assist in quitting smoking.
E-cigarettes seem to have the same effect. In fact, the WHO calls e-cigarettes "electronic nicotine delivery systems" and examines them together with other nicotine substitutes.
However, although e-cigarettes are similar to nicotine substitutes, the behavior of e-cigarette use is similar to smoking, so we cannot simply assume that e-cigarettes can help people quit smoking.

Research results are inconsistent as to whether e-cigarettes can help people quit smoking.

For example, a paper published in JAMA in 2014 showed that through a longitudinal analysis of two online surveys of 949 smokers conducted one year apart, the success rate of smoking cessation among e-cigarette users did not increase, nor did their cigarette consumption decrease. However, the authors of the paper also stated that this survey relied on personal verbal reports and did not provide sufficient information about the respondents’ e-cigarette usage, frequency, and habits.
Other studies suggest that e-cigarettes can help smokers quit or reduce smoking.
A 2016 meta-analysis showed that people who chose to quit smoking with e-cigarettes were 28% more likely to successfully quit smoking than those who did not.
A recent study published in the Cochrane Database of Systematic Reviews found that e-cigarettes can help people quit smoking, and their effect is better than the placebo effect.
Another meta-analysis study in 2015 showed that people are more likely to quit smoking by using nicotine-containing e-liquid than by using nicotine-free e-liquid; this shows that e-cigarettes can indeed play the same role as traditional nicotine replacement therapy to a certain extent. This study even showed that e-cigarettes are more successful than traditional nicotine replacement therapy and are more likely to help people quit smoking (20% success rate VS 10% success rate)
In a study titled "Survey on the Use of Electronic Cigarettes by Smokers in Beijing" published in the 2015 Chinese Journal of Clinical Doctors, the authors also stated that electronic cigarettes can help smokers quit smoking or reduce their smoking, with 47.1% of smokers saying they had reduced their smoking habits.

The situation in the UK is more optimistic. In 2018, the UK Department of Public Health published a blog stating that, at least in the UK, e-cigarettes can help people quit smoking. More than half of the 2.9 million e-cigarette users in the UK have completely quit smoking, and e-cigarettes are expected to help 20,000 people quit smoking each year. With the promotion of e-cigarettes, the smoking rate in the UK has declined year by year, reaching a historical low of 15.5%, which is only higher than Sweden in Europe.

To be conservative, according to WHO in 2014, existing research is not enough to prove that using e-cigarettes can help people completely quit smoking, and traditional nicotine therapy, which has been proven to be effective, is recommended first.
WHO also believes that although it is impossible to completely quit smoking, many people still use two cigarettes at the same time, but because they will smoke less cigarettes, e-cigarettes can still be recommended to smokers.

Should e-cigarettes be banned?

However, the problem of e-cigarettes is not that simple. On the one hand, there is a huge number of smokers; on the other hand, there are the future flowers of every country - teenagers.
Should we emphasize that “e-cigarettes are 95% less harmful than cigarettes” or “e-cigarettes are harmful”? For public health, this is a real dilemma.
If the policy tends to promote that e-cigarettes are less harmful than cigarettes, then smokers are more likely to switch to e-cigarettes, and the harm caused by cigarettes will be less; however, the problem of smoking among teenagers may not be solved yet, and once they hear that e-cigarettes are less harmful, they may start smoking e-cigarettes again; it may even increase the overall number of smokers, which is counterproductive.
However, if we only talk about the dangers of e-cigarettes, it will cause smokers to distrust e-cigarettes and scare off smokers who want to switch to e-cigarettes.
In 2013, only 7% of British people mistakenly believed that e-cigarettes were as harmful as cigarettes, but in 2018, 25% of people thought so. The UK Department of Public Health pointed out that some remarks overemphasized the harm of e-cigarettes, but ignored the comparison with cigarettes, which affected the public's correct understanding of the harmfulness of e-cigarettes and cigarettes.

In the dilemma mentioned above, which side to focus on depends on the different situations faced by different countries and the attitudes of different parties within each country.

The UK as a whole tends to support the promotion of e-cigarettes, and emphasizes that "e-cigarettes are less harmful than cigarettes" in propaganda, dispelling smokers' concerns about the safety of e-cigarettes and emphasizing the comparison between the harm of e-cigarettes and cigarettes. In December 2018, the UK Department of Public Health (PHE) produced a short film using cotton balls to show people the difference between smoking cigarettes for a month and e-cigarettes for a month.
The UK seems more optimistic about young people's use of e-cigarettes.
For example: In January 2019, a charity called Cancer Research UK said that in the UK, there is a lack of evidence that e-cigarettes lead teenagers to smoke. Smoking among young people has been declining, and the probability of non-smoking young people using e-cigarettes is very low, around 0-1%.
The document further states that in Europe, although young people are more willing to try e-cigarettes, they are less likely to end up using e-cigarettes than older people, which means that trying e-cigarettes does not lead to smoking.

The problem of e-cigarette use among young people in the United States is more serious, and they are more cautious about e-cigarettes.

According to the National Youth Tobacco Survey in the United States, from 2017 to 2018, the proportion of high school students exposed to e-cigarettes soared from 11.7% to 20.8%, an increase of 78%; the proportion of junior high school students increased from 3.3% to 4.9%, an increase of 48%, an increase of 1.5 million people in one year. It is estimated that a total of 3.6 million middle school students have been exposed to e-cigarettes [11]. (Exposure is considered to be if one has tried e-cigarettes within 30 years of the survey interview)
The United States' caution towards e-cigarettes can be seen from the title of the e-cigarette material released by the Centers for Disease Control and Prevention (CDC): "What's the bottom line" (pun intended).
Both this material and the UK Department of Public Health’s promotional video were released in December 2018, but they reveal different tendencies. This material emphasizes that e-cigarettes are harmful, that the effectiveness of e-cigarettes in helping people quit smoking is unclear, and that it is more inclined to believe that e-cigarettes will cause young people to smoke[6].
In October 2018, Hong Kong, China announced that it was preparing to completely ban the sale of e-cigarettes, but did not completely ban the sale of ordinary cigarettes. This behavior inevitably makes people who don’t know much about it doubt whether e-cigarettes are more harmful.
However, this decision is more likely related to the fear of young people using e-cigarettes. Hong Kong’s tobacco control is relatively successful, with the smoking rate for people over 15 years old only around 10%, and the occasional smoking rate for secondary school students only 2.7% [13]. There are not many smokers in Hong Kong, so this decision may have been made because of concerns about the more complicated tobacco control environment brought about by e-cigarettes.
Now let’s look back at mainland China. The overall tobacco control results in mainland China are very worrying. China has the largest smoking population in the world. According to the 2015 China Adult Tobacco Survey Report by the Chinese Center for Disease Control and Prevention, the smoking rate of adults aged 15 and above in China is as high as 27.7%, and 52.1% of males are smokers (2.7% of females). There are as many as 316 million smokers aged 15 and above in China[5].
Smokers have a serious lack of knowledge about the harm of e-cigarettes and cigarettes, and few people use e-cigarettes to quit smoking. However, trend bloggers on video websites are luring young people, and e-cigarette-like snacks have appeared at the entrance of primary schools.
In short, if you are an old smoker who has failed to quit smoking many times, e-cigarettes may be a solution to quit smoking; but if you have never smoked, you should not try any e-cigarettes.

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