E-cigarette use was associated with elevated risk for incident heart failure compared with never use.
The association was significant even after adjustment for concomitant substance use and other risk factors.
ATLANTA — Individuals with a history of e-cigarette use may have increased risk for incident heart failure, regardless of concomitant cigarette, cigar, hookah or smokeless cigarette use, a speaker reported.
“More and more studies are linking e-cigarettes to harmful effects and finding that it might not be as safe as previously thought,” Yakubu Bene-Alhasan, MD, resident physician at MedStar Health in Baltimore, said in a press release. “The difference we saw was substantial. It’s worth considering the consequences to your health, especially with regard to heart health.”
E-cigarette use was associated with elevated risk for incident heart failure compared with never use.
Bene-Alhasan and colleagues used electronic health record data from the NIH-sponsored All of Us Research Program and responses to the Population Assessment of Tobacco and Health-styled questions to conduct a prospective analysis to better understand the association between e-cigarette use and incident HF. The overall cohort included 175,667 participants.
During a median follow-up of 45 months, 3,242 HF events occurred.
The findings were presented at the American College of Cardiology Scientific Session.
After adjusting for demographic factors, socioeconomic factors, diabetes, hypertension, hyperlipidemia, BMI and concomitant substance use — including cigarette, cigar, hookah, smokeless cigarette and alcohol use — users of e-cigarettes had an 19% greater risk for incident HF compared with never users (adjusted HR = 1.19; 95% CI, 1.06-1.35).
The researchers noted an increased risk for HF with preserved ejection fraction (aHR = 1.21; 95% CI, 1.01-1.47) and not HF with reduced EF (aHR = 1.11; 95% CI, 0.9-1.37).
The association between e-cigarette use and risk for incident HF was attenuated slightly after researchers excluded participants who reported having a history of cigarette, cigar, hookah and smokeless cigarette use (aHR = 1.04; 95% CI, 0.57-1.89).
“I think this research is long overdue, especially considering how much e-cigarettes have gained traction,” Bene-Alhasan said in the release. “We don’t want to wait too long to find out eventually that it might be harmful, and by that time a lot of harm might already have been done. With more research, we will get to uncover a lot more about the potential health consequences and improve the information out to the public.”
Researchers found higher quit rates for smoking with e-cigarette use vs. nicotine replacement therapy.
It is likely that nicotine e-cigarettes aid more individuals in quitting than non-nicotine e-cigarettes.
Individuals using nicotine e-cigarettes have a higher likelihood of quitting smoking compared with nicotine replacement therapy users, according to data published in Cochrane Database of Systematic Reviews.
“Vaping (using e-cigarettes) is not risk free but is considerably less harmful than smoking,” Jamie Hartmann-Boyce, MA, DPhil, assistant professor of health policy and promotion in the School of Public Health and Health Sciences at University of Massachusetts Amherst, told Healio. “Evidence from well-conducted randomized controlled trials [RCTs] shows that nicotine e-cigarettes can help people quit smoking and are more effective at doing so than nicotine replacement therapies.”
Individuals using nicotine e-cigarettes have a higher likelihood of quitting smoking compared with nicotine replacement therapy users, according to data published in Cochrane Database of Systematic Reviews.
In this update of a living systematic review, Hartmann-Boyce and colleagues investigated how e-cigarettes compare with nicotine replacement therapy (NRT), non-nicotine e-cigarettes and behavioral support/no treatment in terms of 6-month smoking abstinence. This review was last updated in 2022.
To find relevant studies, researchers looked through the Cochrane Tobacco Addiction Group’s Specialized Register up until February 2023, as well as MEDLINE, Embase and PsycINFO up until July 2023.
Researchers also consulted the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, all through Issue 6 of CENTRAL 2023.
Ten of the 88 trials/studies (n = 27,235; 47 RCTs) included in this analysis were published since the 2022 update
More than half of the trials (58 studies) had a high risk for bias, whereas 10 studies had a low risk for bias. The risk for bias in the rest of the studies was unclear, according to researchers.
NRT vs. e-cigarettes
Seven studies (n = 2,544) evaluated nicotine e-cigarettes against nicotine replacement therapy. Between the two treatments, researchers found high certainty evidence of heightened quit rates with nicotine e-cigarette use (RR = 1.59; 95% CI, 1.29-1.93), and this may equate to an achievement of four more quitters per 100.
Researchers further found a comparable rate of adverse events among those using e-cigarettes and those using NRT (RR = 1.03; 95% CI, 0.91-1.17) in five of the studies (n = 2,052), which was supported by moderate certainty evidence.
When evaluating serious adverse events between the two sets of individuals, the current evidence was not enough to make a conclusion on this outcome. Notably, individuals from all study arms rarely reported these events, according to researchers.
Non-nicotine e-cigarettes vs. nicotine e-cigarettes
Using six studies (n = 1,613) that reported on quit rates between non-nicotine e-cigarette users and nicotine e-cigarette users, researchers again found higher quit rates with nicotine e-cigarettes (RR = 1.46; 95% CI, 1.09-1.96), which may mean three more quitters per 100. Notably, there was only moderate certainty evidence to support this outcome.
“This is a living systematic review, which means we are constantly looking for new evidence and regularly updating the review,” Hartmann-Boyce said. “From that perspective, the results themselves are actually really consistent with the picture that’s been emerging over the past 5 years or so — namely that the evidence is clear that e-cigarettes with nicotine can help people quit smoking.”
The rate of adverse events and serious adverse events between the two treatments was similar to that observed between NRT and e-cigarettes. Five studies (n = 1,840) showed moderate certainty evidence of a comparable rate of adverse events among the two sets of e-cigarette users (RR = 1.01; 95% CI, 0.91-1.11), whereas there was not enough evidence to make a conclusion on differences in serious adverse events.
Behavioral support/no support vs. e-cigarettes
Nine studies (n = 5,024) reported on quit rates between those receiving behavioral support/no support and those using nicotine e-cigarettes. Evidence from these studies was of low certainty, so researchers could only conclude that the e-cigarette group may have greater quit rates (RR = 1.88; 95% CI, 1.56-2.25), which could lead to four more quitters per 100.
When placed against behavioral support/no support, more nicotine e-cigarette users experienced adverse events (RR = 1.22; 95% CI, 1.12-1.32) based on four studies (n = 765), but this evidence was of low certainty.
For the third time, researchers could not compare the rate of serious adverse events between those receiving behavioral support/no support and those using nicotine e-cigarettes because of a lack of evidence.
When asked about future studies, Hartmann-Boyce said different e-cigarette models and flavors need to be researched.
“We need more studies testing newer types of e-cigarettes and investigating how differences in their characteristics — such as flavors — may impact their effects,” Hartmann-Boyce told Healio. “Fortunately, there are some studies in the pipeline which will help answer these questions.”
Although this systematic review focuses on comparing e-cigarettes to other smoking cessation treatment options, it serves as a reminder that e-cigarettes do not put individuals at as much harm as cigarettes.
As Healio previously reported, many U.S. adults appear to believe that e-cigarettes contain a larger amount of dangerous chemicals than cigarettes, but Hartmann-Boyce told Healio this is not the case.
“Nicotine e-cigarettes don’t involve burning tobacco,” she said. “The harm from smoking traditional cigarettes comes not from the nicotine but from all the chemicals that are released when tobacco is burned. This harms people who smoke and can harm the people around them, too.”
In a new study, researchers detected the presence of synthetic cooling agents in U.S.-marketed e-cigarettes, at levels that may exceed current safety thresholds.
“We were concerned that menthol and synthetic compounds or artificial compounds that are similar to menthol are also in e-cigarettes,” Sven-EricJordt, PhD, associate professor in anesthesiology and associate professor of pharmacology and cancer biology at Duke University School of Medicine, told Healio during the American Thoracic Society International Conference. “These compounds have the same cooling effect as menthol. We wanted to see what the levels are, how much is added to the e-cigarettes and whether there might be some concerns about toxicity in these compounds. They are permitted for use in foods, but we don’t know their safety when you inhale them in tobacco products. Some international regulatory organizations have issued threshold values for raising toxicity concerns.”
According to Jordt, e-cigarette manufacturers use these compounds to create a cooling effect to reduce unpleasant sensations and allow users to inhale more nicotine.
Jordt and colleagues searched e-liquid vendor sites for the terms “koolada,” “kool/cool,” “ice” and researched whether the companies sold products with the specific synthetic cooling agents WS-3 and WS-23. Researchers compared ice flavor varieties of the currently most popular disposable e-cigarette brand, Puff Bar, and non-ice varieties.
Using gas chromatography-mass spectrometry, Jordt and colleagues characterized e-liquids and synthetic cooling agents and calculated the margin of exposure to determine risks associated with exposure to synthetic cooling agents from using e-cigarettes. A margin of exposure of 100 means that the user’s exposure is 100 times lower than levels proven to cause toxic effects in the organs of animals. Scientists studying potentially harmful substances are aware that a margin of exposure below 100 indicates increased risk, according to a press release.
The synthetic cooling agent WS-3 was identified in 24 of 25 e-liquid refills. In addition, 13 of 14 Puff Bar disposable e-liquid flavor varieties contained the synthetic cooling agent WS-23 and five also contained WS-3 in ice and non-ice flavors.
Researchers observed a margin of exposure below the safe margin of 100 or more for most daily vaping levels in modeling WS-3 consumption from vaped e-liquids with 3 mL in 14 e-liquids, 5 mL in 18 and 10 mL in 20. In 11 of 13 Puff Bar products, the margin of exposures for WS-23 were less than 100 in all e-cigarette use scenarios.
“This should raise concerns for regulators, such as the FDA, to look into this and issue limitations on how much of these components should be added into these products,” Jordt said. “This is still a market with very little oversight by government regulators and many of the chemicals in there are of concern, may be toxic and the levels are higher than would be allowed in food.”
These synthetic cooling agents were found in mint, menthol, fruit and candy-flavored e-cigarette products.
“Our findings confirm that the cigarette industry is disregarding safety levels of the chemicals they add into their products to make them more addictive,” Jordt said. “They constantly evade regulation, and the FDA has a hard time to catch up and people should be cautious using these products and becoming addicted to them.”
For more information:
Sven-Eric Jordt, PhD, can be reached at sven.jordt@duke.edu.
Use of electronic cigarettes continues to rise among teens, and there is new evidence that a growing number of high school-age youth who don’t smoke cigarettes are taking up the e-cigarette habit.
Among surveyed teens living in North Carolina, electronic cigarette use increased more than four-fold between 2011 and 2013, reflecting the upward trend among teenagers nationwide.
And one-in-five nonsmoking teens who participated in the 2013 survey said they planned to try e-cigarettes within the next year.
This finding is particularly troubling, given the growing evidence linking e-cigarette use to smoking initiation, wrote researcher Liling Huang, PhD, of the University of North Carolina, Chapel Hill, and colleagues in the CDC online journal Preventing Chronic Disease, published August 4.
“Given that e-cigarettes have recently become the leading form of tobacco used by U.S. adolescents, the rapid increase in e-cigarette use among North Carolina cigarette ‘never smokers’ is concerning,” the researchers wrote.
They examined e-cigarette and cigarette use prevalence using data from the school based, cross-sectional North Carolina Youth Tobacco Survey from 2011 (n=4,791 respondents) and 2013 (n=4,092 respondents).
Among the main study findings:
Current e-cigarette use increased significantly from the 2011 to the 2013 survey, from 1.7% (95% CI, 1.3% to 2.2%) to 7.7% (95% CI, 5.9% to 10.0%).
Among dual users, current e-cigarette use was negatively associated with intention to quit cigarette smoking for good (relative risk ratio [RRR]=0.51; 95% CI, 0.29 to 0.87) and with attempts to quit cigarette smoking in the past 12 months (RRR=0.69; 95% CI, 0.49 to 0.97).
Current e-cigarette smokers were less likely than those who only smoked cigarettes to have ever abstained from cigarette smoking for 6 months (RRR=0.42; 95% CI, 0.21 to 0.82) or 1 year (RR=0.21; 95% CI, 0.09 to 0.51) and to have used any kind of aids for smoking cessation (RRR=0.46; 95% CI, 0.29 to 0.74).
“Our findings about rising dual use of e-cigarettes and cigarettes, along with associations between e-cigarette use and lower cessation intention and behaviors have implications for public health practice and cessation clinic services,” the researchers wrote.
They added that the analysis also support federal government’s regulation of the e-cigarettes as tobacco products, announced by the FDA in May. Provisions of the tobacco deeming regulations banning e-cigarettes sales to minors and greatly restricting the marketing and advertising of e-cigarettes go into effect August 8.
In an interview with MedPage Today, Amy Lukowski, PsyD, of National Jewish Health, Denver, Colorado, said the uptake in e-cigarette use among teens is particularly troubling because the long-term impact of nicotine addiction on a developing brain is not well understood.
“We do know that the sooner you introduce nicotine the more it impacts the brain,” she said, adding that there is concern that adolescents may more vulnerable to nicotine dependency than adults.
The growing use of e-cigarettes by a significant percentage of teens who do not smoke cigarettes is also not surprising, she said.
“Curiosity and risk taking behavior are fundamental to adolescent development, and the (e-cigarette) industry exploits that and continues to target teens,” she said.
E-cigarettes are far less harmful than tobacco and could be prescribed to help smokers quit, a report in England found. But the Welsh government wants to ban their use in public places. Why are approaches in the neighbouring countries so different?
Some look like traditional cigarettes, with a light to mimic the glow of burning ash. Others are more ornate – long metallic devices that more closely resemble pipes or even torches.
These days you don’t have to go very far to spot one.
Around 2.6 million adults in Britain have used e-cigarettes in the decade or so that they have been on the market. And there’s wide disagreement about the extent to which this is a good or a bad thing.
No-one is advising non-smokers to take them up, but a recent report by Public Health England and found they were 95% less harmful than tobacco and could be a “game changer” when it came to persuading people to quit cigarettes.
And yet while the report heralded the possibility of prescribing e-cigarettes to English smokers who want to stop, neighbouring Wales is taking quite a different approach.
The devolved government there is looking to ban them in enclosed public places – in common with 40 other countries that have already imposed similar restrictions. The World Health Organization also supports regulating them more stringently. Scotland has not gone as far as Wales, but e-cigarettes are currently forbidden in almost all Scottish hospital grounds, which the Holyrood government plans to put on a statutory footing.
E-cigarettes are not covered by the UK’s anti-smoking laws, and they are permitted in some pubs. But many businesses and organisations have imposed their own restrictions.
All Bar One, Caffe Nero, KFC and Starbucks are among the food chains that have banned them on their premises. Manchester City, Manchester United and Chelsea forbid using them in their stadia although Burnley FC has a “vaping zone”.
Pub chains Mitchell’s and Butlers, JD Wetherspoon and Fuller’s have all banned e-cigarette use on the premises, citing the possibility of confusion for customers and staff. Stonegate Pub Company said they were not allowed in non-smoking areas because of their “remarkable likeness” to cigarettes. Enterprise Inns leaves the decision down to its tenants and has done a deal with one brand of e-cigarettes to sell them.
The devices are forbidden on National Express coaches as well as on CrossCountry Trains, Northern, Thameslink and Virgin as well as all Transport for London routes. Many train stations ban their use even on open platforms as they can “unsettle passengers” and leave them thinking actual smoking is allowed.
Most airlines and airports ban them although London Heathrow permits their use up to the flight gate and Ryanair sells its own “smokeless” cigarettes, which aren’t electronic and work like nicotine inhalers. This year the industry body Oil and Gas UK advised companies not to allow e-cigarettes to be used offshore following a health and safety report.
Opinion is divided among UK public health professionals. The anti-smoking charity Ash strongly backed the PHE report’s recommendations and the Royal College of Physicians believes they could lead to “significant falls” in smoking. But the British Medical Association (BMA) supports banning their use in enclosed public places.
There is some consensus, however. The weight of evidence suggests that e-cigarettes – which heat liquid nicotine to form a vapour – are much less harmful to chronic smokers than conventional tobacco smoke, which has far higher levels of carcinogens and toxicants.
On some e-cigarettes, inhalation activates the battery-powered atomiser. Other types are manually switched on
A heating coil inside the atomiser heats liquid nicotine contained in a cartridge
The mixture becomes vapour and is inhaled. Many e-cigarettes have an LED light as a cosmetic feature to simulate traditional cigarette glow.
Different brands of e-cigarettes contain different chemical concentrations.
But nor does anyone believe e-cigarettes are without risks. The PHE report acknowledges there are no studies on what harmful effects might result from long-term use. Official advice is to give up completely.
“No research has said these products are completely safe and efficient – the comparison is with the known risks of smoking,” says Ann McNeill, professor of tobacco addiction at Kings College London and one of the PHE report’s authors.
But it did find that e-cigarettes cause just a fraction of the harm done by tobacco cigarettes. Most of the chemicals which cause smoking-related diseases are not present in e-cigarettes and they contain only 1/50th of the formaldehyde of conventional cigarettes. They also release so little nicotine into ambient air that the risks to passers-by are marginal, the PHE team concluded.
The researchers also said e-cigarettes may be contributing to falling smoking rates, that there was no evidence so far they acted as a “gateway” to tobacco – and that half of people were unaware they they were less harmful than conventional smoking.
While it was not clear whether e-cigarettes were more or less effective than other stop-smoking medications, the fact the devices were more popular offered “an opportunity to expand the number of smokers stopping successfully”. PHE says they have helped 1.1 million people stop smoking.
But not everyone was convinced. The Welsh government issued a statement warning of the risk that e-cigarettes might nonetheless “normalise” smoking, “especially for a generation who have grown up in a largely smoke-free society”. Previously, in 2014, Dame Sally Davies, the chief Medial Officer for England, also warned they risked “normalising” the practice.
It’s not an argument that sways McNeill. “The best test of normalisation is what happens to smoking rates in the population,” she says.
“We commented in our report that since the introduction of e-cigarettes to the market the smoking prevalence has continued to decline.” Less than one in fiveEnglish adults was a smoker in 2013, down from 26% in 2003, a year before e-cigarettes entered the market.
The PHE report found that of the one in 20 adults in Great Britain who use e-cigarettes, about 60% are current tobacco smokers and the vast majority of the remainder are former smokers. Just 0.2% had never smoked.
There are other sources of scepticism. Some are concerned that the huge variety of the market means different e-cigarette brands deliver varying amounts of nicotine, toxins, and carcinogens. The BMA says there are “significant concerns from medical professionals around the inconsistent quality of e-cigarettes”.
In 2016, the EU’s Tobacco Products Directive will come into effect, however, which will tighten regulation on e-cigarettes and cap nicotine levels.
At present there are no e-cigarettes licensed through the Medicines and Healthcare Products Regulatory Agency, so they cannot be prescribed by the NHS. If this were to change, says Rosanna O’Connor, director of alcohol, drugs and tobacco at PHE, medical regulation would result in e-cigarettes being made available alongside nicotine patches and gum and “provide reassurance of their quality and effectiveness”.
England’s policies towards e-cigarettes, which already are among the most liberal in the world, have much to do with a decision by the government’s Behavioural Insight Team – nicknamed the “nudge unit” – not to “regulate these out of existence” on the basis that they had the potential to reduce harm.
By contrast, Welsh policy was underpinned by a different set of assumptions. Julie Bishop, of Public Health Wales, has argued that, while there may be no conclusive evidence that children were taking up vaping in large numbers, the “precautionary principle” required “not waiting for conclusive evidence of harm” before taking action to protect young people.
Public health officials in England do not share this concern. “The evidence tells us that while there is some experimentation among young people, there is almost no regular use among young people or adults who have never smoked before,” says O’Connor.
The PHE report found around 13% of young people have tried them, but only 5% use them at least monthly and 0.5% weekly. Only 0.3% of young people who had never smoked before were regular e-cigarette users.
Bans on the sale of electronic cigarettes to under-18s are due to be introduced by authorities in England, Wales, Scotland and Northern Ireland. But the different regimes appear to all have different philosophies when it comes to judging whether harm reduction should be a priority over minimising the risk of the devices.
Some objections are more visceral, based on the health professionals’ experience of the tobacco industry.
“My understanding of basic economic theory is that if it was bad for the big tobacco companies, they wouldn’t be doing it,” says David Bailey of the BMA’s Welsh GPs committee. “If these things are intended as a way to give up, why are they being marketed in 20 fruity flavours?”
Also, he asks whether it’s appropriate that taxpayers “should be funding someone’s lifelong addiction”.
The idea of “evidence-based policy” is a fashionable one. But while the evidence surrounding e-cigarettes is broadly accepted, there’s still much debate among decision-makers on what sort of policy should result from it.
More from the Magazine
Nic level? Three milligrams. And, let’s go for organic kosher shazamazam – it’s a bit like the grape candy you can get in Korea, if you’ve ever had that.
Any idea? That’s vape talk – the new vocabulary that surrounds e-cigarettes.
Among ninth graders who did not use combustible tobacco products, e-cigarette use was associated with increased risks for smoking combustible cigarettes, cigars, and hookah during the subsequent year.
An estimated 16% of U.S. tenth graders have tried e-cigarettes, of whom 43% have never smoked combustible cigarettes. To determine whether use of e-cigarettes during adolescence increases the likelihood of subsequently using combustible tobacco products (cigarette, cigar, or hookah), investigators analyzed data from a longitudinal study of high school students surveyed in the fall of ninth grade (baseline) and then 6 and 12 months later.
Of 2530 students who had never used combustible tobacco control products at baseline (mean age, 14 years; 53% female; 19% Asian, 44% Hispanic, 16% white), 222 (9%) had used e-cigarettes. At each follow-up period, e-cigarette users at baseline were more likely than nonusers to begin using any combustible tobacco product during the previous 6-month period (31% vs. 8% at 6 months; 25% vs. 9% at 12 months). Adjustment for peer smoking, impulsivity, any previous use of non-nicotine and non-tobacco substances, delinquent behavior, and smoking expectancies — but not for socioeconomic status or other psychosocial variables — attenuated but did not eliminate the significant relationship between baseline e-cigarette use and transition to using combustible cigarettes (adjusted odds ratio, 1.75), cigars (AOR, 2.96), or hookah (AOR, 2.26). Baseline use of cigarettes or hookah but not cigars was associated with e-cigarette initiation across follow-up periods in fully adjusted models.
COMMENT
This well-executed study provides strong evidence that use of e-cigarettes is prospectively associated with uptake of combustible tobacco product use among ninth graders. Although the authors controlled for numerous key variables related to both e-cigarette use and combustible tobacco product use, the possibility of unknown confounding remains. It would be interesting to know what variables were protective for the 70% of baseline e-cigarette users who did not initiate combustible tobacco product use during the following year.
There are more than 8,000 different flavours of e-cigarettes
The World Health Organization says there should a ban on the use of e-cigarettes indoors and that sales to children should stop.
In a report the health body says there must be no more claims that the devices can help smokers quit – until there is firm evidence to support this.
WHO experts warn the products might pose a threat to adolescents and the foetuses of pregnant women.
But campaigners say regulations must be proportionate.
Tempting flavours
According to the WHO legal steps need to be taken to end the use of e-cigarettes indoors – both in public spaces and in work places.
And the report focuses on the potential for products to spark wider cigarette use in children.
The health experts call for a ban on advertisements that could encourage children and non-smokers to use the devices.
And they say fruit, candy or alcoholic-drink style flavours should be prohibited too, while the sales of electronic cigarettes from vending machines should be heavily restricted.
1. On some e-cigarettes, inhalation activates the battery-poweredatomiser. Other types are manually switched on
2. A heating coil inside the atomiser heats liquid nicotine contained in a cartridge
3. Liquid nicotine becomes vapour and is inhaled. The ‘smoke’ produced is largely water vapour. Many e-cigarettes have an LED light as a cosmetic feature to simulate traditional cigarette glow.
‘Health threats’
The WHO warns exhaled e-cigarette vapour could increase the background air levels of some toxicants and nicotine.
Observing a lab test comparing traditional smoking with e-cigarettes
According to the team while e-cigarettes are likely to be less harmful than traditional cigarettes, they may pose threats to adolescents and the foetuses of pregnant women who use these devices.
But some researchers suggest tough regulations may prevent smokers having access to products that are potentially less harmful than conventional cigarettes.
A spokesman for the British American Tobacco company said: “We have always said that given nicotine is addictive, minimum age laws of 18 for the sale of e-cigarettes should be introduced.
“However, if overly restrictive regulations are introduced hampering innovation or adult usage, then this could simply stifle the growth of new products and prevent smokers from being aware of and having access to them – this can only be bad thing for public health.”
Charles Hamshaw-Thomas, E-Lites: Ban on indoor use would be “troubling”
‘Proportionate regulation’
Hazel Cheeseman, at the charity Action on Smoking and Health, said there was no evidence of any harm to bystanders and warned regulation needed to be proportionate.
She added: “Smoking kills 100,000 people in the UK alone.
“Smokers who switch to using electronic cigarettes in whole or in part are likely to substantially reduce their health risks.
“Although we cannot be sure that electronic cigarettes are completely safe, as the WHO acknowledges, they are considerably less harmful than smoking tobacco and research suggests that they are already helping smokers to quit.”
Global guidelines
A UK Department of Health spokeswoman said: “More and more people are using e-cigarettes and we want to make sure they are properly regulated so we can be sure of their safety.
“We have already set out our intention to change the law to ban the sale of e-cigarettes to children under 18.
“The UK has an existing licensing system for higher strength products and those that claim to help people quit.
“We are also bringing in new European rules to cover lower strength products which will ban most advertising, limit nicotine levels and set standards for ingredients, labelling and packaging.”
The WHO’s recommendations were published ahead of a meeting involving all countries that have signed up to an international convention on tobacco control.
New global guidelines could be agreed during the October meeting.
ARYAN'S BLOG 
COMMENT
This well-executed study provides strong evidence that use of e-cigarettes is prospectively associated with uptake of combustible tobacco product use among ninth graders. Although the authors controlled for numerous key variables related to both e-cigarette use and combustible tobacco product use, the possibility of unknown confounding remains. It would be interesting to know what variables were protective for the 70% of baseline e-cigarette users who did not initiate combustible tobacco product use during the following year.