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Rapid response to:

Clinical Review State of the Art Review

What are the respiratory effects of e-cigarettes?

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5275 (Published 30 September 2019) Cite this as: BMJ 2019;366:l5275

Rapid Response:

Re: What are the respiratory effects of e-cigarettes?.. Even less if you don't inhale or use Nicotine Salts

Vaping has certainly dramatically lowered risk than the alternative, smoking cigarettes. (1) There maybe some residual risk but this potentially is becoming even less with new developments in e-liquids.

"Vapers" have traditionally used free based nicotine that most find quite irritating and puts off many potential vapers as it makes them cough. As a GP, I usually warn my patients about this and suggest that they learn a different "smoking" style of not inhaling.

This is what traditional pipe and cigar smokers do: absorbing the nicotine through the oral and nasal mucosa. This is similar to chewing tobacco, snuff or NRT systems. This often does not give the same "hit" of nicotine, especially now that the legal concentration of nicotine in e-liquids is just 20 mg/ml.

The alternative is to lower the concentration of nicotine, and many vape and inhale with concentrations of just 3-6 mg/ml. This obviously requires the inhaling of much larger quantities of e-liquid, raising the cost of vaping.

JUULs, an e-cigarette system that has induced what been described as "moral panic" in the USA, uses a nicotine salt (2). This allows much higher concentrations of nicotine to be vaped. As mentioned in the article in the USA, this is 59 mg/ml and results in a much lower volumes of juice being inhaled. In the UK the legal limit of nicotine being 20 mg/ml means that this is an expensive system, costing £10.99 for four 0.7ml pods.

There are alternatives becoming available. "88 Vape", one of the low cost juices widely available, has brought out its own "nic salt e-liquid" that retails for just £1/10ml.

These nicotine salts should allow more smokers to switch to vaping and quit smoking, and inhale less e-liquid. If the legal limit on the concentration of nicotine was raised then even less e-liquid would be needed by vapers to get the same hit of nicotine that they desire.

If the authors are really concerned about the small residual risk that may or may not exist from vaping then I suggest that they recommend nicotine salts to their patients, and call for a raising of the legal maximum strength of nicotine in e-liquids.

1. NHS Smokefree https://www.youtube.com/watch?v=SSn5ZZQkzKs down loaded 21/11/2019

2. https://www.clivebates.com/the-us-media-is-losing-its-mind-over-vaping-a... downloaded 21/11/2019

Competing interests: No competing interests

21 November 2019
John Ashcroft
GP
Derby