Young adults and e-cigarettes: a qualitative exploration of awareness, experience and attitudes

8 Health and safety issues

8.1 The safety of e-cigarettes was a key issue for focus groups participants. This was included as a specific discussion topic but it was also raised spontaneously in initial discussion exploring participants' knowledge and experience of e-cigarettes. Topics included perceptions of the health and safety risks of using e-cigarettes; experience and awareness of health and safety incidents; and information and evidence. Each of these is addressed below. The chapter concludes with a discussion about overall attitudes and behaviours linked to health and safety, which highlights the high degree of uncertainty amongst young adults about the safety of e-cigarettes.

Perceptions of the health and safety risks of using e-cigarettes

8.2 The focus groups included individuals who regarded e-cigarettes as 'safe' at one end of the spectrum and those who regarded them as 'dangerous' at the other end. There was a mix of views present in all groups, and most discussed their views in terms of relative safety in comparison with tobacco cigarettes. Participants expressed concerns on both health and safety grounds. However, while it was common for participants to recount (sometimes dramatic) examples illustrating their safety concerns, the possible health risks of using e-cigarettes attracted more debate in the focus group discussions.

8.3 The most common view among participants was that e-cigarettes were safe or, at least, saf er than tobacco cigarettes. Participants offering such views thought that e-cigarettes contained no toxins or fewer toxins than tobacco cigarettes, and several participants specifically noted that e-cigarettes did not contain tar. Some regular vapers confidently explained the safety of e-cigarettes based on their knowledge of the ingredients:

'It's just really nicotine, water and flavouring. I've not seen any solid evidence to suggest otherwise… I don't see any evidence that's really suggesting that there's anything really in them that's that bad, you know.' ( FG8, Male, smoking group, aged 19-25, in employment)

8.4 More often participants stressed the relative safety compared with tobacco cigarettes - they thought e-cigarettes were safer than tobacco cigarettes, but were not convinced they were completely safe. One participant, for example, commented:

'Yeah, it's not as bad as smoking, but there is still, like, an element of harm to yourself, so that's why I am trying got get off it.' ( FG7, Male, vaping group, aged 19-25, unemployed)

8.5 Some who shared this view referred to the nicotine content in e-liquids as a potential source of harm:

'They're not [safe] because you are still smoking the nicotine… Safer than cigarettes, but they are not safe, obviously.' ( FG5 Male, smoking group, aged 19-25, in employment)

8.6 The view that e-cigarettes were 'safer than cigarettes, but not entirely safe' was often linked to a lack of information, with participants saying that they were concerned about the health risks because they did not know what was in them. Further, the discussion amongst participants often suggested a general sense that inhaling any substance into the body was 'not natural' and therefore could not be healthy.

8.7 There were a few instances, however, of participants noting specific factors which they thought affected the safety of e-cigarettes. These included:

• The pattern of usage - long-term use, frequency of use and the amount of vapour inhaled were all seen as having an effect on safety
• The flavours used - some flavours were reported to be safer than others
• The price and / or quality of the products used - there was particular concern about the ingredients in cheap e-liquids
• The age of the user - young people were said by some to be more vulnerable to negative health effects.

8.8 The remaining participants generally thought that e-cigarettes and tobacco cigarettes were 'equally as bad' or 'just as bad as each other'; or that they were less safe than tobacco cigarettes. Younger participants - smokers and non-smokers - were most likely to offer such views.

8.9 These participants sometimes referred to unspecified 'chemicals' (or other ingredients) in e-liquids as harmful to health, and tended to give greater weight than other participants to accidents and product malfunctions, rather than just the possible impact on general health in reaching their conclusions. Some also suggested that the nature of the product - combining electricity, heat and 'oil' - made using it inherently risky. As with those who thought e-cigarettes were safer than tobacco cigarettes, this group also made it clear that a lack of information was contributing to their views.

8.10 Although participants often offered views on health and safety risks associated with e-cigarettes, they also frequently expressed a degree of uncertainty on this issue. It was not uncommon for participants to phrase their comments on this topic as rhetorical questions, or questions to the group, asking: 'Are they not bad for you?'; 'I know that smoking is toxic, but does a vape not have a really bad toxic chemical in it too?'; 'Do vapes give you cancer?', etc.

Health and safety incidents

8.11 As part of the discussion, participants often referred to health and safety 'incidents' caused by e-cigarettes which they had either experienced personally or were otherwise aware of. These included adverse health effects and physical injuries.

8.12 In relation to possible health problems, participants often relied on the media and 'hearsay' as their main source of information. They had, for example, heard that e-cigarettes could cause cancer, harm your liver, damage your hearing, and damage your lungs, and there was a discussion in several focus groups about a condition called 'popcorn lung' which participants had read about on the internet.

8.13 Participants had less personal experience of health problems caused by e-cigarette use. Those who had used e-cigarettes did, however, occasionally say that their health had initially been affected when using e-cigarettes - e.g. they reported coughing and pains in the lungs - but that this had, in most cases, resolved itself with continuing use (these might be seen as typical symptoms associated with stopping smoking). There were also some reports of family members being affected by respiratory problems caused by 'oil on the lungs' as a result of using an e-cigarette, or suffering from asthma attacks as a result of being exposed to e-cigarette vapour. In contrast to these types of comments, some vapers described how their health had improved since switching from tobacco cigarettes. They talked of improved breathing, being able to exercise more, no longer coughing, and generally feeling healthier (see Chapter 5, paragraphs 5.23- 5.24).

8.14 In relation to external injuries caused by e-cigarettes, participants across all the groups were able to provide examples of this, either first- or second-hand. Most commonly, people mentioned burns and blisters caused by hot liquid leaking or 'spitting' from e-cigarettes, or from e-cigarettes breaking, 'popping' or exploding, apparently, in some cases, while not in use. Some of these incidents had resulted in the need for hospital treatment.

8.15 While some respondents had had direct experience of such incidents, others related episodes involving family members or others in their wider social circles. Participants had also become aware of accidents involving e-cigarettes from the media, and social media in particular.

8.16 Some suggested that injuries could largely be attributed to poor quality products and components. Others thought that misuse of devices - perhaps resulting from inadequate knowledge - was a contributory factor in some accidents. Such participants tended to be regular vapers who stressed the importance of 'knowing your stuff' when using e-cigarettes, and maintained that they were safe 'if you know what you are doing'.

Concerns about health and safety risks for children

8.17 Participants often voiced particular concerns about the potential health risks for children exposed to e-cigarettes: the harm that might be caused by inhaling 'second-hand' vapour; and the risk of injury caused by handling e-cigarettes and liquids owned by others ( e.g. family members). Some vapers reported that they avoided using their e-cigarettes if children were present.

Information and evidence on the health effects of using e-cigarettes

8.18 Participants occasionally indicated some awareness of ongoing scientific and policy debates about the health effects of using e-cigarettes. Regular vapers were most likely to be aware of evidence and to refer to this in general terms, arguing that e-cigarette use presented a low risk to health. Interestingly, one vaper referred to research that he said showed e-cigarettes to be '95% safer than cigarettes'. This is likely to be the evidence review published by Public Health England in August 2015 which received media coverage in the months prior to the fieldwork for this research. ^[18] Other participants indicated a vague awareness of current research with one saying, for example, that 'they are trying to figure out if vapes are worse for you in the long run'.

8.19 However, more often, participants indicated a degree of confusion and / or scepticism about available evidence and related health advice. One participant was aware of research that had shown chemical levels in e-cigarettes to be low, but went on to say, 'I don't know if that's lying or not'; another said he was not sure what to believe. Others drew comparisons with constantly changing public health messages on issues such as diet. Others believed that the tobacco companies were involved in e-cigarette research and therefore questioned the validity of the findings.

8.20 Participants consistently referred to a perceived lack of evidence about the health risks. They repeatedly made the point that e-cigarettes were relatively new and it took time to build up hard evidence, particularly in relation to long-term health risks. Many respondents compared the situation to that of tobacco, and highlighted how it had taken many years for the health risks to be established and accepted. One individual said, 'Our generation will basically be the test subjects for long-term vaping,'

8.21 Participants often indicated that their own uncertainty was due to a lack of information. They suggested that they had insufficient information or that there was insufficient evidence currently available to reach a conclusion about safety, variously making statements such as: 'Nobody knows what's in them'; 'Nobody knows the long term effects'; and 'I don't know how safe they are because you don't know what kind of chemicals are actually inside it.'

Overall attitudes and behaviours linked to health and safety concerns

8.22 In terms of overall attitudes towards the safety of e-cigarettes, participants can be characterised as falling into the following main categories:

• Those who regarded e-cigarettes as safe products and had no concerns about using them. Participants in this category generally based their position on a relatively good understanding of the contents of e-liquids and how e-cigarettes worked; they also tended to use more expensive, better quality products.
• Those who had concerns, largely fuelled by first- and second-hand experiences of harm caused by e-cigarettes and a lack of clear evidence demonstrating their safety, but who were nevertheless of the view that e-cigarettes were 'not as bad as tobacco cigarettes'.
• Those who were aware of concerns but were unperturbed by the possible health risks. These participants were smokers and held the same position with regard to tobacco cigarettes, with one person saying 'I've been smoking [tobacco cigarettes] for plenty of years and I don't care what's in them'. Their attitude was summed up by another participant who said 'you might get run over by a bus tomorrow'.
• Those whose concerns stemmed from the apparent shortage of information and evidence, and who therefore preferred to continue smoking tobacco cigarettes. The position of this group was best characterised as 'better the devil you know than the devil you don't'.
• Those who regarded e-cigarettes as 'dangerous', based on first- and second-hand experiences of harm caused by e-cigarettes. In general, this group was not interested in using e-cigarettes.

8.23 Some young adults reported that their use of e-cigarettes had been influenced by health and safety concerns, as follows:

• Some vapers reported not using their e-cigarettes around other people (children) because of health concerns, and one said he had stopped using e-cigarettes altogether because of his increasing concerns.
• Some smokers had been put off using e-cigarettes because of injuries caused by e-cigarettes, either to themselves or others.
• Some non-smokers and non-vapers said that health and safety concerns contributed to their decisions to not try e-cigarettes.

8.24 For the most part, however, concern about health and safety aspects of e-cigarettes was not a significant factor in overall behaviours and attitudes towards their use. Rather, it was more often the health and safety concerns related to tobacco cigarettes which influenced behaviour, encouraging people to switch to e-cigarettes despite their concerns.

8.25 Across all groups, though, there was a great deal of uncertainty about the health and safety implications of using e-cigarettes, particularly in relation to health risks, and participants called for more information. They wanted information on what was in e-cigarettes, how their use affected the body, whether they were more or less harmful than tobacco cigarettes, and what the long-term effects of use were.