Read this article to learn more about: the latest recommendations on the use of electronic cigarettes

advice that should be given to smokers about e–cigarettes.

When I was a student, I joined an anarchist group. I enjoyed the beer-drinking, the producing, on an old Roneo printer, of smudgy political flyers, the screenprinting of posters that we’d go out and fly-post after dark (taking care not to get caught with wallpaper paste all over our hands). Part of me thought privately that if any of the group found a burglar had trashed their home, they wouldn’t hesitate to call the maligned police, but I did unswervingly believe one principal tenet: that the end justified the means.

Older and more respectable now, I manage a Stop Smoking Service for Leicestershire Partnership NHS Trust. In early 2013, we started to realise that the numbers of people using our service were falling sharply, despite years of success in delivering an excellent model for helping long-term smokers kick the habit. The phones stopped ringing, people did not turn up to appointments, and if they did start treatment, they would more often than not drop out of it early.

We followed two key lines of enquiry: first, we asked other stop smoking services, and all our colleagues across England were seeing the same phenomenon. At the same time we talked to smokers, who told us that they had bought an e-cigarette and that they were going to give that a go.

Electronic cigarettes—the debate

Electronic cigarettes are neither electronic nor cigarettes, but they have opened up a whole new world of debate, some of it bitter and contentious, some of it heartening and filled with promise. This debate has been among public health workers, academics, industry observers, and the general public—and has involved both smokers and non-smokers. Vapers (the term used for people who use these devices to enjoy nicotine) have been caught in the crossfire: they have been celebrated because they have switched to a safer form of nicotine (people smoke cigarettes for the nicotine but die from the carbon monoxide and tar) but also demonised as ‘astroturf’ (false grass-roots) for only wanting to promote a new way of getting young people dependent on nicotine.

The language itself causes problems; there is a degree of guilt by association. If the devices had never looked like cigarettes, if they were called something different, would they have caused so much antipathy? Personally, I use the term ‘nicotine vaporiser’ when it feels right in context, but the term ‘ecig’ has gained such currency, and is understood so widely, that to try and change it now would be like trying to stop a television being called a TV. Additionally, #ecig, on Twitter, is only five characters, leaving 135 characters for the rest of the tweet. The 18 characters of #nicotinevaporiser could scarcely compete.

It seemed to me that unless our stop smoking service learned more about ecigs, we would eventually have so few service users that we would not be viable.

There followed an intense period of discovery. We soaked up every scrap of intelligence we could, particularly from people who were using the devices. Some spoke of poor experiences, and these were typically people who got no further than using the early lowquality ‘cigalikes’ bought at a service station. Others had migrated on to the much more effective ‘second generation’ vaporisers (the ones that sometimes look like a fancy pen), and these people impressed me and my team with their delight with the product, their stories of money saved, cravings satisfied and, more importantly, their commitment never to smoke combustible tobacco again.

Taking something of a leap of faith, on No Smoking Day 2013 we branded ourselves the first ecig-friendly stop smoking service in the country. Although we couldn’t supply ecigs (they are not licensed as a medicine, unlike our usual treatments of patches, gum, inhalators, varenicline, and so on), we could very much offer the behavioural support that makes a quit attempt so much more successful than trying to go smoke-free unassisted.

While our service was adapting to this new landscape and learning what worked and what didn’t, others were building up their own head of steam on a parallel track. Two sources of national guidance became available, as detailed below.

NICE Public Health Guidance 45

NICE Public Health (PH) Guidance 45 on Tobacco: harm-reduction approaches to smoking (June 2013, see www.nice.org.uk/guidance/PH45) offers recommendations for reducing the harm done by smoking and addresses the needs of people who:1

may not be able (or do not want) to stop smoking in one step

may want to stop smoking without necessarily giving up nicotine

may not be ready to stop smoking, but want to reduce the amount they smoke.

NICE PH45 cautiously indicates that not enough is known about unlicensed products such as electronic cigarettes, but that these are likely to be less harmful than combustible cigarettes.2 In practice, what we as a service felt strongly was that if people who smoke are choosing to use this route to reduce their own risks, it was our duty to offer them an equal service alongside smokers who choose the traditional route using licensed medication.

National Centre for Smoking Cessation and Training guidance

The National Centre for Smoking Cessation and Training (NCSCT), always at the forefront of new developments and quick to respond to the needs of services where guidance is required, produced a very timely e-cigarette briefing during 2014 (see here and Box 1, below). 2

The recommendations offered by the briefing have been enormously helpful, for instance among healthcare workers who needed an authoritative resource to equip themselves with the right information to share with their patients. When I circulated them to local GPs and other general practice staff, many replied that their smoking patients were deluging them with questions about ecigs. Were they safe? Where could they be obtained? Could the stop smoking service provide them?

We were able to say with confidence that although these smokers would have to supply the devices themselves, we would be pleased to see anyone wanting to quit smoking, whether by giving up nicotine altogether or by switching to a less harmful form of nicotine.

All the NCSCT guideline recommendations have helped our team to develop their practice. For example, there is encouragement to practitioners and service users alike to realise that giving additional multisession behavioural support to people who choose to use electronic cigarettes will increase the likelihood that this time, they will not go back to smoking. This is commonly after they have had a number of attempts at quitting smoking by using other means. Indeed, what we are hearing from service users when we call them back at a later date is that ‘vaping’ suits their needs like no other product ever did.

This is not to say that ecigs suit everyone, and again, the benefit to individuals of being enrolled in the stop smoking service is that advisors can respond helpfully to developments within the service user’s journey. If at any time someone feels that their choice of product is not protecting them from breakthrough urges to smoke, we can advise on additional or different products and methods to sustain them through difficult times.

Box 1: National Centre for Smoking Cessation and Training ecigarette briefing recommendations for practice2 Be open to electronic cigarette use in people keen to try them; especially in those who have tried, but not succeeded, in stopping smoking with the use of licensed stop smoking medicines

Provide advice on electronic cigarettes that includes the following: electronic cigarettes can provide some of the nicotine that would have otherwise been obtained from smoking regular cigarettes electronic cigarettes are not a magic cure, but some people find them helpful for quitting, cutting down their nicotine intake, and managing temporary abstinence there is a wide range of electronic cigarettes available and clients may need to try various brands, flavours, and nicotine dosages before they find a brand that they like electronic cigarette use is not exactly like smoking and users may need to experiment and learn to use them effectively (e.g. longer ‘drags’ are required and a number of short puffs may be needed initially to activate the ‘vapouriser’ and improve nicotine delivery)

Although some health risks from electronic cigarette use may yet emerge, these are likely to be, at worst, only a small fraction of the risks of smoking. This is because electronic cigarettes do not contain combustion chemicals that cause lung and heart disease and cancer

Multi-session behavioural support, as provided by trained stop smoking practitioners, is likely to improve the efficacy of electronic cigarettes in the same way such support markedly increases the efficacy of NRT

Stop smoking services can provide behavioural support to clients who are using electronic cigarettes and can include these clients in their national data returns.* As with other unlicensed nicotine containing products, the stop smoking service cannot provide or prescribe them until such time as there are licensed options available

If a client being seen at a stop smoking service is using an electronic cigarette but also wants to use NRT, then it is OK for them to use the two in conjunction. They do not need to have stopped using the electronic cigarette before they can use NRT.

Outcomes

The proof that this approach works, and that embedding guidelines into practice is a winner, was the change in success rates in our service for the first quarter this year. We saw that there were 20% more successful quitters in the group that had used ecigs, either with or without nicotine replacement therapy, compared with the average success rate for all types of treatment.3

The clarity offered by the NCSCT guidelines, and the reminder that services can now include ecig users in their national data returns, will hopefully reassure those who have remained nervous about what to do and say when faced with the ecig dilemma. We have seen a worldwide shower of scare-stories, public policies based on guesswork, prejudice, moralising, and supposition; smokers, advisors, commissioners, and the general public are likely to be unsettled by this. Despite the fears that ecigs will act as a gateway to increased numbers of people starting to smoke, we continue to see smoking rates fall, with no evidence of young never-smokers starting regular use. Far from the scenario of worsening smoking prevalence, it appears that visible ‘vaping’ promotes more switching from tobacco.4 Professor West highlighted this trend in an interview on BBC Radio 4’sToday programme in September 2014.5

Brands, strengths, and flavours

My team have also used the NCSCT recommendations to help advise service users about brands, strengths, and flavours. We have to be clear that we cannot be experts in this area, especially with the accelerated pace of developments in the ecig market. Our advisors encourage people to:

do their own research

always buy from a reputable retailer

always use the correct charger supplied with the device and never leave it charging unattended or overnight

experiment with what works best for them.

As with other treatments in our ‘usual care’ package, listening carefully to what individuals say and ask is crucial to person-centred care and a good outcome.

Summary

I would like to encourage other stop smoking services and commissioners, healthcare workers, and smokers to read the NCSCT guidelines, and consider how they could take a positive view of this unanticipated opportunity to help lifelong smokers to switch from combustible tobacco to a less harmful form of nicotine. Some people may be uncomfortable with endorsing a nicotine-containing product that people enjoy so much that they want to continue its use long after they decide they will never smoke again. Think of this though: NICE PH45 states that longterm nicotine use may be used as a way of reducing the harm from smoking. As Professor Peter Hajek said, following the MHRA announcements on e-cigarette regulation earlier this year:6

‘E-cigarettes … are the best chance we had so far to end the tobacco epidemic—and to do it with no government expenditure. The product needs to develop further to give smokers exactly what they want, but it is on the way to remove tobacco related harm on the population scale. Medicinal licensing of [e-cigarettes] would seriously undermine this opportunity.’

In the author’s opinion, the only thing that really matters is whether smoking rates are going up, or going down. Smoking prevalence in England is dropping faster than ever before, and ecigs have a real potential to accelerate this trend. To save more lives that will otherwise be lost through smoking, the end justifies the means.

Declaration

Louise Ross is an Associate of the New Nicotine Alliance (NNA), which works to foster a greater understanding of safer nicotine products and technologies. For more information about this independent, not-for-profit organisation, see nnalliance.org