E-cigarettes Contents

3E-cigarettes and smoking cessation

The evidence on smoking cessation

31.The Tobacco Control Plan reported that in 2016 there were 470,000 people using e-cigarettes as a way to stop smoking conventional cigarettes.60 The Department of Health and Social Care estimates that e-cigarettes contribute to between 16,000 and 22,000 people successfully quitting smoking each year who would not otherwise have done so had they used nicotine replacement therapies or willpower alone.61 Professor Paul Aveyard from the Cochrane Review highlighted that e-cigarettes are a popular alternative to other smoking cessation tools.62 Professor John Newton from Public Health England similarly told us:

E-cigarettes are the most popular quitting aid among smokers. Whatever we think of the evidence on their effectiveness, smokers are choosing to use e-cigarettes much more widely than other available forms, such as nicotine patches and nicotine-containing gums. There is no doubt that they are popular among smokers. The first step to being an effective aid is that they have to be used by smokers. That is very much in their favour. We have recognised that by introducing references to e-cigarettes in our campaigns.

32.Professor Newton recognised gaps in the evidence on the effectiveness of e-cigarettes as a smoking cessation tool, but said that this should not detract from their already apparent usefulness:

There is a lack of hard, randomised control-trial evidence of their effectiveness in cessation, but the evidence from observational studies, which are quite convincing, is that many smokers have used e-cigarettes to quit—and to quit completely, not just for dual use. We need to continue to build the evidence base. At the same time, we need to be clear that this is for smokers, particularly those who have tried to quit before. If they have not tried an e-cigarette, they should try an e-cigarette, because that might be their route out of smoking.63

Action on Smoking and Health similarly highlighted both the benefits of e-cigarettes as a stop smoking route and the need for further research on their effectiveness as a cessation aid.64 The Royal Society for Public Health noted that although e-cigarettes appear to be successful as a cessation tool, especially when combined with behavioural support, more “high quality research” is needed.65

33.One of the difficulties in undertaking research to assess their effectiveness is that some people continue to smoke conventional cigarettes, albeit fewer, at the same time—cutting down rather than giving up completely.66 This means that some studies which have claimed that e-cigarettes hamper smoking cessation have been based on observations that e-cigarette users still describe themselves as “smokers”.67 The UCL Research Group also argued that claims that e-cigarettes could reduce smoking cessation rates did not tally with the significant increases seen in the number of conventional smokers quitting in the UK and the US.68

The British Medical Association concluded:

Although the data in favour of the effectiveness of e-cigarettes as a cessation aid is not conclusive, given the quality of the studies, the overall picture—at present—is that they do play a helpful role in helping people to stop smoking.69

The UK Centre for Tobacco and Alcohol Studies argued that e-cigarettes, as an alternative consumer product to tobacco rather than a medical therapy like other nicotine replacements products, had allowed them to reach more people. They believed, in that context, that this gave e-cigarettes a better result overall: “A low efficacy treatment used by large numbers of smokers will generate more quitters than a high efficacy treatment used by a small minority”.70

34.Heat-not-burn products, the Centre for Tobacco and Alcohol Studies suggested, may also have a role in helping those smokers to quit who do not find e-cigarettes a solution:

The role of heat-not-burn products is, thus, far from clear: if more toxic than e-cigarettes and no more effective and acceptable to smokers as smoking substitutes, then their role is likely to be limited. If more effective however, or (for example) as a result of being more similar in taste and experience to tobacco cigarettes, heat-not-burn products are able to appeal to sectors of the smoking population who find e-cigarettes ineffective or otherwise unacceptable, then they may offer a public health benefit despite their relative hazard.71

Young people and a potential gateway to conventional smoking

35.One of the concerns that has been raised about e-cigarettes has been a fear that they could appeal to young people and potentially act as a ‘gateway’ to conventional smoking. The evidence we received, however, has not shown this to be the case. Research undertaken by the Association for Young People’s Health found that the proportion of young people ‘experimenting’ with e-cigarettes ranged between an eighth and a quarter of young people, but that regular use by secondary school children was limited to about 1%, and those children generally engaged in smoking behaviour.72

36.Professor Peter Hajek of Queen Mary University nevertheless cautioned:

We need to keep an eye on it, because somebody will figure out what you need to add to e-cigarettes to make them more addictive to non-smokers. At the moment, non-smokers do not progress to daily vaping; it is really difficult. If they do, they often vape nicotine-free, just for some kind of flavour and behaviour. There would be a very legitimate concern if we saw large numbers of young people who have never smoked becoming daily vapers, but you would be hard pushed to find anybody.73

Public Health England and the MHRA similarly concluded:

British youth experiment with e-cigarettes but regular use is rare and very largely confined to young people who have smoked. There is some evidence that young people who have vaped but never smoked are more likely subsequently to smoke but there is no evidence that this relationship is causal. The UK has good data on this issue from surveys.74

37.There remain some gaps in the evidence about how effective e-cigarettes are as a stop smoking tool in comparison to other nicotine replacement therapies. Nevertheless, an estimated 2.9 million people in the UK are using e-cigarettes, and tens of thousands are using them to successfully quit smoking each year. Concerns about the risk of e-cigarettes potentially providing a ‘gateway’ into conventional smoking have not materialised to any significant degree. Similarly, the risk of the variety and type of flavours being attractive to young non-smokers, who would be drawn into e-cigarette use, also appears to be negligible.

E-cigarettes as a medically licensed product

38.While many conventional smokers have taken up vaping, some of our witnesses believed that more would do so if an e-cigarette was approved for medical use, and thereby able to be prescribed by a doctor. They saw advantages in two ways. Firstly, a medically licensed product would enable health professionals to feel able to recommend e-cigarettes as a smoking cessation tool, knowing that the device and liquid had been tested and approved by the Medicines and Healthcare products Regulatory Agency (MHRA). Professor Newton from Public Health England told us:

We would like to see a medicinally licensed product because […] it would send a stronger message about relative safety, and it would also provide another avenue and help smoking cessation services to use e-cigarettes more. We think there would be considerable advantages if there was a medically licensed product.75

39.Deborah Arnott from Action on Smoking and Health similarly told us:

We have doctors saying to us all the time, “If we had products that we could prescribe and that were licensed, we would feel much more comfortable.” They would be effective on prescription and highly cost-effective. There have been criticisms, with people asking why they should be on prescription. These are cheap products that are highly effective in helping smokers to quit. It would be reassuring to consumers, as well as to the medical profession.76

The Royal Society for Public Health stressed the importance of smoking cessation advisors being able to provide information, with assurance, to smokers:

Research has shown that perceptions of harm can indeed inhibit the use of e-cigarettes among smokers, and this barrier will only be exacerbated if the concerns of the public go unaddressed. Responsible messaging could help to counteract this threat, for example highlighting that smoking cessation services are advised to support smokers who choose to quit using e-cigarettes.77

40.A licensed product could also provide the basis for a doctor-patient relationship that could extend over the period needed to give up smoking, and help overcome some smokers’ reluctance to swap to e-cigarettes because of cost considerations. Several studies show that smokers receiving specialised cessation assistance through their GP are more likely to stop successfully.78 The initial start-up cost of e-cigarettes, Hazel Cheeseman from Action on Smoking and Health explained, may stop some people from swapping to vaping:

Although for most people using an electronic cigarette is cheaper than continuing to smoke, there is a group of people, particularly people with mental health conditions, for whom there is a barrier to entry—an initial cost that you have to meet. For somebody on a low income, that is quite a risk to take, potentially, if you are not sure that the product will work for you. Having something on prescription can help to ease that risk for people. It will also lock people into a relationship with medical professionals and quit services, which we know can significantly improve people’s chances of quitting successfully. Having something on prescription would be a benefit for both of those reasons. For groups that are vulnerable, have high levels of addiction and face lots of barriers to quitting, a prescription product could be really valuable.79

41.As we discuss in Chapter 4, the regulation of e-cigarettes currently prohibits claims being made for their harm-reduction properties. Dr Ian Hudson from MHRA noted that medicines’ licensing would allow such health claims to be made:

Gum, patches and so on have smoking cessation or harm-reduction claims, and those can be promoted as such. The advertising restrictions would be different. They would be able to promote a bit more in relation to the claims for medicines available on prescription […] if these were authorised as ‘medicines’.80

We heard, however, that the MHRA medical authorisation process was itself a barrier. Dr Ian Jones from Japan Tobacco International told us:

The concern that we have, other than the cost, is mainly about the time. These products are innovating and changing so fast—if you run for a medicinal licence approval, you essentially freeze the product at the start, and you have to have the same product at the end. By that time, particularly in today’s environment, the other products have evolved so fast that your product is out of date by the time you reach the other end.81

MHRA highlighted that as a “relatively new” product, it would take longer to go through the generation of the evidence for a ‘medicine’ and through the review process.82

42.Action on Smoking and Health argued for a shorter licensing period to make it a more attractive route for e-cigarette producers to take, and to ensure there were more medically licensed e-cigarettes on the market:

There are precedents for adopting a less restrictive approach, in particular in the area of nicotine regulation. Until nicotine replacement therapy was liberalised in 2005, NRT products were licensed for a maximum of 12 weeks. In 2005 this was extended for some products to a year, and in 2009 the MHRA approved a ‘harm reduction’ extension to the license of the nicorette inhalator without a limit to duration of use. This was on the basis that, “it had become widely accepted that there were no circumstances in which it was safer to smoke than to use NRT.” The Commission went on to say that there was a need for further research and data collection to assess long term safety and agreed that the holder of the market authorization “should be asked to provide a robust risk management plan that would satisfactorily address the outstanding issues”.83

‘Leicester partnership’

43.Leicester City Council’s “e-cigarette friendly” smoking cessation service was highlighted in our inquiry as a model for others to follow. They actively encourage those interacting with patients to recommend e-cigarettes as a stop smoking tool, provide online resources describing experiences of individual smokers who have switched to e-cigarettes, and in some cases supply a free e-cigarette ‘start-up’ kit. The Council emphasises the importance of also providing behavioural support to increase the chances of quitting permanently.84 Leicester City Council told us:

Our advice to those stopping smoking with e-cigarettes is that it is their choice whether they continue to vape—the nicotine they get from their vaporiser could be exactly what stops them relapsing to smoking, and it’s the smoke that kills. The key difference that we see among service users who have switched to vaping though is their increased confidence in their determination never to smoke again. Most have tried many, many times before, with medicinal products, or by willpower alone, and have relapsed to smoking. Vaping has made a difference that has taken them (and often their families) by surprise.85

44.Leicester City Council told us about their experience of allowing them in mental health facilities (which we discuss below):

Even highly dependent smokers such as those with poor mental health, and homeless people, are doing really well with vaping. Nursing staff in the mental health wards who were initially sceptical about vaping have been pleasantly surprised at how much easier it has been for their patients who have started using a vaporiser to manage their nicotine needs.86

45.The Minister called the public health team running the Council initiative “a trailblazing group” who were “achieving good things”.87

46.A medically licensed e-cigarette could assist smoking cessation efforts by making it easier for medical professionals to discuss and recommend them as a stop smoking treatment with patients. It would also make it easier for claims to be explicitly made about their harm-reduction relative to conventional smoking, which regulations currently prevent (Chapter 4). The Government should review with MHRA and the e-cigarette industry how its systems for approving stop smoking therapies could be streamlined; to be able to respond appropriately should manufacturers put forward a product for licensing.

E-cigarettes in mental health facilities

47.The Government’s Tobacco Control Plan highlights the need to tackle the much higher rate of smoking among those with mental illness. It reports that 40% of adults with mental illness smoke,88 compared with 16% of the general population.89 The Mental Health and Smoking Partnership told us that:

While people with a mental health condition are as motivated to quit smoking as other smokers they are less likely to be successful. As a consequence, while the rates of smoking in the general population have fallen steadily over the last few decades, the same rate of progress is not apparent for people with a mental health condition, with almost no decline recorded.90

The Tobacco Control Plan states that “Smoking causes premature death, disability and poverty and if we do not reduce smoking prevalence among this group [with mental illness], we will have failed to reduce inequalities”.91

48.The Plan sets out the Government’s goal for all sites providing mental health inpatient services to be smoke-free by 2018. The document states that:

People with mental health conditions have an equal right to be asked whether they smoke. They need to be offered effective methods to quit smoking or reduce harm as part of their care plan and there is an urgent clinical need to improve the support they receive. In some instances, healthcare staff will escort patients on and away from hospital grounds to smoke. This practice is outdated. It reduces the resources available to deliver clinical care and causes direct harm to patients.92

The Mental Health and Smoking Partnership told us that e-cigarettes could play a role in reducing smoking in this group because some evidence indicated that e-cigarettes are seen as more acceptable to people with mental health conditions than other forms of support. They concluded, however, that:

There are barriers to access of e-cigarettes for people with a mental health condition and this includes the policies in NHS settings, attitudes and understanding of health care professionals, false perceptions of harm among smokers with a mental health condition and barriers to entry such as cost of devices.93

49.Heather Thomson from Nottinghamshire Healthcare NHS Foundation Trust told us that restricting patients to specific areas within facilities where they can vape may be counter-productive:

We do not want to make patients become more isolated than they were. If one e-cigarette lasts as long as 30 cigarettes and somebody who is a 40-a-day smoker usually can use it only in their room, we may find that they have even less interaction. We want to encourage them to be a part of activities that are going on. If vaping during an activity enables them to remain focused and within that activity, that is part of their therapeutic recovery and is a good thing.94

While the Care Quality Commission’s (CQC) guidance for its inspectors asks them not to challenge smoke-free policies, it does emphasise how such policies can be mitigated for patients affected:

CQC inspections should not challenge smoke-free policies, including bans on tobacco smoking in mental health inpatient services (for example, by raising such policies as an unwarranted ‘blanket restriction’). Instead, focus should be paid on whether such a ban is mitigated by adequate advice and support for smokers to stop or temporarily abstain from smoking with the assistance of behavioural support, and a range of stop smoking medicines and/or e-cigarettes. Inspections should also consider whether alternative activities are in place and promoted, including regular access to outside areas.95

Encouragingly, it states that a ban on e-cigarettes without “cogent justification” can be criticised as effectively being an unwarranted ‘blanket restrictions’.96

50.We decided to directly survey all English NHS mental health trusts (see Appendix 1), and found that a third of the 50 NHS trusts that responded banned e-cigarettes within their facilities (three failed to respond—Cumbria Partnership NHS Foundation Trust, Greater Manchester West Mental Health NHS Foundation Trust, and Hertfordshire Partnership University NHS Foundation Trust). Some of these NHS trusts stated that e-cigarette use was allowed in designated shelters outside, along with conventional smoking, whilst others designated the facility’s entire estate as smoke-free including for e-cigarettes. Amongst the NHS trusts which allowed e-cigarettes indoors, this was generally in designated areas, to make sure that those patients, staff and visitors who did not wish to be exposed to the vapour could avoid it. Three-quarters of NHS trusts were concerned about ‘second-hand’ e-cigarette vapour despite evidence that it presents negligible, if any, health risks (Chapter 2), and some NHS trusts reported that staff had complained about the smell. Some NHS trusts allowed only certain types of e-cigarettes, usually ‘tamper proof’ models, which had been approved by the NHS trust. Heather Thomson, Smokefree Lead, Nottinghamshire Healthcare NHS Foundation Trust, emphasised possible difficulties caused by not having a consistent approach across NHS trusts, which could mean that e-cigarettes approved by one site were not permitted in another, or that e-cigarettes were stocked in some retail outlets but not others.97

51.Hazel Cheeseman from Action on Smoking Health emphasised a need for “some central guidance and policy in relation to ecigarettes and smoke-free policies, and greater investment in the training of mental health staff”.98 Professor Newton from Public Health England highlighted the importance of evidence-based local decision-making in this area:

We have provided guidance to NHS trusts, including mental health trusts, and to employers on the basis on which they should produce their own policies. We think that there is value in individual organisations developing their own policies, based on a general understanding of the evidence, because they are more likely to know what their particular circumstances are. I agree with you that it seems unlikely that an overall ban [on e-cigarettes] is the right approach, given the evidence.99

52.Heather Thomson believed that a central policy from NHS England would, nevertheless, be beneficial:

It would be very useful to have some central guidance, because there is an anxiety about bringing in something that, in years to come, may prove to have been harmful. However, we need to balance that against the fact that we absolutely know the harms that are associated with smoking. Anything that allays those fears and lays the foundations will be useful.100

NHS Providers recognised “the potential value of national guidance from NHS England to support NHS mental health services in permitting the use of e-cigarettes”, but cautioned that:

[A policy would] need to be sufficiently flexible and allow trusts to incorporate the guidance in an individually tailored way as part of personalised care planning, as well as to manage their permissions as to where e-cigarettes can be used on the trust’s premises. We would also maintain that the cost of using e-cigarettes services remains with the service user and not the trust, unless such a time comes that e-cigarettes are prescribed by the NHS.101

E-cigarettes in prisons

53.In the prison estate, like mental health NHS trusts, a conventional smoking ban is being rolled out across England. The difference however is that e-cigarettes and vaping devices are made available for purchase within the entire prison estate whilst only in some mental health facilities. E-cigarettes had been brought into some prisons on a trial basis in 2014. In 2015 the then Minister for Prisons and Probation told the Justice Committee:

Our steps to date [towards a smoke-free prison service] include the recent and highly successful roll out of electronic cigarettes to all prisons. These are available in every prison shop and offer a comparable alternative to traditional tobacco products in cost terms.102

54.Michelle Jarman-Howe, Executive Director of Public Sector Prisons South, told us that the policy was working well:

At the point at which the [prison] service introduced no smoking, offenders could access disposable e-cigarettes through the offender canteen system on closed sites in the public sector. Later, in October 2017, we also enabled offenders to access rechargeable vaping facilities. That proved to be far more popular.103

55.Smoking cessation is a particular challenge in mental health. People with mental health issues smoke significantly more than the rest of the population and, as the Government warns, if we do not reduce smoking prevalence among this group, “we will have failed to reduce inequalities”. Patients in mental health units who are smokers would benefit from using e-cigarettes to help them stop smoking conventional cigarettes whilst also encouraging them to engage with treatments within the facilities, because they can continue to engage in treatment sessions, when as smokers they would have to leave. Some NHS mental health units are allowing unrestricted use of e-cigarettes—Nottinghamshire Healthcare NHS Foundation Trust is an exemplar—but it is unacceptable that a third of mental health NHS trusts still ban e-cigarettes within their facilities. Three-quarters of NHS trusts are mistakenly concerned about ‘second-hand’ e-cigarette vapour, despite evidence that it presents a negligible health risk.

56.We are concerned that NHS England declined our invitation to give evidence on how it was working to encourage innovative solutions, such as e-cigarettes, to battle the worryingly high numbers of smokers amongst those with poor mental health. NHS England stated that it was unable to provide a representative to put in front of the Committee. NHS England explained that there was no one responsible centrally with “oversight” of e-cigarette policies amongst NHS mental health trusts, nor did NHS England do anything centrally to enforce any type of policy approach. NHS England should take a strong leadership role in ensuring that everything is done to reduce the numbers of smokers amongst those with poor mental health, as smoking is the single largest cause of premature mortality within this group. We also find it very concerning that there is not a dedicated person within NHS England responsible for implementing the Government’s Tobacco Control Plan. NHS England should as a matter of urgency ensure that such a position is created.

57.NHS England should set a clear central NHS policy on e-cigarettes in mental health facilities which establishes a default of allowing e-cigarette use by patients unless an NHS trust can show reasons for not doing so which are demonstrably evidence-based. NHS England should issue e-cigarette guidance to all NHS mental health trusts to ensure that they understand the physical and mental health benefits for their patients.

E-cigarettes in public places

58.Although e-cigarettes are significantly less harmful than conventional cigarettes, and are helping people to stop smoking, they are generally prohibited in closed spaces including workplaces, restaurants and on public transport. Vapers are typically shown to outside ‘smoking areas’ to vape next to a conventional smoker, which could be counter-productive for those attempting to stay away from cigarettes while trying to quit smoking. John Dunne from the UK Vaping Industry Association compared making vapers stand with smokers as “putting an alcoholic in a bar: It just does not make sense”.104

59.Smoking has been banned in closed public spaces and many workplaces to protect non-smokers from the effects of second-hand smoke, and in some cases to reduce fire-risk, but it appears that the same logic is being used to prevent e-cigarette vaping. Yet, as we discussed in Chapter 2, second-hand vapour does not cause harm. Professor Newton from Public Health England pointed to another more basic factor potentially involved, noting that while “there is no evidence that exposure to the vapour of e-cigarettes is harmful, […] some people do not necessarily like it”.105

60.Many businesses, public transport providers and owners of other public places do not allow e-cigarettes in the same way that they prohibit conventional smoking. There is some hostility towards the use of e-cigarettes in public areas, if only because some bystanders find its vapour unpleasant. As we have described in this Report, there is no public health rationale for treating use of the two products the same. Indeed, forcing vapers to use the same ‘smoking shelters’ as conventional smokers could undermine their efforts to quit. There is now a need for a wider debate on how e-cigarettes are to be dealt with in our public spaces, to help arrive at a solution which at least starts from the evidence rather than misconceptions about their health impacts. A liberalisation of restrictions on e-cigarettes, which provide a popular route for people to stop smoking, would result in non-vapers having to accommodate vapers (for a relatively short period of time).