Louise Ross describes how practice nurses can capture the potential of electronic cigarettes to help their patients stop smoking
Read this article to learn more about:
- why smokers use electronic cigarettes
- how to tackle misconceptions and answer questions
- safety issues and cost comparisons with smoking.
Few contacts between practice nurses and their patients have such a rapid and effective outcome as advice and support to stop smoking.
Many practice nurses and healthcare assistants run clinics on behalf of their local stop smoking service, and many more give brief opportunistic advice during appointments for reasons other than smoking but when stopping smoking will bring considerable benefits and improve outcomes, such as when patients attend for leg dressings, diabetes checks, hypertension reviews, and asthma clinics.
For practice staff who would like to brush up their skills on giving brief advice on smoking, I strongly recommend spending the short time needed to complete the National Centre for Smoking Cessation and Training (NCSCT)’s ‘Very brief advice’ module.1
This is a user-friendly and informative guide on the most effective way to raise the subject with patients, using an approach that encourages rather than shuts down any interest that the patient might have in stopping smoking.
The ecig opportunity
Practice nurses may believe that everyone who really wanted to stop smoking has already done so and that those who are left are resistant to the stop-smoking message and at the same time fatalistic about their health and the likelihood of early death—in other words, they are dismissive of a message they have heard time and time again. However, it will not have escaped anyone’s notice, particularly those working in a healthcare setting, that many smokers have started using electronic cigarettes (ecigs).
Most of these people are vaping (the term that distinguishes using an ecig as opposed to smoking a regular cigarette) either to stop smoking completely by switching to this alternative method of using nicotine or by reducing the amount they smoke, intermittently using ecigs at times when they cannot have a cigarette—for example, at work, in bars and pubs, and in other enclosed places where it is illegal to smoke.
The NCSCT, aware that clinicians working in stop smoking services need to understand what role they should play in providing information about ecigs to service users, has produced a very informative guide,2 which covers the devices themselves and how practitioners should respond to this new challenge (see Box 1, below). The briefing is enormously helpful, for example, for healthcare workers who need an authoritative resource to share with their patients.
Since I sent the link to our local general practices, I have had many replies from staff saying that it was both useful and welcome in terms of providing guidance on answers for patients.
Box 1: National Centre for Smoking Cessation and Training’s recommendations for practice on electronic cigarettes for smoking cessation2
- 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:
- 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, which 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
- * providing they adhere to the national data definitions in the service and monitoring guidance, which are based upon the Russell Standard
- NRT=nicotine replacement therapy
- National Centre for Smoking Cessation and Training. Ecigarette briefing. Electronic cigarettes. NCSCT, 2014. Available at: www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf
Confusion around ecigs
Patients often tell us about information they have read that turns out to be misleading. I hope, in this article, to address some of the questions that practice nurses might have so that they can tackle misconceptions and are able to answer patients’ questions confidently.
The Medical Organizations supporting Vaping and Electronic cigarettes (MOVE) website, which is supported by a growing number of scientists, physicians, and other healthcare professionals, provides insight into some of the many misleading stories publicised over the past year.3 Many stories, purporting to be scientific in origin, have been exposed as speculative and misleading and, sadly, have undermined the confidence of those wanting to take action to reduce either their own or others’ harm from smoking combustible cigarettes. More detail can be found here.4
Can stop smoking services see patients using ecigs?
For the benefit of practice nurses subcontracted by their local stop smoking service to deliver treatments to patients, I want to confirm that it is quite legitimate to see service users who are using ecigs—whether or not they are also using nicotine replacement therapy (NRT).
The national data-collection tool has a category for ‘unlicensed products’,5 and the results are a subject of great interest for national tobacco control leaders, research academics, and others, who are analysing trends to ascertain whether those who use ecigs alongside the behavioural support offered by stop smoking services are more likely to quit.
Our service in Leicester City has seen around 20% higher than average quit rates among those using ecigs. Licensed products still work very well for many patients, but ecigs—used alone or together with licensed medications—are showing great promise for those who did not think they would ever be able to stop smoking.
Are ecigs safe?
Arguably the most important issue is the safety of ecigs. With this in mind, it is important to remember that people smoke for the nicotine but they die from the carbon monoxide and tar breathed in from combustible cigarettes. Even taking the most cautious approach, ecigs are estimated to be 95% safer than cigarettes, because the inhaled vapour contains none of the harmful products of combustion.6
Dr Lynne Dawkins provides an in-depth video reflection on the science and growth of ecigs, ‘What we know so far’,7 and the detailed references in Action on Smoking and Health (ASH)’s briefing on electronic cigarettes provide accurate information on the safety of ecigs.8
Nicotine has been seen for many years as the addictive villain that keeps people smoking, but this substance seems to be far less addictive when used without combustible tobacco. Professor Peter Hajek likens it to caffeine and encourages clinicians to remain open-minded about its place among harm-reduction strategies,9 as do Professor John Britton,10 Professor Linda Bauld,11 and many other leading experts in the field of smoking cessation.
It seems that when nicotine is removed from the other chemicals in smoked tobacco, the ‘dose’ is often titrated down by users, who do not experience any loss of pleasure.
On the other hand, titrating down to zero or stopping vaping completely may not be a goal for your patient, and it is important to be led by their choices rather than to impose your own view on what should or should not happen after the patient stops smoking tobacco. This may seem counterintuitive to practitioners who, for years, have told patients that nicotine is as addictive as heroin or cocaine.
However, I invite you to consider the approach taken in NICE’s Public Health Guideline 45 on harm reduction,12 which offers recommendations for reducing the harm done by smoking and addresses the needs of those who may not be able (or do not want) to stop smoking in one step, those who may want to stop smoking without necessarily giving up nicotine, and those who may not be ready to stop smoking but want to reduce the amount they smoke. This guidance cautiously indicates that not enough is known about unlicensed products such as electronic cigarettes but that they are likely to be less harmful than combustible cigarettes.
As a service manager, I feel strongly that if smokers are choosing to use this route to reduce their own risks, it is our duty in clinical practice to offer them a service that is equal to that offered to those who choose the traditional route using licensed medications. We should not be fearful of or discouraging about long-term use of vaporised nicotine, which may, in fact, reduce relapse rates, because it provides nicotine via a safer route than combustible cigarettes but has the associated comfort of the smoking ritual—the lack of which frequently drives ex-smokers back to their smoking habit.
It is important that we, as practitioners, examine what aspect of our attitude is driven by health concerns and what might be a deeply-ingrained distaste for anything that looks like smoking. Until we have reached some clarity about this distinction, we may not be able to maximise the help we provide smokers to tackle their dependence on tobacco, because we risk pushing them away by not understanding their ongoing choice to use nicotine.
Inadvertent nicotine poisoning is a concern that some frontline workers have raised, and it is vital to emphasise that the devices and liquids must be kept out of the reach of children and pets. However, general fears about poisoning via ecig products have been widely exaggerated considering that licensed NRT products bring nicotine into contact with skin or mucous membranes and are supplied daily to smokers trying to stop.
Recharging is another safety issue given a number of news stories about devices exploding. 1314 Users of ecigs, especially those new to the products, should be advised never to use a charger other than the one supplied with the kit, never to leave the ecig charging unattended, especially overnight, and not to overtighten the cartridge.
As a non-ecig user is unlikely to become expert in all of the different aspects of ecig use, any advice you give can and should be supplemented by knowledge gained from patients through internet searches, vapers’ forums, and talking with experienced vapers. I gather personal insights whenever I can and have often cornered and engaged a vaper in casual conversation to hear what flavours they like and what changes they have noticed since they switched from smoking to vaping.
Does vaping ‘renormalise’ smoking?
Although even the most inattentive glance at someone using a vaporiser will detect that it is not a cigarette, the issue of vaping looking like smoking has prompted some authorities to call for a ban in indoor places on the grounds that it could renormalise smoking.15 However, this so-called ‘gateway effect’ seems in real life to work in entirely the opposite way.
Smoking rates are going down as the use of ecigs goes up, as Professor Robert West demonstrates in his comprehensive Smoking Toolkit Study,16 and we hear from established vapers that they had a go when they saw a friend using one. Indeed, most ecig users are former smokers or smokers who are reducing the number of cigarettes they smoke,17 and this self-initiated harm reduction is the very opposite of renormalisation.
Do flavourings mean that ecigs appeal to children?
Another aspect of ecigs that provokes fierce debate is the subject of flavours. Some very risk-averse figures in public health have argued that flavours simply help to market these products to children, who they believe will be seduced into becoming ‘addicts’ by the attractive fruit or bubble-gum flavours.18
First, no evidence suggests that young people are starting to use ecigs in anything more than negligible numbers, although studies have shown that a proportion of young already-smokers do abandon cigarettes for the less-harmful alternative. 19 Second, adults really like the flavours, and tobacco-flavoured liquids are quite unpopular with some vapers, who are keen to completely step away from old habits.
In our stop smoking service, some service users have even commented that the sweet flavours are just enough to stop them bingeing on chocolates—and how many times do people tell us they are scared of stopping smoking again because of the weight they put on the last time they tried?
Where can smokers obtain ecigs?
Smokers also want to know where to get ecigs. The stop smoking service cannot currently provide them, as they are a consumer product and not licensed as a medication.
People who are keen to try them need to buy their own; at our stop smoking service in Leicester, which was the first in the country to go ‘ecig friendly’ (but, just over a year later, by no means the only one), we recommend that people go to a well-informed local retailer and discuss what models, strengths, and flavours might suit them. We suggest that people buy from retailers with a reputation to protect rather than from car-boot fairs or other suppliers that might sell poorer quality devices or liquids.
An often-asked question is, which would be the best starting device? The cheap ‘cigalikes’ (also known as first-generation models) that are usually bought in newsagents or at service stations tend to deliver very low amounts of nicotine and are generally unsatisfying. Unfortunately, this can put some people off trying anything more effective, and it may be useful to explain that better quality models are on sale. The other deterrent is the price of a starter kit that includes a second-generation vaporiser and some liquid, which, at around £20, may be out of reach for poorer smokers.
At our stop smoking clinic, we encourage people to see that the savings made from not smoking can comfortably cover this; indeed, one service user told his advisor that he had never been so well off financially since he had saved up to buy his first vaporiser—he now spends about £30 a month on liquids for his ecig compared with the £200 a month he had been spending on cigarettes.
What language should be used with patients?
My final suggestion is to consider the language that you use with patients who are hovering on the edge of a decision to try ecigs.
If they have been smoking all of their adult lives (and possibly a lot of their young lives too), this might be the first time that genuine hope of breaking free from smoking is stirring inside them. Nurture that hope and do not allow your own lack of knowledge, prejudice, or fear that your encouragement might come back to haunt you to leak out during your discussion and ruin this fresh start for the patient. Do not say ‘we can’t recommend them’, ‘we don’t know what’s in them’, ‘you’re just substituting one habit for another', or any of the other many disheartening things we hear that practitioners have said.
Professor Robert West, in his excellent book The smokefree formula,20 encourages people who want to try ecigs to go for it. It is well known that if you do what you have always done, you get what you have always got, and, in this case, ignoring innovative ways of reducing harm from smoking could be soundly blamed for adding to the continuing tragedy of more smoking-related death and disease.
If you still have doubts, perhaps look at Professor John Britton’s blunt challenge to the health community in a presentation he gave at the UK Society for Behavioural Medicine’s conference in December 2014, as reported on Clive Bates’ blog ‘The counterfactual’.10 By being open-minded about ecigs and not insisting that the traditional medical way is the only way, you will begin to see success stories for patients who thought (like you did) that they would never stop smoking. Think of ecigs not as part of the problem but as part of the solution.
Louise Ross is the manager of the Leicester City Stop Smoking Service, and an Associate of the New Nicotine Alliance (NNA), which works to foster greater understanding of safer nicotine products and technologies. For more information about this independent, not-for-profit organisation, see www.nnalliance.org.
- Use of ecigs remains controversial, but health risks associated with them are likely to be, at worst, only a small fraction of the risks of regular smoking
- Electronic cigarettes offer smokers the nicotine they crave and the associated comfort of the smoking ritual but without the combustible products that result in smoking-related harms, making them an attractive option for smoking reduction and cessation, especially for long-time smokers who have previously struggled to stop by using licensed NRT medications
- Practice nurses subcontracted by local stop smoking services to deliver treatments to patients cannot prescribe or provide ecigs while licensed products are not available, but they can legitimately see service users who are using ecigs—whether or not they are also using NRT
- National guidance covering the use of ecigs provide authoritative resources to help practitioners equip themselves with the right information to share with patients:
- Reliable websites such as www.sciencecig.wordpress.com/move and onvaping.com/the-ultimate-list-of-studies-on-e-cigarettes-and-theirsafety identify speculative and misleading information so you can confidently dispel myths and misconceptions about ecigs
- Be open-minded about the use of ecigs as part of a smoking-cessation strategy, seeing them not as part of the problem but as part of the solution.
ecigs=electronic cigarettes; NRT=nicotine replacement therapy
- National Centre for Smoking Cessation and Training. Very brief advice. NCSCT, 2012. Available at: www.ncsct.co.uk/publication_very-brief-advice.php (accessed 1 October 2015).
- National Centre for Smoking Cessation and Training. Ecigarette briefing. Electronic cigarettes. NCSCT, 2014. Available at: www.ncsct.co.uk/usr/pub/e-cigarette_briefing.pdf
- Medical Organizations supporting Vaping and Electronic cigarettes (M.O.V.E) website. Available at: sciencecig.wordpress.com/move/ (accessed 1 October 2015).
- Amann D. The ultimate list of ecig studies: are e-cigs actually safe? [blog]. On Vaping, 2014. Available at: onvaping.com/the-ultimate-listof-studies-on-e-cigarettes-and-their-safety/ (accessed 1 October 2015).
- Health and Social Care Information Centre. NHS Stop Smoking Services 2012. Available at: www.hscic.gov.uk/stopsmoking (accessed 1 October).
- Public Health England. E-cigarettes: an evidence update. PHE, 2015. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf
- Dawkins L. What we know so far. YouTube, 2013. Available at: www.youtube.com/watch?v=f6KBGH2F63A (accessed 1 October 2015).
- Action on Smoking and Health. ASH briefing. Electronic cigarettes. 2014. Available at: www.ash.org.uk/files/documents/ASH_715.pdf (accessed 1 October 2015).
- Hajek P. On ecigarettes. YouTube, 2014. Available at: www.youtube.com/watch?v=SVS0_BGHHjM (accessed 1 October 2015).
- Britton J. A blunt challenge to some common arguments against e-cigarettes. Clive Bates’ personal blog, The counterfactual: 2014. Available at: www.clivebates.com/?p=2570 (accessed 1 October 2015).
- Bauld L. There’s no evidence that e-cigarettes are as harmful as smoking. The Guardian. February 2015. Available at: www.theguardian.com/science/sifting-the-evidence/2015/feb/23/theres-no-evidence-e-cigarettes-are-as-harmfulas-smoking (accessed 1 October 2015).
- NICE. Tobacco: harm-reduction approaches to smoking. Public Health Guidance 45. NICE, 2013. Available at: www.nice.org.uk/guidance/PH45
- Sims A. Exploding e-cigarettes spark national safety concerns. The Independent. July 2015. Available at: www.independent.co.uk/life-style/health-and-families/health-news/exploding-e-cigarettes-spark-national-safetyconcerns- 10382229.html (accessed 1 October 2015).
- Hodgekiss A. Smoker’s legs are ‘nearly torn off’ after e-cigarette EXPLODES ‘like a grenade’. Mail Online. October 2014. Available at: www.dailymail.co.uk/health/article-2791061/smoker-s-legs-nearly-torn-e-cigarette-explodeslike-grenade.html (accessed 1 October 2015).
- BBC News. E-cigarette ban in enclosed spaces in Wales pushes ahead. June 2015. Available at: www.bbc.co.uk/news/uk-wales-33025872 (accessed 1 October 2015).
- West R, Beard E, Brown J. Electronic cigarettes in England: latest trends. Smoking Toolkit Study, 2015. Available at: www.smokinginengland.info/latest-statistics/ (accessed 1 October 2015).
- Roberts M. E-cigarette ‘lure’ fears might be unfounded (data from the Office of National Statistics). BBC News Health, 2014. Available at: www.bbc.co.uk/news/health-30192181 (accessed 1 October 2015).
- Wasowicz A, Feleszko W, Goniewicz M. E-cigarette use among children and young people: the need for regulation. Expert Rev Respir Med 2015: Aug 7; 1–3. [Epub ahead of print.] Available at: www.ncbi.nlm.nih.gov/pubmed/26248640
- Public Health England. Electronic cigarettes: a report commissioned by Public Health England. Public Health England, 2014. Available at:www.gov.uk/government/uploads/system/uploads/attachment_data/file/311887/Ecigarettes_report.pdf
- West R. The smokefree formula: a revolutionary way to stop smoking. London: Orion, 2013. G