A burning issue A hazardous gimmick that glamourises smoking or a valuable aid to help smokers quit? Jennifer Trueland reports on the e-cigarettes debate
SUMMARY
Whenever a patient mentions e-cigarettes – and it happens a lot – Rachel Clay has a standard answer. ‘I explain that I cannot condone them because they are not prescribable. But I do not say to stop using them – they are certainly less harmful than smoking cigarettes.’ Ms Clay, a practice nurse at Bentham Medical Practice in North Yorkshire, has been working in smoking cessation for more than a decade. Along with a colleague, she offers a combination of nicotine replacement therapy and behavioural change support for patients in one-to-one sessions. And she is keen to have an extra weapon in her anti-smoking armoury. ‘I think that e-cigarettes are helping people to quit,’ she says. In the world of smoking cessation, electronic or e-cigarettes are currently the big story. More and more people are turning to the products to help them give up, or cut down on, tobacco. E-cigarettes are battery-powered devices that contain nicotine – but not tobacco – and produce a vapour. They are marketed as a safer and cheaper substitute for cigarettes. One of the leading products on the market is E-Lites. The manufacturer claims they are
How to help a patient who wants to use e-cigarettes to quit smoking Ensure that they are getting behavioural support from a trained stop smoking practitioner. Inform the patient that we do not know how effective or safe e-cigarettes are, although they are definitely safer than smoking cigarettes. If they remain keen to use e-cigs then combination nicotine replacement therapy (NRT) involving a nicotine patch and e-cigs is a reasonable compromise. Use an evidence-based medication such as varenicline (Champix) or combination NRT (nicotine patch plus one of the faster-acting products such as nicotine mouth spray or nicotine lozenge). Advice supplied by Andy McEwen, director of the National Centre for Smoking Cessation Training. www.ncsct.co.uk
E-cigarettes are popular, but critics say the devices, which contain nicotine but not tobacco, may cause health problems or be addictive. Some nurses view them as a valuable anti-smoking tool and are looking forward to e-cigarettes becoming a licensed medicine in 2016. Author Jennifer Trueland is a freelance journalist
28 november 20 :: vol 28 no 12 :: 2013
‘an authentic tobacco alternative, as they look, taste and feel just like smoking’. According to the product website, E-Lites – which come in packs that look very similar to cigarette packets – ‘have a nicotine hit, but have no tar, tobacco and carbon monoxide, or the thousands of additional chemicals found in traditional cigarettes’. At 70 per cent cheaper and ‘legal everywhere’ they are sold as the ‘perfect smoking alternative’. Not everyone is convinced though. Concerns have been raised about the quality and variability of e-cigarettes, and there is evidence that some products contain the same toxins that are present in standard cigarettes. Earlier this year, the Medicines and Healthcare products
Regulatory Authority (MHRA) announced that e-cigarettes will have to be licensed and regulated as medicines from 2016. This means that they will face stringent checks by the MHRA and healthcare professionals will be able to prescribe them in the same way as any other medicine. Until then, they will remain on sale. But do e-cigarettes actually work in terms of helping people to quit, or cut down on, smoking? The jury would appear to be out. According to NHS Choices, the evidence so far is not strong enough to be conclusive (tinyurl.com/mwnuvca). One study, conducted by researchers at the University of East London and published in the journal Addiction, found that e-cigarettes reduced cravings in nine out of ten users. Seven out of ten said they did not have the urge to smoke as much as before. The study participants were, however, recruited through the websites of e-cigarette manufacturers so may not be representative of the general population of e-cigarette users.
Inconclusive evidence
There have also been claims that e-cigarettes might themselves damage the lungs by restricting the absorption of oxygen. But, once again, NHS Choices cautions that the research is not conclusive (tinyurl.com/nt5cfa6). Anti-tobacco campaigners have mixed views. Chief executive of ASH Scotland Sheila Duffy says there is ‘real potential’ for e-cigarettes to help people stop using tobacco. But she adds: ‘There is also the potential
NURSING STANDARD
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Of course this does not include e-cigarettes, because they are not yet licensed – and Professor Bauld does advocate caution. ‘If someone asks about e-cigarettes, the key bit of information is that we do not have good knowledge about safety. However, we can reassure people that they are safer to use than continuing to smoke. ‘The other thing is that the products are hugely variable, although some larger brands seem to be making more effort [in terms of quality], so the advice would be to try different brands.’
ALAMY
Quitting device
for harm, with commercial companies seeking to recruit new populations of nicotine addicts and the tobacco companies looking for opportunities to regain acceptability for themselves and for smoking in general. ‘We need quality standards for these products, so they are effective as stop smoking devices, and we need regulation to make sure they are not advertised or promoted in a way that would entice young people into nicotine addiction. ‘There is a risk that all the hard work that has been done to de-glamourise smoking could be undermined by the attractive imagery some companies use.’ The fear that e-cigarettes will help turn back the clock is not shared by Linda Bauld, professor of health policy at the University of Stirling and a former scientific adviser on tobacco control to the Department of Health. ‘Potentially, there is an issue with enforcing smoke-free legislation,’ she says,
NURSING STANDARD
adding that some train companies and pub groups have banned e-cigarettes to avoid confusion. ‘But on the issue of whether their use will make smoking normal again, we do not have the evidence to suggest that. We also do not have evidence that it is a gateway to smoking.’
THE WORK THAT HAS BEEN DONE TO DE-GLAMOURISE SMOKING COULD BE UNDERMINED – Sheila Duffy Professor Bauld chaired the NICE guidance development group, which recently – and controversially – recommended a harm-reduction approach for people who are unable to stop smoking in one go. The guidance was based on a thorough examination of the evidence and says that licensed, nicotine-containing products can be used to help people reduce their smoking.
Andy McEwen, director of the National Centre for Smoking Cessation Training, says that e-cigarettes are increasingly chosen by people trying to reduce their smoking. ‘E-cigs are very popular with smokers,’ he says. ‘Some 20 per cent of all quit attempts involve e-cigs and 12 per cent of smokers use e-cigs for quitting, cutting down or temporary abstinence.’ A large number of studies are under way to determine the effectiveness of e-cigarettes, he adds. Dr McEwen believes that nurses should welcome enquiries from patients about e-cigarettes. ‘It is a teachable moment,’ he says. ‘It suggests the person is interested in managing their smoking.’ Ms Clay agrees and says that she ‘grabs every opportunity’ to offer advice and help with giving up smoking. Indeed, she is sorry she will have to wait until 2016 before e-cigarettes become a regulated medical product. ‘It is a shame,’ says Ms Clay ‘If I could prescribe them along with a patch then I would not be resistant. Anything that helps people get off cigarettes deserves a chance’ NS Further information: www.ash.org.uk/ files/documents/ASH_715.pdf NICE guidance: guidance.nice.org.uk/PH45
november 20 :: vol 28 no 12 :: 2013 29
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SUMMARY
Whenever a patient mentions e-cigarettes – and it happens a lot – Rachel Clay has a standard answer. ‘I explain that I cannot condone them because they are not prescribable. But I do not say to stop using them – they are certainly less harmful than smoking cigarettes.’ Ms Clay, a practice nurse at Bentham Medical Practice in North Yorkshire, has been working in smoking cessation for more than a decade. Along with a colleague, she offers a combination of nicotine replacement therapy and behavioural change support for patients in one-to-one sessions. And she is keen to have an extra weapon in her anti-smoking armoury. ‘I think that e-cigarettes are helping people to quit,’ she says. In the world of smoking cessation, electronic or e-cigarettes are currently the big story. More and more people are turning to the products to help them give up, or cut down on, tobacco. E-cigarettes are battery-powered devices that contain nicotine – but not tobacco – and produce a vapour. They are marketed as a safer and cheaper substitute for cigarettes. One of the leading products on the market is E-Lites. The manufacturer claims they are
How to help a patient who wants to use e-cigarettes to quit smoking Ensure that they are getting behavioural support from a trained stop smoking practitioner. Inform the patient that we do not know how effective or safe e-cigarettes are, although they are definitely safer than smoking cigarettes. If they remain keen to use e-cigs then combination nicotine replacement therapy (NRT) involving a nicotine patch and e-cigs is a reasonable compromise. Use an evidence-based medication such as varenicline (Champix) or combination NRT (nicotine patch plus one of the faster-acting products such as nicotine mouth spray or nicotine lozenge). Advice supplied by Andy McEwen, director of the National Centre for Smoking Cessation Training. www.ncsct.co.uk
E-cigarettes are popular, but critics say the devices, which contain nicotine but not tobacco, may cause health problems or be addictive. Some nurses view them as a valuable anti-smoking tool and are looking forward to e-cigarettes becoming a licensed medicine in 2016. Author Jennifer Trueland is a freelance journalist
28 november 20 :: vol 28 no 12 :: 2013
‘an authentic tobacco alternative, as they look, taste and feel just like smoking’. According to the product website, E-Lites – which come in packs that look very similar to cigarette packets – ‘have a nicotine hit, but have no tar, tobacco and carbon monoxide, or the thousands of additional chemicals found in traditional cigarettes’. At 70 per cent cheaper and ‘legal everywhere’ they are sold as the ‘perfect smoking alternative’. Not everyone is convinced though. Concerns have been raised about the quality and variability of e-cigarettes, and there is evidence that some products contain the same toxins that are present in standard cigarettes. Earlier this year, the Medicines and Healthcare products
Regulatory Authority (MHRA) announced that e-cigarettes will have to be licensed and regulated as medicines from 2016. This means that they will face stringent checks by the MHRA and healthcare professionals will be able to prescribe them in the same way as any other medicine. Until then, they will remain on sale. But do e-cigarettes actually work in terms of helping people to quit, or cut down on, smoking? The jury would appear to be out. According to NHS Choices, the evidence so far is not strong enough to be conclusive (tinyurl.com/mwnuvca). One study, conducted by researchers at the University of East London and published in the journal Addiction, found that e-cigarettes reduced cravings in nine out of ten users. Seven out of ten said they did not have the urge to smoke as much as before. The study participants were, however, recruited through the websites of e-cigarette manufacturers so may not be representative of the general population of e-cigarette users.
Inconclusive evidence
There have also been claims that e-cigarettes might themselves damage the lungs by restricting the absorption of oxygen. But, once again, NHS Choices cautions that the research is not conclusive (tinyurl.com/nt5cfa6). Anti-tobacco campaigners have mixed views. Chief executive of ASH Scotland Sheila Duffy says there is ‘real potential’ for e-cigarettes to help people stop using tobacco. But she adds: ‘There is also the potential
NURSING STANDARD
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Of course this does not include e-cigarettes, because they are not yet licensed – and Professor Bauld does advocate caution. ‘If someone asks about e-cigarettes, the key bit of information is that we do not have good knowledge about safety. However, we can reassure people that they are safer to use than continuing to smoke. ‘The other thing is that the products are hugely variable, although some larger brands seem to be making more effort [in terms of quality], so the advice would be to try different brands.’
ALAMY
Quitting device
for harm, with commercial companies seeking to recruit new populations of nicotine addicts and the tobacco companies looking for opportunities to regain acceptability for themselves and for smoking in general. ‘We need quality standards for these products, so they are effective as stop smoking devices, and we need regulation to make sure they are not advertised or promoted in a way that would entice young people into nicotine addiction. ‘There is a risk that all the hard work that has been done to de-glamourise smoking could be undermined by the attractive imagery some companies use.’ The fear that e-cigarettes will help turn back the clock is not shared by Linda Bauld, professor of health policy at the University of Stirling and a former scientific adviser on tobacco control to the Department of Health. ‘Potentially, there is an issue with enforcing smoke-free legislation,’ she says,
NURSING STANDARD
adding that some train companies and pub groups have banned e-cigarettes to avoid confusion. ‘But on the issue of whether their use will make smoking normal again, we do not have the evidence to suggest that. We also do not have evidence that it is a gateway to smoking.’
THE WORK THAT HAS BEEN DONE TO DE-GLAMOURISE SMOKING COULD BE UNDERMINED – Sheila Duffy Professor Bauld chaired the NICE guidance development group, which recently – and controversially – recommended a harm-reduction approach for people who are unable to stop smoking in one go. The guidance was based on a thorough examination of the evidence and says that licensed, nicotine-containing products can be used to help people reduce their smoking.
Andy McEwen, director of the National Centre for Smoking Cessation Training, says that e-cigarettes are increasingly chosen by people trying to reduce their smoking. ‘E-cigs are very popular with smokers,’ he says. ‘Some 20 per cent of all quit attempts involve e-cigs and 12 per cent of smokers use e-cigs for quitting, cutting down or temporary abstinence.’ A large number of studies are under way to determine the effectiveness of e-cigarettes, he adds. Dr McEwen believes that nurses should welcome enquiries from patients about e-cigarettes. ‘It is a teachable moment,’ he says. ‘It suggests the person is interested in managing their smoking.’ Ms Clay agrees and says that she ‘grabs every opportunity’ to offer advice and help with giving up smoking. Indeed, she is sorry she will have to wait until 2016 before e-cigarettes become a regulated medical product. ‘It is a shame,’ says Ms Clay ‘If I could prescribe them along with a patch then I would not be resistant. Anything that helps people get off cigarettes deserves a chance’ NS Further information: www.ash.org.uk/ files/documents/ASH_715.pdf NICE guidance: guidance.nice.org.uk/PH45
november 20 :: vol 28 no 12 :: 2013 29
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