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North East North Cumbria ICB Smokefree NHS/Treating Tobacco Dependency Taskforce Position Statement on Nicotine Vaping

April 2023

This is the position statement on nicotine vaping from the North East North Cumbria ICB Smokefree NHS/Treating Tobacco Dependency Taskforce. It outlines the evidence on vaping in relation to tobacco smoking and seeks to provide to staff working in NHS, including in Trusts, guidance on promoting vaping to support smoking cessation. It can be read in conjunction with the Association of Directors of Public Health North East position statement on nicotine vaping. It has been developed following publication of the 8th Nicotine vaping in England 2022 evidence update. Please note that for the purposes of this document, any references to vapes, vaping or e-cigarettes relate to nicotine-containing vapes, nicotine vaping and nicotine-containing e-cigarettes that comply with UK regulations.

Position statement – key points

Smoking is still our biggest avoidable killer

The ICB recognise that tobacco smoking is still our biggest killer, with up to two out of every three long term users dying early as a result of their addiction. As a system, the ICB has prioritised treating tobacco dependency and is committed to the shared ambition of making tobacco smoking obsolete by reducing smoking rates to 5% or less by 2030. The priority for the Taskforce must be to reduce the number of people who smoke a known uniquely lethal product.

Vaping poses a fraction of the risks of smoking

The most robust evidence on nicotine vaping is contained in the 8th Nicotine Vaping in England: 2022 evidence update covering national and international evidence It found:

  • In the short and medium term, vaping poses a small fraction of the risks of smoking, but that vaping is not risk-free, particularly for people who have never smoked.
  • There is significantly lower exposure to harmful substances from vaping compared with smoking. However, there is similar or higher exposure to harmful substances from vaping compared with not using any nicotine products.

In smoking households, vaping offers a less harmful alternative for non-smokers.

Vaping is effective in helping people quit smoking

NICE is clear in its tobacco guidance that healthcare professionals should be supportive of patients switching to e-cigarettes completely and the Cochrane living systematic review on electronic cigarettes for smoking cessation shows that there is high certainty evidence that vaping is effective at stopping people smoking. Completely switching to vaping should be promoted as an accessible, less harmful alternative for smokers and we support healthcare professionals to help their patients understand that vaping is a significantly less harmful option than continuing to smoke.

We need to promote effective quitting options – including vaping – while protecting children from using nicotine.

While vaping poses a fraction of the risks of tobacco smoking, and can help people quit smoking, we recognise that vaping is not risk-free and that those who don’t smoke should not vape. Most importantly, the use of vapes – and tobacco – by children should be discouraged. Action is needed nationally to improve regulation for e-cigarettes – and tobacco – to reduce appeal and accessibility among young people.

Prof Sanjay Agrawal,Consultant in Respiratory and Intensive Care Medicine, National Clinical Advisor for tobacco dependency to NHS England & Improvement, Chair of Royal College of Physicians (RCP) tobacco advisory group:

“I see on a daily basis the devastating impact of tobacco use on patients in hospital and as clinician recognise that more needs to be done to reduce these harms amongst smokers. Vaping is a highly effective treatment option for tobacco dependency and should be offered to patients who smoke alongside all other treatments available to help smokers quit as recommended by NICE.”

Dr Ruth Sharrock, Respiratory Consultant Gateshead NHS Foundation Trust, and Clinical Lead for Tobacco Dependency, NENC:

"As a doctor, being able to encourage smokers to stop and switch to vaping is vital. 1 in 2 long term smokers will die early, and those odds are even worse for heavier smokers in our poorer communities. Most people with lung cancer and COPD would not end up in my clinic if they had never smoked. When patients are diagnosed, their life changes with health anxiety, and numerous tests and appointments before starting treatment. It’s crucial at that point they get the best treatment outcome and quitting smoking is part of that.

“Allowing them to get their nicotine and the hand-to-mouth action of vaping is a crutch during a difficult time. It is vital we help current patients but also prevent people ending up on our hospital wards in the future. As with any quit product we need to monitor the evidence but my experience so far is that vapes are helping people to quit and vastly reduce their risks.”

Smoking is still our biggest avoidable killer

Smoking tobacco is the biggest avoidable cause of death, disease and disability, killing up to two out of every three long term users and significantly reducing healthy life expectancy. It accounts for more years of life lost than any other modifiable risk factor and is a leading cause of health inequalities. The ICB, working as a system, has prioritised treating tobacco dependency and is committed to the shared regional and national ambition of making tobacco smoking obsolete by reducing smoking rates across the general population to 5% or less by 2030.

Cigarettes are the only legal consumer product that will kill when used exactly as the manufacturer intends them to be used. Tobacco and vapes both contain nicotine which is an addictive substance. Nicotine itself has been used safely for many years in medicines to help people stop smoking. However, tobacco and the smoke it produces contains a toxic mix of over 6,000 chemicals, many of which cause cancer and other fatal and life limiting conditions including respiratory and cardiovascular disease, not just among smokers but also among those who are exposed to secondhand smoke.

14.8% of adults in the North East smoke, down from 29% in 2005, but despite faster progress in this region than other areas, an inequalities gap remains. The smoking rate among routine and manual workers is 24.3% and among those with mental health conditions, it is 27%, though it can be much higher in certain populations. As well as being a significant driver of household poverty, smoking costs the North East nearly £888 million every year, £67 million of which is spent on smoking-related social care and £125 million on health care.

Our priority for the Taskforce must be to reduce the number of people who smoke a known uniquely lethal product:

  • People who smoke make up a significant number of those admitted to hospital and the impact of smoking-related admissions affects every hospital and all clinical pathways from pregnancy through to children and adults.
  • Many smokers find quitting difficult due to addiction, previous failed quit attempts and living or working around other smokers. Being admitted to the NHS can present a compelling opportunity to stop smoking, or at least stop while in hospital to improve the chances of a quick and successful recovery.
  • The Royal College of Physicians has clarified that cigarette smoking should be understood first and foremost as addiction, with nicotine delivered by tobacco as addictive as ‘hard’ drugs such as heroin. Smokers usually start as children and are addicted by the time they are adults. Most smokers wish they had never started, and most have tried to stop.

Vaping poses a fraction of the risks of smoking

The most robust evidence on nicotine vaping is contained within the Nicotine Vaping in England: 2022 evidence update. The report is the most comprehensive to date, its main focus being a systematic review of the national and international evidence on the health risks of nicotine vaping. The summary of conclusions is that:

  • In the short and medium term, vaping poses a small fraction of the risks of smoking, but that vaping is not risk-free, particularly for people who have never smoked.
  • There is significantly lower exposure to harmful substances from vaping compared with smoking, as shown by biomarkers associated with the risk of cancer, respiratory and cardiovascular conditions. However, there is similar or higher exposure to harmful substances from vaping compared with not using any nicotine products.

In households where tobacco smoking occurs, vaping offers a less harmful alternative for non-smokers. Exposure to secondhand tobacco smoke is dangerous. Compared with cigarettes, vaping products produce no or little side-stream emissions. The evidence update found that there is no significant increase of toxicant biomarkers after short-term secondhand exposure to vaping among people who do not smoke or vape. This is an important consideration for healthcare professionals working with patients whose conditions are made worse by exposure to tobacco smoke including asthma and heart disease.

ASH regularly monitor the use of vapes by adults. Their 2022 survey showed:

  • The proportion of the adult population using e-cigarettes is 8.3%, the highest rate ever, amounting to 4.3 million people in Great Britain.
  • Most current vapers are ex-smokers (57%). The proportion peaked in 2021 at 64%.
  • Only 1.3% of never smokers are current vapers, amounting to 8.1% of vapers. The proportion of adult smokers who have never tried e-cigarettes is continuing to decline slowly, down to 28% in 2022. The proportion of smokers who are current vapers has increased from 2021 (17%) to 2022 (22%).

Vaping is effective in helping people quit smoking

The evidence is clear that, for smokers, vaping is a far less harmful option and, in the short and medium term, vaping poses a small fraction of the risks of smoking. Completely switching to vaping should be promoted as an accessible, less harmful alternative for smokers who want to reduce their risk of developing a smoking-related disease. However, only a small proportion of adults who smoke accurately believe that vaping is less harmful than smoking. We support healthcare professionals to have discussions with their patients, based on the evidence, to ensure smokers understand that completely switching to vaping is a significantly less harmful option than continuing to smoke:

  • NICE clearly suggests in its tobacco guidance that healthcare professionals should be supportive of patients switching to e-cigarettes completely.
  • The Cochrane living systematic review on electronic cigarettes for smoking cessation shows that there is high certainty evidence that vaping is effective at stopping people smoking: more people stopped smoking for at least six months using nicotine e‐cigarettes than using nicotine replacement therapy.
  • A recent article (paywall) from Professor Ann McNeill (lead author on the 8th OHID evidence review) and colleagues looks at the role of nicotine e-cigarettes as a smoking cessation tool and summarises that “there is abundant evidence that e-cigarettes can help some individuals to quit smoking, so they should be more widely recommended as smoking cessation aids.” The article also provides a series of recommendations for healthcare professionals to provide advice and guidance to smokers.
  • Vapes are currently the most common aid used by smokers to help them to quit. However the majority who use them are doing so without behavioural support: quit rates will increase if behavioural support is provided alongside switching to vaping.
  • A critical recommendation to the government from Dr Javed Khan OBE’s independent review on making smoking obsolete is to promote vaping as an effective tool to help people to quit smoking tobacco, outlining the role that vaping can play in an effective tobacco control strategy.
  • While e-cigarettes are not currently available on prescription in the UK, in October 2021 the MHRA updated its guidance to encourage manufacturing firms to submit products for prescription regulatory approval.
  • It is important to note that the benefits of vaping are only realised when a smoker switches completely away from tobacco.
  • Guidance has been developed to support NHS Trusts in incorporating a vape offer into Treating Tobacco Dependency Services covering topics such as the cost involved, types of vapes available, supply, policy, training and shared learning. A portal will soon be available through OHID to support Trusts through the procurement process.
  • A NENC pilot scheme supporting NHS Foundation Trust staff who smoke to make a quit attempt saw 80% of those accessing support opt for a refillable vaping device as a tool to quit smoking. Many of the staff utilising the regional vape offer had either never thought about quitting previously, or had a previous failed quit attempt. This provides a clear preference from a vast majority of those who smoke to utilise a vape over traditional nicotine replacement therapies. There are pilots underway in different areas of the NHS to utilise vapes as a quit aid for different cohorts.
  • A recent study published in Nature Medicine found that vaping was as safe as and may be more effective than NRT in helping pregnant women to quit smoking. NHS guidelines also state that ‘if using an e-cigarette helps you to stop smoking, it is much safer for you and your baby than continuing to smoke.’

We need to promote effective quitting options – including vaping – while protecting children from using nicotine.

In its guidance on preventing uptake of tobacco, NICE recommends that, with children, e-cigarettes are talked about separately from tobacco products.

ASH regularly monitor youth use of vapes. Their 2022 survey showed:

  • 83.8% of 11-17 year olds have never tried or are unaware of e-cigarettes.
  • 15.8% of 11-17 year olds had tried vaping, compared to 11.2% in 2021 and 13.9% in 2020.
  • 7.0% of 11-17 year olds were current users, compared to 3.3% in 2021 and 4.1% in 2020. Children under 16 are least likely to try e-cigarettes. 10.4% of 11-15 year olds have tried vaping, compared to 29.1% of 16-17 year olds. Among 18 year olds 40.8% report having tried an e-cigarette.
  • Use among 11-17 year olds who have never smoked remains low and largely experimental, while 7.5% of never smokers have tried an e-cigarette in 2022 only 1.7% report at least monthly use.

Data from North East young people’s surveys show similar results in terms of the proportion of young people currently using vapes.

Vapes are tightly regulated in the UK through legislation relating to quality, safety, age of sale and advertising. Enforcement of laws on underage sales, sales of non-compliant products, and point of sale advertising is the responsibility of Trading Standards. Enforcement of other advertising and promotion of vaping to under-18s, for example on social media, is the responsibility of the Advertising Standards Authority. However, we need to reduce the accessibility and appeal of vapes to young people and to reduce the amount of non-compliant e-cigarettes available for sale. We also need to continue to advocate for tighter e-cigarette regulations where needed, ensuring the right balance is taken around protecting young people and supporting smokers to quit. A policy brief has been developed, drawing on North East evidence, setting out key policy recommendations for the government including taxing single use vapes which are the cheapest and most popular vape for children.

“There is a need for regulation to reduce direct and indirect adverse effects of e-cigarette use, but this regulation should not be allowed significantly to inhibit the development and use of harm-reduction products by smokers.

“However, in the interests of public health it is important to promote the use of e-cigarettes, NRT and other non-tobacco nicotine products as widely as possible as a substitute for smoking in the UK.”

- Nicotine without smoke: Tobacco harm reduction | RCP London

Further reading and resources

8th Nicotine Vaping in England: 2022 evidence review

ASH briefing for local authorities on youth vaping

ASH Smokefree GB survey data on e-cigarette use by adults and young people

APPG Smoking and Health report on Delivering a Smokefree 2030

Independent review into making smoking obsolete – Dr Javed Khan OBE

For smokers

OHID Better Health pages on vaping to quit smoking

Fresh Quit

Smoking in Pregnancy Challenge Group: Using e-cigarettes before, during and after pregnancy

For health care professional and public health colleagues

Cochrane living systematic review on the use of e-cigarettes for smoking cessation

NICE guidance on tobacco: preventing uptake, promoting quitting and treating dependence

NCSCT guidance on incorporating e-cigarettes into stop smoking services

Smokefree Action Coalition information on vaping during pregnancy

PHE guidance on using e-cigarettes in NHS mental health organisations

NCSCT guidance on supporting clients who want to stop vaping

For schools

ASH guidance for schools and colleges