This site is intended for health professionals only

Alternatives to smoking

Key learning points:

- Better support for patients who smoke

- How e-cigarettes can help patients

- How to get more information about smoking alternatives

I'd be really surprised if any nurse hadn't been told by one of their smoking patients in the last year that they were thinking about using an e-cigarette to stop smoking. Like advisors in stop smoking services, nurses will see patients who have smoked all their lives, have tried and failed to quit, and those who have become disheartened. There are also patients who claim to be happy smoking, and don't want any advice about stopping.

So this new interest in e-cigarettes may have taken some healthcare professionals by surprise, and while smokers are looking for advice, so will the nurses and doctors to whom they turn to for information.

This article outlines some suggestions to support patients who want to take a giant step away from smoking tobacco.

What are e-cigarettes?

They are devices that, despite having many different forms, essentially heat a liquid containing nicotine, water, flavourings, propylene glycol and/or vegetable glycol into a vapour that the user inhales.

They either come as first generation cigalikes (disposable, sold in supermarkets, service stations, poorer nicotine delivery), second generation vaporisers (refillable, better nicotine delivery, look very different to cigarettes) and mods (modifiable third generation devices with large batteries that can be used for much longer).1

Using licensed medication and behavioural support

For years, the stop smoking services, and the primary care nurses and pharmacists who support smokers, have done a sterling job of helping smokers to quit, using patches, gum, ZYBAN, inhalators, and more recently CHAMPIX, mouth spray and mouth strips. However, since the boom in this new technology, smokers are talking to friends and family who have tried e-cigarettes, and 2.6 million people in the UK have started using them, the majority of those being people who have used them to stop smoking or to reduce the amount they smoke.2

Leicester City's experience

The Leicester stop smoking service was the first in the country to go 'ecig-friendly' on No Smoking Day 2014. Since then the team has built up a comprehensive bank of knowledge and insights, developed from many discussions with both vapers and smokers, that can be drawn on to help people get the best advice when they decide they've had enough of smoking. E-cigarettes don't suit everyone, and there is still the wide range of licensed stop smoking medication to use alongside behavioural support, but those who are keen to try an e-cigarette are encouraged to give it a go.

The National Centre for Smoking Cessation and Training (NCSCT) has produced valuable guidance to support this approach3 and Professor Robert West, in his fascinating book The Smokefree Formula4 is enthusiastic about smokers trying a range of routes out of smoking that may be successful for them.

Which side of the fence?

There have been fierce debates in tobacco control, public health, primary and secondary care, and among the general public about which side of the fence to be on. Are e-cigarettes a game-changer that could see the end of smoking in our lifetime, or should we wait for more evidence?

Public Health England has published an authoritative report5 which examines the evidence, and Professor John Britton, along with Dr Ilse Bogdanovica,6 make the point that e-cigarettes offer vast potential public health benefits. One of the biggest concerns among respected tobacco control and public health experts7 is that the public are being misled by scare stories into thinking that vaping is more hazardous than smoking. Therefore, to support nurses to contribute to public confidence in the use of clean nicotine-delivery devices, here is an A-E-I-O-U on how to discuss e-cigarettes with patients.

A - Advice

Your patients will be looking to you for advice, and you may feel uncomfortable about recommending something that you don't know much about yourself. You don't have to be an expert about something to have a discussion about it. Saying that you've heard that people do really well with them could be enough to develop the conversation. You could also do some action-based research yourself, by talking to people who have used e-cigarettes.

As an ice-breaker, I have asked complete strangers what flavour liquid they're using. I've never been snubbed by a vaper; most are really keen to chat with someone who's interested, and they often go on to say why they started vaping, and how it made stopping smoking so much easier. As you gather stories of lived experience, you will be in a much stronger position to give advice to your patients needing to make the switch from smoker to non-smoker.

E - Encouragement

When you have this conversation, remember that this may be the first time that quitting smoking has ever been a real possibility in that person's mind. Don't crush it with your own prejudices. I frequently talk to healthcare workers who have been anti-smoking for so long that they have a mind-set of 'guilt by association' about vaping. Because it looks like the act of smoking due to the vapour, and because the person is taking in nicotine, they experience an antipathy to it that drives them to want to stop the person from doing it. This is not helpful. Think how happy you would be when you see your patient at their next appointment and they tell you that they haven't smoked a regular cigarette
for weeks.

If they have been using an e-cigarette instead, that is a good thing. People smoke for the nicotine, but die from the carbon monoxide and tar.8

I - Information

There is a wealth of information about vaping, and you can encourage your patient to do their own research (while you do yours). Some of it will come via the internet (for instance vapers' forums), or experienced vapers might meet in their day-to-day life and vape-shops, which from my experience are run by sincere and interested people who genuinely want to help people stop smoking. The Leicester team has worked closely with e-cigarette retailers, and they have provided invaluable expertise to complement our own skills in smoking cessation treatments.

O - Opportunity

This new interest from your patient in stopping smoking could be a great opportunity to refer him or her to their local stop smoking service. More and more services are becoming ecig-friendly, and certainly the Leicester service has seen around 20% greater success among people who have used e-cigarettes and behavioural support. Some also used nicotine replacement therapy (NRT) at the same time, and this combination appears to work well.

U - Understanding

There seems to be a particularly strong urge among healthcare workers to get people off nicotine. This is unsurprising, especially when we know that burnt cigarettes kill half the people who use them, and cause years of disease and disability for many more.9 However, NICE guidance10 emphasises that long-term nicotine use, if it stops the person relapsing to smoking, is an appropriate harm-reduction measure.

A decision about using nicotine from a licensed product (NRT) or a consumer product (an e-cigarette) becomes a matter of personal choice, and for many using a vaporiser may be the single most important factor in whether they stay off deadly cigarettes or start smoking again. If they are told by a respected healthcare professional that they should wean themselves off their nicotine, simply because of the worker's ingrained distrust of nicotine, the opportunity for health gains could be lost.

 A useful analogy is alcohol: many people enjoy a glass of wine or a beer. Alcohol is a poison, and no one needs to use it, but it's enjoyable and has value in the lives of those who choose to enjoy it. The same could be said for nicotine, which appears to be no more addictive than caffeine when not combined with the other chemicals in a smoked cigarette.11

Residual concerns

Healthcare professionals may be worried that vaping could renormalise smoking. There appears to be no evidence that this is the case, in fact as e-cigarette use rises, smoking rates are falling.12 It also may be a concern that young people might start to smoke because they used an e-cigarette. Again, there is no evidence of this13 although Public Health England and Action on Smoking and Health will be monitoring this closely. Additionally, accidental swallowing can be a concern. Therefore, patients should be informed to keep their liquids out of reach of children and pets. Fire risks are another worry. Patients should be told to buy from a reputable supplier, to always use the charger that came with the vaporiser and to never leave it charging overnight or unattended.

Conclusion

As front-line healthcare professionals, nurses are exquisitely positioned to make a difference to health outcomes. With vaping they have an opportunity here to change patients' lifelong smoking.

References

1. Dawkins, L. Electronic cigarettes: what are they and are they effective? slideshare.net/lindsayfox/dr-lynne-dawkins-e-cigarette-summit (accessed 17 October 2015).

2. Action on Smoking and Health. Use of electronic cigarettes (vapourisers) among adults in Great Britain. ash.org.uk/files/documents/ASH_891.pdf (accessed 17 October 2015).

3. National Centre for Smoking Cessation and Training. E-cigarette Briefing. Electronic Cigarettes. NCSCT, 2014. ncsct.co.uk/publication_ecigarette_briefing.php (accessed 17 October 2015).

4. West R. The smokefree formula: a revolutionary way to stop smoking now. London: Orion, 2013. smokefreeformula.com/ (accessed 17 October 2015).

5. GOV.UK. E-cigarettes around 95% less harmful than tobacco estimates landmark review - Press releases. gov.uk/government/news/e-cigarettes-around-95-less-harmful-than-tobacco-estimates-landmark-review (accessed 17 October 2015).

6. Britton J, Bogdanovica I. Electronic cigarettes: a report commissioned by Public Health England. Public Health England, 2014.

7. Bates, C. Stop demonising a potentially useful product for smokers, 2014. pharmaceutical-journal.com/opinion/comment/stop-demonising-a-potentially-useful-product-for-smokers/20066415.article (accessed 17 October 2015).

8. Bauld L. There's no evidence that e-cigarettes are as harmful as smoking. The Guardian, 2015. theguardian.com/science/sifting-the-evidence/2015/feb/23/theres-no-evidence-e-cigarettes-are-as-harmful-as-smoking (accessed 17 October 2015).

9. British Thoracic Society. Smoking Cessation. brit-thoracic.org.uk/clinical-information/smoking-cessation/ (accessed 17 October 2015).

10. NICE. Tobacco: harm-reduction approaches to smoking. Public Health Guidance 45. NICE, 2013. nice.org.uk/guidance/PH45 (accessed 17 October 2015).

11. Hajek P. On ecigarettes. youtube.com/watch?v=SVS0_BGHHjM (accessed 17 October 2015).

12. BBC News Health. E-cigarette fears might be unfounded (data from the Office of National Statistics). BBC News Health, 2014. bbc.co.uk/news/health-30192181 (accessed 17 October 2015).

13. Action on Smoking and Health. Use of electronic cigarettes among children in Great Britain, 2015. ash.org.uk/files/documents/ASH_959.pdf (accessed 17 October 2015).