Guidance

Using electronic cigarettes in NHS mental health organisations

Published 4 March 2020

1. Summary

Electronic cigarettes (e-cigarettes) allow people to inhale nicotine without exposing the users to tobacco smoke. Although they are not completely risk free, the available evidence shows them to be far less harmful than smoking.

E-cigarettes are effective in helping smokers to quit, especially when combined with behavioural support.

E-cigarettes are not covered by smokefree legislation and there is no evidence that passive exposure can cause harm other than to people with pre-existing respiratory conditions.

You should base policies about vaping on evidence of relative harm compared with smoking, and e-cigarettes’ role in supporting smokers to quit or stop during their inpatient care. This includes designating areas within the hospital grounds and buildings where e-cigarette use is allowed or prohibited.

2. Purpose of this advice

This advice only applies to vaping UK-regulated, nicotine-containing products. Vaping illicit substances such as ‘spice’, THC (tetrahydrocannabinol), or black market e-liquids carries unknown risks.

In England, 1 in 3 cigarettes is smoked by a person with a mental health condition, so supporting them to stop smoking must be the overriding priority.

While e-cigarettes offer an effective route to stopping smoking, there are still some risks associated with their use. But evidence suggests they are far less harmful than smoking.

We have based the recommendations on the current scientific understanding of the relative risks and benefits of the use of e-cigarettes and had input from a range of national experts.

We expect NHS trusts and service providers to review local policies and adopt the recommendations unless there are valid evidence-based reasons not to. This might include setting proportionate and justifiable restrictions to improve security and safety in some secure and longer-stay mental health services.

This advice does not apply to heated tobacco products, for which there is currently little independent evidence.

This advice can also support wider NHS trust action for achieving smokefree status. There should be no new costs to trusts from implementing this advice.

3. Introduction

Smoking tobacco remains the largest single cause of preventable death in England. While smoking prevalence in the general population is at an historic low (14.4%), smoking rates in hospital patients average 25% and over 40% of people with serious mental illness (SMI) smoke. The Smoking and Mental Health Partnership reported that smoking prevalence in mental health units was as high as 70%.

Premature mortality rates are more than 3 times higher among people with mental health conditions compared to the general population, with recent analyses suggesting that the gap is widening. Smoking is the main contributing factor for this difference in life expectancy.

4. The difference between smoking and vaping

E-cigarettes, or ‘vapes’, are devices that deliver an inhalable aerosol by heating a solution (or ‘e-liquid’) that typically contains nicotine, propylene glycol or glycerol, plus flavours. Their use is known as vaping.

Cigarettes rely on the combustion of tobacco which produces far more dangerous substances, including carbon monoxide and tar.

Nicotine, when it is not delivered in tobacco smoke, is safe and well tolerated in healthy adults. This is important when considering how long people might want to vape for, because it is important that people can use nicotine for as long as they need to stay smokefree. Stopping nicotine use too early can lead to a relapse to smoking.

E-cigarettes have been available since 2004 but did not become popular in the UK until 2011. Prevalence of e-cigarette use has been static at approximately 5% since 2013. It’s now estimated that there are 3.6 million e-cigarette users in Britain. The University College London’s (UCL) Smoking Toolkit Study suggests that they have been the most common aid in quitting smoking for over 5 years.

5. Current position of leading health organisations on e-cigarettes

The National Institute for Health and Care Excellence’s (NICE) updated guidance on smoking states that healthcare professionals should not discourage the use of e-cigarettes as an aid for quitting smoking.

The Mental Health and Smoking Partnership advises:

To help smokers to stop smoking and stay smokefree, a more enabling approach to vaping should be considered to make it an easier choice than smoking. Vapers should not be required to use the same space as smokers, as this could undermine their ability to quit and stay smokefree.

The Care Quality Commission’s brief guide on smokefree policies in mental health inpatient services recommends:

E-cigarettes should not routinely be treated in the same way as smoking. It is not appropriate to prohibit e-cigarette use in health services as part of smokefree policies.

The Royal College of Psychiatrists has published guidance on prescribing varenicline and electronic cigarettes to patients with severe mental illness which recommends that psychiatrists tell patients who smoke that e-cigarettes may help them to quit, particularly when used with stop smoking treatments and are safer than continuing to smoke. But it also says that psychiatrists should also encourage patients to avoid e-cigarettes in the long-term where possible, provided this does not lead to a return to smoking.

Most mental health trusts in England allow the use of e-cigarettes and many provide them for free to patients. A survey by Action on Smoking and Health (ASH) (with responses from 45 NHS mental health trusts) reported that:

• 91% of the mental health trusts that responded allowed some or all inpatients to use e‐cigarettes
• 47% of the trusts allowed people to use all types of e‐cigarettes
• 31% of the trusts only allowed the use of non‐rechargeable, disposable devices
• 42% of the trusts provided e‐cigarettes free to their patients
• all but one trust restricted where people could use e‐cigarettes
• 44% of the trusts allowed the use of e‐cigarettes indoors
• 76% of the trusts allowed the use of e‐cigarettes in ward courtyards

6. The evidence on quitting with e-cigarettes

Studies have found e-cigarettes help people to stop smoking and contribute between 50,000 and 70.000 additional quits in England per year. Another study found that among smokers who reported trying to quit, the most successful had used an e-cigarette or the stop smoking medication varenicline (Champix).

In 2019, a randomised control trial set in English stop smoking services found that combining e-cigarettes with behavioural support could double the chances of successfully quitting smoking tobacco compared to nicotine replacement therapy (NRT) and behavioural support.

Public Health England’s 2019 evidence update looked at stop smoking services data between April 2017 and January 2018. The authors found the highest 4-week quit rates were seen when the quit attempt involved behavioural support from stop smoking adviser and:

• using a licensed medicine and an e-cigarette one after the other (73%)
• using a licensed medicine and e-cigarette at the same time (60%)
• using an e-cigarette on its own (60%)

People using a licensed medicine by itself or with other licensed medicines (so not using an e-cigarette) had a quit rate of 50%.

American research also shows that people vape for longer than use traditional NRT when trying to quit. The incidence of relapse was lower too (than with NRT).

E-cigarette use avoids the associated higher health risk of smoking. Smokers who see e-cigarettes as harmful are less likely to try e-cigarettes and much less likely to switch completely. And people who smoke and vape who see e-cigarettes as less harmful than cigarettes are more likely to completely switch to vaping and stop smoking than those who view vaping as more harmful.

7. Recommendations for organisational policies

1. Ensure that policies are clear about the distinction between smoking and vaping and are based on evidence.

2. Incorporate the use of e-cigarettes into service provider policies and procedures, including clear directions on when and where it is appropriate to use them and how patients can access them.

3. Include advice on e-cigarettes into formal organisational smokefree policy, with agreed processes for regular review.

4. Providers and commissioners should align policies about delivering smokefree premises with the NICE guidance Smoking: acute, maternity and mental health services (PH 48).

5. The Medicines and Healthcare products Regulatory Agency (MHRA) operate a Yellow Card reporting system for reporting suspected adverse effects of e-cigarette devices and e-liquids. Providers should report any adverse events to the MHRA.

6. Review and act on new guidance on the use of rechargeable electronic devices in hospitals in line with Northern Ireland’s Estates and Facilities Alerts Publications (EFA/2018/007) and the National Fire Chiefs Council.

7. Clarify that policies apply equally to staff, patients and the public, so consider everyone when making vaping policies.

8. Provide practical information, advice and training to staff about:

• the impact of smoking on the mental and physical health of patients
• the mental health benefits of long-term cessation
• changes in prescribing associated with stopping smoking (such as reducing a patient’s dose of clozapine)
• switching from cigarettes to e-cigarettes, including types of device, nicotine strength and how to use an e-cigarette
• maintaining the upkeep of e-cigarettes so they can best support patients (such as replacing parts and topping up e-liquids)
• safe charging of e-cigarettes and safe disposal

8. Recommendations for care

1. Provide clear information to both staff and patients about the difference between vaping and smoking and the associated risks of both.

2. Encourage patients to stop smoking or to abstain temporarily and offer behavioural support and prescribed smoking medications in support of any quit attempt.

3. Ensure patients have access to vaping products and consider whether to provide them proactively to patients who smoke.

4. Do not discourage patients using their own e-cigarettes in a quit attempt or when trying to abstain from smoking temporarily (unless an individual risk assessment suggests it is unsafe to do so).

5. Nicotine replacement supports temporary abstinence and quitting smoking, so do not rush patients to stop vaping as this may increase the risk of relapse to smoking.

6. Where patients are admitted who already vape, allow them to continue to use e-cigarettes. They do not need a stop smoking intervention unless they are also smoking cigarettes.

7. NHS trusts that provide stop smoking support should consider offering a wider package of support to the family at home, such as information on referral to local stop smoking services.

8. It is an offence to sell a nicotine inhaling product to anyone under the age of 18 or to buy one on their behalf. Public Health England (PHE) does not recommend the use of e-cigarettes by anyone under 18.

9. Next steps

We designed these recommendations to provide a single reference point for NHS service providers to standardise smokefree policies on the use of e-cigarettes.

These recommendations recognise that e-cigarette use is not risk free but also acknowledge that they can play a role in reducing harm in patients who have struggled to quit or do not want to stop smoking traditional cigarettes.

PHE, NHS England and NHS Improvement, working with NICE, will continue to look at the available evidence and regularly review this advice.

10. Other useful resources

Other resources that commissioners and providers may find useful.

The National Centre for Smoking Cessation and Training (NCSCT) produced a briefing on e-cigarettes for stop smoking services that makes recommendations for stop smoking practitioners and services, provides common questions and suggested answers about e-cigarettes, and summarises the evidence which these recommendations are based on.

The NCSCT has also produced a briefing on smoking cessation and smokefree policies that provides good practice advice for mental health services.

NCSCT also provides a training course to help health and social care professionals support people who want to use e-cigarettes to help them quit smoking.

PHE’s e-cigarette and vaping policy regulation and guidance collection includes the evidence on the impact of e-cigarettes, information on government policy and regulation, and guidance for organisations on vaping policies.

Cancer Research UK’s guidance for health professionals provides information and a range of resources on e-cigarettes.

PHE’s One You campaign offers help and advice on stopping smoking and switching to e-cigarettes.

The NHS Smokefree website has a section on using e-cigarettes to stop smoking.

PHE’s stop smoking options guidance supports conversations between clinicians and people who want to quit smoking on what method to choose.

The British Medical Association published a position paper on the regulation of e-cigarettes that sets out how to maximise the potential of e-cigarettes to reduce the health burden associated with smoking.

The Royal College of Nursing has produced guidance for nurses to encourage patients to stop smoking and make every contact count.

The Royal College of General Practitioners’ position statement on e-cigarettes advises primary care clinicians who may wish to promote e-cigarettes to patients as a means to stop smoking.

PHE’s Health Matters guidance details different ways to quit smoking and the evidence for their effectiveness, including the evidence on e-cigarettes.

PHE has published blogs on how e-cigarettes can help create a smokefree NHS and how a mental health trust is using e-cigarettes as a tool to go smokefree.

The Royal College of Physicians’ report Hiding in plain sight: Treating tobacco dependency in the NHS looks at the harm and costs of smoking and argues for a new approach to treating smokers. The Mental Health and Smoking Partnership has produced resources, a paper and webinar on e-cigarettes and mental health.

11. Case study

South London and Maudsley NHS Foundation Trust (SLaM) has a smokefree policy that has evolved over time. Disposable e-cigarettes have been allowed since 2012 and all types since 2017.

They designed their smokefree policy with input from patients. The policy allows the use of e-cigarettes only as part of a second-line treatment plan when licensed NRT or varenicline has not been effective in supporting the patient to quit, or they are a current vaper when they are admitted.

Following a risk assessment and recording this in a care plan, SLaM allows patients to use e-cigarettes in single use bedrooms, trust grounds, but not in communal areas, ward gardens or during therapeutic conversations.

To make e-cigarettes as accessible as possible, patients can buy them from hospital shops and canteens across SLaM. The trust only currently stocks e-cigarettes that are not affiliated with the tobacco industry.

Patient feedback on the support to vape as an alternative to smoking is extremely positive. For example, a man who smoked 80 cigarettes every day for 60 years before admission was comfortable and happy using an e-cigarette because NRT was a poor alternative for him.

For more information contact smokefreeready@slam.nhs.uk