How are the English Stop Smoking Services responding to growth in use of electronic cigarettes?

Abstract

Objective

To assess extent of electronic cigarette use by smokers attending Stop Smoking Services, the advice given about electronic cigarettes and whether this usage is recorded.

Methods

Fifty-eight managers and 1284 practitioners completed an online survey. Questions covered use of electronic cigarettes, the advice given and whether use was recorded in client databases.

Results

Ninety per cent (n = 1150) and 95% (n = 1215) of practitioners respectively, reported that their clients were using electronic cigarettes and that they had been asked about them. Seventy-one per cent (n = 41) of managers reported that they had a policy on the advice to be given; of whom 85% (n = 35) said that practitioners should say that products were unlicensed. Fifty-five per cent (n = 707) of practitioners reported giving such advice and 11% (n = 138) said they warned smokers about their safety. Only 9% (n = 119) reported that they recorded clients’ use.

Conclusion

Although use of electronic cigarettes by smokers in Stop Smoking Services is common, few provisions are in place to record their use. Practitioners mostly advise that products are not licensed.

Practical implications

There is a need to consider additional training for practitioners on use of e-cigarettes and harm reduction generally to ensure that advice is consistent and evidence-based.

Introduction

The number of countries around the world offering some form of Stop Smoking Service to smokers who wish to quit is accumulating steadily, although these often differ extensively in structure and outreach [1]. Perhaps one of the most comprehensive is the United Kingdom Stop Smoking Services established in 1999, which have been instrumental in reducing smoking rates [2] and have served as a model for other countries. These services are under the direction of local authorities, with each configuring itself on the basis of national guidelines. The services aim to provide evidence-based behavioural support and access to smoking cessation medication [3], [4].

With the release of the National Institute of Health and Care Excellence guidance on tobacco harm reduction in June 2013, the English Stop Smoking Services may be extended to offer support and guidance to smokers who are unable or unwilling to stop smoking [5]. The guidance covers two main forms of harm reduction – smoking reduction and temporary abstinence – which have both been shown to increase the propensity of smokers to stop, particularly if supported by licenced nicotine containing products [6], [7], [8]. Although this advice may take many forms, one recommendation is that guidance on harm reduction is incorporated into the brief advice given by health-care professionals prior to service attendance. This will ensure that disruption to the services does not occur and that the message is still that of complete abstinence [9]. However, smokers attempting harm reduction should be encourage to attend the services when they feel ready to quit smoking and given support to stop abruptly (note: although clinical trials have found that gradual cessation has similar efficacy as abrupt cessation, it appears to be less effective in the real world [10], [11], [12]).

The National Institute of Clinical and Care Excellence guidance also acknowledged the potential contribution of electronic cigarettes (e-cigarettes) to tobacco harm reduction, but would only advocate this approach if they became licenced medicines in the UK. Studies have shown that these devices are becoming increasingly popular, and that they may help users to reduce or quit smoking [13], [14], [15], [16], [17], [18], [19], [20]. They also deliver clinically significant levels of nicotine into the blood, albeit, at least for some smokers, at a much lower level than traditional tobacco products [21], [22], [23]. Potentially harmful constituents have been identified in some cartridges [24], [25]; though levels are much lower than those found in cigarettes [26].

However, a major limitation with many of these studies is that they were based on surveys which recruited smokers from e-cigarette forums who are likely to hold more favourable attitudes towards such products. This is evident in the study by Dawkins et al. [23], where the authors reported that 74% of their sample had not smoked for several weeks since using e-cigarettes. This far exceeds what would be expected for currently available efficacious treatments [27]. Much of the data so far on safety and nicotine intake is also based on clinical trials, thus results may not play out in the real world where smokers will not generally be provided with e-cigarettes free of charge.

In June 2013, the Medicines and Healthcare products Regulatory Agency finalised their consultation on e-cigarettes and reached the decision that they should be regulated as medicines in the UK by 2016, in the belief that licensing would improve their safety and effectiveness [28]. This has put the UK at the forefront of the debate on e-cigarettes, with many other countries deliberating over their use or banning/imposing heavy restrictions, including Australia, Brazil, Lebanon, France, the US and Singapore. Reasons for this hostility include the belief that they contain harmful substances, that they may encourage higher consumption of nicotine and that they will act as a gateway to smoking.

With the release of guidelines on harm reduction, and these regulatory changes to e-cigarettes, there is a need to determine the role that Stop Smoking Services will play. A first step, and the aim of this paper, is to ascertain the procedures stop smoking practitioners and managers have in place to record and advise smokers about the use of electronic cigarettes and to assess their beliefs about the prevalence and reasons for e-cigarette use among their clients.

It is important to discover whether Stop Smoking Services have provisions in place to record e-cigarette use, since careful monitoring will allow for the analysis of the impact of e-cigarettes on quit rates over time and other significant clinical outcomes. It might be hypothesised that since they are not currently licensed, and therefore not available on prescription, that few if any monitoring procedures will be implemented. It is similarly important to determine the advice given by Stop Smoking Practitioners to ensure that the Stop Smoking Services are maintaining an evidence-based approach; since although there is strong endorsement for evidence-based practice in health-care fields, its use is often lacking [29], [30], [31], [32].

One reason for this is that health-care professionals’ personal beliefs often conflict with the evidence base and are more likely to influence practice [33], [34], [35]. For example, previous research shows that health-care professionals hold erroneous views about nicotine containing products and harm reduction generally, and that these beliefs are associated with the advice offered to smokers [36], [37]. Thus if similar views are established about e-cigarettes it is plausible that Stop Smoking Practitioners may advise against their use. This situation may change in the UK in light of the recent guidance and recommendations by the National Institute of Clinical and Care Excellence and the Medicines and Healthcare products Regulatory Agency, and with training on e-cigarettes and harm reduction offered to Stop Smoking Practitioners by organisations such as the National Centre for Smoking Cessation and Training.

Finally, it is of interest to assess their beliefs about how many clients are using e-cigarettes and the reasons for their use, in order to inform future polices and the training offered to Stop Smoking Practitioners. Previous research suggests that smokers use e-cigarettes as they are less toxic than tobacco, to quit smoking or avoid relapsing, to deal with cravings for tobacco, during periods of temporary abstinence, for smoking reduction, and because they are cheaper than cigarettes [14], [15]. If a substantial proportion of e-cigarette users are attempting harm reduction then the prevalence of use in Stop Smoking Services may be low, on the basis that smokers who use nicotine containing products for harm reduction often do not approach health-care professionals and hold hostile beliefs about the services offered to smokers [38], [39].

The specific questions addressed by the current study are as follows:

• Do stop smoking services have procedures in place to record clients’ cigarette use?

• What advice do stop smoking practitioners give their clients about e-cigarettes and is this consistent with the recommendations given by managers of Stop Smoking Services?

• How many clients have asked questions about e-cigarettes, tried them, or report regularly using them?

• What reasons do smokers give Stop Smoking Practitioners for using of e-cigarettes?