Tobacco: preventing uptake, promoting quitting and treating dependence
In a world where tobacco harm reduction, specifically vaping, is stigmatised daily by policy-makers and scientists desperate to search for harms and dangers of a technology that, if adopted and supported worldwide, could have already slashed rates of smoking, the new NICE guidance Overview | Tobacco: preventing uptake, promoting quitting and treating dependence | Guidance | NICE published 30.11.21 is a welcome breath of fresh air. Although conservative and cautious, as NICE guidance has to be, based on evidence rather than testimony or optimism (as my Stop Smoking Service’s vape-launch was in early 2014), this provides a clear message to the rest of the world that here in the UK at least, there is support for the use of vaping to stop smoking. Vaping for recreational purposes is not considered, of course; that is outside the scope of the guidance, but longer-term nicotine use is addressed, and that is welcome.
NG209 provides a disclaimer about medically-licensed products:
"At the time of publication (November 2021), no nicotine-containing e-cigarettes were licensed as a medicine for stopping smoking by the Medicines and Healthcare products Regulatory Agency (MHRA) and commercially available in the UK market. All nicotine-containing e-cigarettes in the UK that are not licensed as a medicine by the MHRA are regulated by the Tobacco and Related Products Regulations 2016, and cannot be marketed by the manufacturer for use for stopping smoking."
Whether a product ever gets a medicinal license remains to be seen. The barriers are high and the costs even more so. Opinion is divided on whether this helps get more ‘respectability’ for the category, but it cannot be denied that being able to prescribe to young smokers, or those in hospital, could be a benefit.
The NICE take on nicotine is something that other countries’ medics, researchers and policy-makers could well heed:
Provide the following information about nicotine:
- smoking is highly addictive mainly because it delivers nicotine very quickly to the brain and this makes stopping smoking difficult
- most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine
- nicotine levels in medicinally licensed nicotine-containing products are much lower than in tobacco, and the way these products deliver nicotine makes them less addictive than smoking.
The references are about licensed nicotine-containing products, because that’s where the evidence is found, and the emphasis on relative harms of smoking and non-combusted nicotine use serve to strengthen the argument for nicotine without the smoke.
"Provide the following information about the effectiveness and safety of medicinally licensed nicotine-containing products:
- any risks from using medicinally licensed nicotine-containing products are much lower than those of smoking; nicotine replacement therapy (NRT) products have been demonstrated in trials to be safe to use for at least 5 years
- lifetime use of medicinally licensed nicotine-containing products is likely to be considerably less harmful than smoking"
The language used by NICE makes a positive and welcome contribution to de-stigmatising the use of nicotine, and the term ‘dependence’ has begun to replace ‘addiction’. Even more importantly though, there is a distinct move towards an open-minded and person-centred approach, not regarding vaping as an option of last resort. It also recommends that extra information on how to make that first step wouldn’t go amiss.
"Offer behavioural support to people who smoke regardless of which option they choose to help them stop smoking. Explain how to access it.
Advise people (as appropriate for their age) that the following options, when combined with behavioural support, are more likely to result in them successfully stopping smoking:
- varenicline (offered in line with NICE’s technology appraisal guidance; see stop-smoking interventions in the NICE Pathway on tobacco use)
- a combination of short-acting and long-acting NRT
- nicotine-containing e-cigarettes"
A criticism that I would raise is the assumption, below, that youth vaping leads to youth smoking. This confuses correlation with causation and should be corrected; many factors influence the uptake of smoking and must be taken into consideration.
"The committee wanted to discourage e-cigarette use among young people and young adults who do not smoke because evidence shows that use of e-cigarettes is linked with a higher chance of ever smoking later in life. The committee members agreed that ideas about smoking and what is normal can start from a young age so the recommendation should also apply to this age group."
The simple statement below should be noted, especially where evidence reviews cherry-pick research to ‘prove’ that vaping does not help smoking cessation. If more was done to give people who smoke the confidence that vaping can help, and is not the same as smoking, more people would switch.
"They also agreed that offering behavioural support to people using nicotine-containing e-cigarettes would increase their chances of stopping smoking.
Evidence showed that nicotine-containing e-cigarettes can help people to stop smoking and are of similar effectiveness to other cessation options such as varenicline or long-acting and short-acting NRT.
There was a small amount of evidence about short-term adverse events of e-cigarettes that did not show that they caused any more adverse events than NRT, e-cigarettes without nicotine or no treatment."
On health harms, the guidance is clear that so-called EVALI outbreak was restricted in place and time, and the risks controlled by effective regulation.
"The committee discussed the outbreak of serious lung disease in the US in 2019, which US authorities identified was largely caused by vaping cannabis products containing vitamin E acetate. They also noted there has been a Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update highlighting serious lung injury with e-cigarettes issued in January 2020 (E-cigarette use or vaping: reporting suspected adverse reactions, including lung injury). The committee discussed that the UK has well-established regulations for e-cigarettes that restrict what they can contain. Experts from the MHRA described to the committee the monitoring process for both short- and long-term harms of using e-cigarettes. Monitoring is ongoing and the evidence may change in the future, but the committee was not aware of any major concerns being identified."
The following paragraph could have been strengthened, in my opinion. Less harmful – good to emphasise, and I sincerely hope that the healthcare community takes note of this, instead of telling their patients that vaping is as bad as, or worse than, smoking. The caveat about only as long as they need is a mixed message. Some people will need that for life. I’ve seen too many people lapse even years later, and if vaping keeps them smokefree forever, that’s a win. However, pleasure from vaping (outside the scope of NICE guidance), should also be recognised, especially when put in the context of pleasure from enjoying alcohol, eating chocolate and drinking coffee.
"The [committee] agreed that because many of the harmful components of cigarettes are not present in e-cigarettes, switching to nicotine containing e-cigarettes was likely to be significantly less harmful than continuing smoking. So the committee agreed that people should be able to access them as part of the range of interventions they can choose to use. They also agreed that people should be given up-to-date information on what is known about e-cigarettes to help them make an informed decision about whether to use them. The committee agreed that with the limited data on effects of longer-term use, people should only use e-cigarettes for as long as they help prevent them going back to smoking. They also agreed that people should be discouraged from continuing to smoke when using e-cigarettes, even if they are smoking less, because there is no information on whether this will reduce their harm from smoking."
I was concerned about the guidance for healthcare professionals that they should talk to patients about:
- How long the person intends to use nicotine-containing e-cigarettes
- Using them for long enough to prevent a return from smoking and
- How to stop using them when they are ready to do so
No one really knows how long they intend to vape – as experience develops, minds are changed. An individual may decide to stop sooner than they really should, and risk going back to smoking, or they could choose to continue vaping for the foreseeable future. They will not know, within weeks of switching, how their choices will change. Also, there are certain or universally-applicable ways of stopping vaping; clinical experience in my service demonstrated that people are generally comfortable with reducing the strength of their vape, and stopping if that’s their choice, without any intervention from support services.
The statement below is a hidden gem, appearing as it does towards the end of a very long document. Not enough nicotine is one of the primary reasons for failure when trying to stop smoking. Even would-be quitters who use a vape tend to think they are better off with a non-nicotine vape, and wonder why they cave and grab a cigarette. Use enough, people!
"The committee discussed that it is more likely that people will not get enough nicotine to help them stop smoking, than get too much. They agreed that not getting enough nicotine is likely to increase the risk that the person will return to smoking, so they recommended that people should be encouraged to use as much as they need and told how to use the products effectively."
And finally, an appeal to the interests of commissioners and providers: a little extra effort could increase success in quitting, and save money in treatment costs for smoking-related illness.
Extra time may be needed to discuss e-cigarettes with people who are interested in using them. If these recommendations lead to more successful quit attempts, this may mean fewer appointments per person and substantial savings in downstream costs associated with smoking.
I believe that the committee worked extremely hard to get the balance right, and I’m sure that some members deserve a special round of applause for their determination to have the vaping category included. It would have been so easy to default to licensed medications only, thus missing an exceptional opportunity to push down rates of smoking, by recognising that switching to vaping will save lives.
Louise Ross, December 2021