Over the summer, US media reported that two National Health Service hospitals in England were allowing Ecigwizard, a vape retailer, to open stores inside their facilities.
What some critics quoted in these reports missed was that these stores were established in order to encourage patients who struggle to quit smoking to switch to vaping. The stores had a secondary purpose of enabling hospital employees to benefit from store associates’ vaping knowledge.
It should be no surprise that these hospitals were able to create such partnerships. The United Kingdom is a world leader in regulating vaping products. Its government, unlike much of the world, has developed a permissive vapes market within a strict, age-controlled regulatory framework.
And unlike in the United States, the UK’s public health community has been sending a risk-proportionate message to the people it serves. Public Health England (PHE) commissioned the seminal independent 2015 evidence review that found e-cigarettes to be about 95 percent safer than combustibles. The agency and its Tobacco Control lead, Martin Dockrell, endorsed vaping for smoking cessation based on this evidence.
NHS pregnancy advice: “If using an e-cigarette helps you to stop smoking, it is much safer for you and your baby than continuing to smoke.”
Since then, UK vaping has developed in a pro-harm reduction environment, with products regulated by the equivalent to the US Food and Drug Administration: the Medicines and Healthcare Products Regulatory Agency (MHRA).
The National Health Service has now wholly adopted a smoke-free policy position that encourages vaping for smokers. It sensibly states in its pregnancy advice, for example, “If using an e-cigarette helps you to stop smoking, it is much safer for you and your baby than continuing to smoke.”
Members of Parliament have even called for e-cigarettes to be prescribed for smokers in pharmacies. (While the NHS promotes vaping for smoking cessation, it has yet to prescribe them as an alternative to traditional nicotine replacement therapies.)
Amid all this risk-proportionate messaging, what’s happening on the ground?
Well over 3 million Brits now vape—with an estimated 10 percent rise from 2017-2018. Just over half are now ex-smokers, and almost all of the rest are engaging in dual use—which may mean they’re transitioning to vaping-only, or that they’re just reducing their smoking. Smoking rates continue to decline, particularly among young people—for whom the rise of vaping has not “normalized” smoking. Regular vaping among youth who have never smoked remains rare.
Opposite Approaches to a Lung Disease Outbreak
A comparison between UK and US public health authorities’ messaging, in the context of the US outbreak of lung injuries that began this summer, is instructive.
The US Centers for Disease Control (CDC) quickly branded “e-cigarettes” as responsible, without clarifying its uniquely all-encompassing use of the term, and waited well over a month before conceding that “THC products may play a role.” We now know that vaping of contaminated and unregulated THC oils, containing, for example, vitamin E acetate, was the primary factor. Yet the CDC continues to advise against all vaping.
“These cases are worrying and need investigating but it is always preferable to vape than to smoke.”
But despite the drug panic across the pond, Public Health England officials reassured vapers that they shouldn’t be alarmed. “Unlike the US, all e-cigarette products in the UK are tightly regulated for quality and safety by the [MHRA] and they operate the yellow card scheme, encouraging vapers to report any bad experiences,” Dockrell told the Guardian in early September.
“These cases are worrying and need investigating but advice from all official bodies in the UK is that it is always preferable to vape than to smoke,” added Paul Aveyard, a professor of Behavioural Medicine at Oxford University. “These reports should not change that advice.”
Even if we were to set aside the overwhelming culpability of adulterated THC, rather than nicotine products, for the recent outbreak—and without minimizing dozens of tragic deaths—the US response would still have been disproportionate.
At publication time there were 2,290 reported cases and 47 confirmed deaths from the outbreak, in the context of many millions of Americans vaping THC or nicotine. In comparison, one in five deaths in the United States is tied to smoking cigarettes or second-hand smoke. There is an average of 1,300 smoking deaths per day, and more than 480,000 Americans die from smoking per annum.
Vaping as a Tool for Health Equity
Public Health England has adopted a patient-oriented, pragmatic approach by supporting the concept (bolstered by an important study earlier this year) that vaping can help people quit smoking. It follows that vaping should be supported in medical and social service settings.
The demographics of health inequalities are similar in the US and UK. Communities of color, LGBTQ communities, older people, lower-income people, people with mental health diagnoses, veterans, homeless populations and people who use illicit drugs all smoke at high rates.
Unencumbered by vaping outcries and crackdowns, the UK is in a position to respond rationally to the question of how best to reduce smoking-related harms for these at-risk groups.
Amid high smoking rates among mental health patients, tailored programs are becoming increasingly common, though not all hospitals have them.
For example, the Daily Telegraph reported last month that an NHS system in London will be providing mental health patients with free e-cigarette starter kits. The South London and Maudsley (SLaM) NHS Foundation trust healthcare system has partnered with vape retailer VPZ to provide products to mental health patients at its Lewisham Hospital psychiatric facility who struggle with quitting smoking. Each kit features instructions for first use, plus e-liquids of various flavors. Patients will be permitted to vape in designated areas.
“Patients may be unhappy about being on a ward where they are not allowed to smoke, but they are likely to be willing to use a vape as an alternative.”
“Knowing that people with poor mental health are more likely to smoke than in the general population, there is an increasing drive to use [vapes] to support smoke-free policies,” Louise Ross, a smoking cessation consultant for the National Centre for Smoking Cessation and Training, told Filter. “This is a popular move among patients. They may be quite unhappy about being on a ward where they are not allowed to smoke, but they are likely to be willing to use a vape as an alternative.”
“Many patients reject the offer of nicotine replacement therapy, having tried it before and found it lacking,” she noted. “The added benefit is that they may stick with the vape on discharge instead of going back to smoking.”
Filter previously interviewed Ross in a video about her work to protect vulnerable people from smoking harms. As manager of the Leicester Stop Smoking Services, she assisted thousands of people in quitting smoking. She worked to make the Leicester service one of the UK’s first smoking cessation programs to adopt a harm reduction model by promoting e-cigarettes for mental health patients and other vulnerable smokers.
Providers like SLaM are simply following the logic espoused by British public health institutions. For example, the Royal College of Psychiatrists, in a 2018 position statement, argues that both the prescription of drugs like Chantix and e-cigarettes can be viable smoking cessation solutions for people who suffer from severe mental illness (SMI).
“Smoking rates among people with SMI are much higher than in the general population, contributing to increased morbidity and premature mortality among this group,” it stated. “Psychiatrists are well placed to help them stop smoking … While we do not fully understand the long-term risks, psychiatrists should advise their patients that [e-cigarettes] are an effective option for some people to give up smoking and are substantially safer than continued tobacco use. All mental health providers should have policies in place that facilitate the safe and effective [vaping].”
Similarly, the Royal College of Physicians has recommended that general health practitioners advise patients to quit smoking through vaping. The list of UK public health supporters of vaping goes on. The Royal Society for Public Health noted in 2015 that nicotine is no more harmful than caffeine. The Smokefree Action Coalition, of which the NHS, along with 300 other UK health organizations is a member, also endorses vaping and recommends use of MHRA-regulated e-liquids.
“Bans on smoking in mental health service facilities are particularly lacking in compassion.”
Dr. Marewa Glover, a smoking cessation expert from Auckland, New Zealand who heads the Centre of Research Excellence: Indigenous Sovereignty and Smoking (she has also written for Filter), told me that when it comes to vaping in healthcare and mental healthcare contexts, the UK offers a compassionate framework that health leaders around the world would do well to emulate.
“Bans on smoking in mental health service facilities are particularly lacking in compassion,” she said, noting that prohibitions in mental health wards have contributed to “avoidable” suicides of some patients and erect barriers to care.
“If mental health facilities ban smoking on the premises then they should have to supply a satisfying nicotine alternative,” Glover said. “Otherwise … some people won’t go to these facilities for treatment.”
Remaining Room for Improvement
Despite its relatively enlightened approaches, the UK still has much room for improvement. A recent letter to the Guardian from a group of pediatricians demonstrated that anti-vaping voices and “think of the children” arguments against harm reduction are not uniquely American. And vaping uptake among marginalized smokers is still not what it could be.
The many intersecting factors that make smoking more likely include poverty.
Accordingly, some public health advocates in England are focusing on potential economic incentives to switch to vaping. Jessica Harding, administrator of the New Nicotine Alliance charity (she has also written for Filter), believes that social services should be an important conduit for this.
“Vaping is affordable in the UK for many but it is still prohibitively expensive for some smokers,” she told Filter. “So initiatives which offer free or heavily discounted devices to people without much money help by overcoming the barrier of cost.”
“Most UK authorities are open-minded about e-cigarettes and look at the evidence. In the US, the situation is very different.”
Mary Yates, a nurse consultant for Health Promotion & Wellbeing at SLaM, describes her organization’s free e-cigarette program in these terms. “Smoking traps vulnerable people in poverty because it is so expensive,” Yates told the Telegraph. “We are taking a very holistic approach where smoking is tackled along with mental health issues with the ultimate objective of improving our patients’ overall wellbeing.”
Programs offering free vape starter kits to low-income people are currently being tested by public support agencies, too. The county of Hertfordshire, near London, announced earlier this year that its community tobacco control strategy will include vaping education and a pilot program to provide clients of food banks with free and discounted starter kits.
Worldwide public-health and political approaches to vaping exist on a spectrum. The UK, while not perfect, stands out for its largely sensible and proportionate attitude. As we digest rapid policy and political developments here in the US, we should remember that the American approach also stands out—for the opposite reasons.
“There are deep ideological differences between health leadership, policymakers, regulators, and politicians when you look at the US compared with the UK,” noted Ross. “Most UK authorities are open-minded about e-cigarettes and look at the evidence. In the US, the situation is very different.”
Long-term health outcomes will reflect this.
*The author is a recipient of a grant from the Knowledge Action Change Tobacco Harm Reduction Scholarship program. This independently administered program is supported by funding from the nonprofit Foundation for a Smoke-Free World. Dr. Marewa Glover’s organization is also a recipient of funding from the Foundation.
The Influence Foundation, which operates Filter, previously received a KAC scholarship grant to support tobacco harm reduction reporting. Per Filter’s Editorial Independence Policy, no funding organization had editorial involvement in the creation of this article.
Photo by Sgt. Jeffrey Anderson, US Marine Corps.