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Clinical briefing: Public vaping

The House of Commons Science and Technology Committee says the use of e-cigarettes should be allowed in mental health facilities and there should be a wider debate about public vaping

Despite numerous public health campaigns and countless warnings, 17.4 per cent of adults in England smoke1 – but many don’t want to. In data collected from January to June 2018, 31.5 per cent of smokers had tried to quit, but just 6.2 per cent had succeeded.1

The House of Commons Science and Technology Committee (STC) noted recently that “e-cigarettes present an opportunity to significantly accelerate already declining smoking rates, and thereby tackle one of the largest causes of death in the UK today. They are substantially less harmful – by around 95 per cent – than conventional cigarettes”.2

A recent meta-analysis of 14 publications involving 35,665 participants suggested that 48.3-58.7 per cent of e-cigarette users reduce smoking by at least 50 per cent, while 13.2-22.9 per cent quit.3 Yet use has declined among recent ex-smokers from a peak in 2016 to about 35 per cent in 2018.1

Smoking and mental health

Smoking rates among people with a mental illness are 70 per cent higher than in the general population4 and remain stubbornly elevated.

An analysis of the Health Survey for England from 1993 to 2011 reported that people who reported long-standing mental illness or recent use of psychoactive medication showed no significant long-term changes in smoking prevalence or consumption. Such smokers may want to quit5 but a simple ban in mental health trusts may not be the answer.

One study compared incidents during the six months after the introduction of a no-smoking policy in an acute mental health trust in the Midlands, with the same months the previous year.

The number of admissions under the Mental Health Act rose by 13 per cent, in some cases possibly because the no-smoking policy led to patients refusing informal admission. The number of reported smoking-related incidents rose about three-fold.

Aggression-related incidents increased by 59 per cent in the psychiatric intensive care unit, which cares for highly agitated patients who “are most susceptible to cause incidents with this enforced lifestyle change”.

While other factors might contribute to the increase in admissions and aggression, the authors suggest offering nicotine replacement therapy “to all patients to minimise the risk of clinical incident”.4

Indeed, smoking cessation can improve mental health. A Czech study enrolled 3,775 smokers. Of these, 14.3 per cent had mild and 15.4 per cent moderate or severe depression. At one year, fewer patients with mild (32.5 per cent) and moderate or severe depression (25.8 per cent) had quit compared with smokers without depression (40.5 per cent). Most people with depression who were abstinent reported less severe depression at follow-up.

Furthermore, 82.8 and 66.3 per cent of abstinent people with mild and moderate or severe depression respectively at baseline had no or minimal symptoms after a year.6

Similarly, a meta-analysis of 26 studies reported that anxiety (standardised mean difference [SMD] –0.37), depression (SMD –0.25), mixed anxiety and depression (SMD –0.31), stress (SMD −0.27), psychological quality of life (SMD 0.22) and positive effect (emotions; SMD 0.40) all improved in people who quit compared with those who continued smoking.7

So, as the STC notes, smokers in mental health units could benefit from using e-cigarettes. Indeed, some units already allow unrestricted vaping and the committee comments that, “it is unacceptable that a third of mental health NHS trusts still ban e-cigarettes”.

Negligible risk

The committee adds that three-quarters of trusts are concerned about second-hand vapour, “despite evidence that it presents a negligible health risk”. It calls on NHS England to “set a clear central NHS policy…which establishes a default of allowing e-cigarette use by patients unless an NHS trust can show reasons for not doing so which are demonstrably evidence-based.”

NHS England should ensure that mental health trusts “understand the physical and mental health benefits [of this policy] for their patients”.2


Stealth vaping

Some people vape discreetly in places where using e-cigarettes is banned – so-called ‘stealth vaping’. Businesses, public transport and public places often ban e-cigarettes but the Science and Technology Committee warns that “forcing vapers to use the same ‘smoking shelters’ as conventional smokers could undermine their efforts to quit” and calls for a wider debate on vaping in public spaces based on evidence.

“A liberalisation of restrictions on e-cigarettes, which provide a popular route for people to stop smoking, would result in non-vapers having to accommodate vapers (for a relatively short period of time),” the STC comments.

The report notes that uncertainties about e-cigarettes remain, especially any long-term health effects. “Ultimately, however, any judgement of risks has to take account of the risk of not adopting e-cigarettes – that is, continuing to smoke conventional cigarettes,” the report concludes. “

Existing smokers should always be encouraged to give up all types of smoking, but if that is not possible, they should switch to e-cigarettes as a considerably less harmful alternative.”

1. smokinginengland.info/latest-statistics Version published 2nd August 2018
2. publications.parliament. uk/pa/cm201719/cmselect/ cmsctech/505/50502.htm
3. Medicine 2018; 97:e0324
4. BJPsych Bulletin 2017; 41:325-330
5. Nicotine & Tobacco Research 2015; 17:356-360
6. Annals of Behavioral Medicine 2017; 51:454-463
7. The BMJ 2014; 348:g1151

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