Mod in hand crossing over with cigarette in hand.

E-Cigarettes and Stop Smoking Services: Notes from the Front Line

Recently I spoke on a panel at the UKVIA forum to discuss Stop Smoking Services’ use of electronic cigarettes.

In preparation for the panel, I spent some time talking to Stop Smoking Services (SSS), trying to understand the challenges they faced. Of course, time was limited in a 45 minute panel, and many questions went unaddressed.

So for those who are interested in more information on the current questions around SSS and vaping, I’ve put this post together. You may also be interested in our previous post on the subject Vaping: A Guide for Stop Smoking Services.

How friendly are stop smoking services?

Wales

It’s not long since Wales tried to ban electronic cigarettes in public places. That announcement was made on the same day as the news of terrible ambulance waiting times. In fact, one civil service friend believes the whole thing kicked off as a way to distract attention away from bad news. (Ironically, the opposition to e-cigs eventually contributed to the failure of the Welsh government health bill.)

Help Me Quit Wales, the Welsh SSS, flatly refuse to have anything to do with electronic cigarettes and have even removed mention of electronic cigarettes from their website. I’ve tried to ask them why to little avail!

Factors that do seem to influence the Welsh attitude towards vaping include:

  • A bigger fear in Wales of the gateway effect
  • A greater fear of long term harms
  • The Welsh arm of the British Medical Association seems to be more sceptical about the benefits of e-cigarettes than its counterpart in England.
  • Blanket opposition from Welsh Labour, in particular the first minister and the Health Minister

I also believe it’s linked to the consistency principle – when people state a strong position in public, it’s psychologically difficult to turn around from that position.

England

Outside Wales, many services are at the stage of dipping their toes in to schemes using electronic cigarettes. Some services are running very cautious pilot schemes. Others hope to reinvest savings they make from more expensive NRT aids into providing more electronic cigarettes.

Why only now? Very few services wanted to be the first to boldly go where others had not been before. In some cases, services have to follow best practice. Until recently there was no practice, let alone best practice, to follow.

But the good news is that the ball is starting to roll, largely down to the example of Louise Ross and Leicester SSS. By demonstrating that vaping can work, taking the first steps and by talking about it, they are encouraging many others to dip their toes into the water.

What’s holding SSS back?

Fear of working with the tobacco industry

One thing I’ve heard mentioned multiple times is fear of alignment with the tobacco industry. Some of this is down to years of viewing tobacco companies as the enemy. One person I spoke to talked of lies and manipulation and of the tobacco industry infiltrating the vape industry for their own nefarious ends. Some SSS are also fearful of the repercussions of dealing with the tobacco industry.

Some services are even reluctant to deal with independent shops which sell even a single big tobacco product. The services I’ve spoken to put a massive emphasis on finding companies which are independent. But not all services have the resources to do this. Some of them also face the problem of dealing with vape shops which often seem to open one week and close the next week.

Partly because of this, some SSS will only deal with companies registered with the Independent British Vape Trade Association (IBVTA). A second factor is National Centre for Smoking Cessation and Training (NCSCT) guidelines, which some SSS interpret as saying they should only work with IBVTA members.

The NCSCT have recently toned these to address this issue, but still encourage use of the IBVTA shop finder and warn about affiliating with big tobacco. While the IBVTA shop-finder can be helpful, there’s a danger that good vape shops which are not members could be excluded.

One complaint I’ve also come across is a lack of clarity over what’s acceptable and what’s not. One service told me they’d like to see more clarification from PHE – not just verbally, but in a written communication.

How SSS’ budgets are structured

Not all stop smoking services control their own budget. In the words of one SSS advisor, “the commissioners are the puppet masters and we are the puppets. They pull the strings and we dance to their tune.”

While there is an appetite for experimentation in some services, it also depends on how budgets are set. Some SSS have a direct budget, making it much easier for them to allocate a portion to vape kits, while others simply refer customers to pharmacies for NRT with the bill being sent elsewhere. The bureaucratic hurdles of switching to vaping are higher with the second.

Fear

There’s a lot of fear. There’s fear over the products – will they explode, will they leak, will they cause a fire.

There’s also fear over litigation, both over the misperception that SSS are not allowed to have any connection with Big Tobacco and whether long term harm consequences could land them in court. At least one service’s commissioners have refused to allow the direct supply of electronic cigarettes because of fear of a class action that could take place in the future.

(Intriguingly, one health professional I discussed this with raised the possibility of a class action against services which withhold access to a product 95% safer than smoking. )

One SSS told me that Public Health England (PHE) could help here by providing clearer written assurances and guidelines to Stop Smoking Services.

Old Attitudes

There’s a split in SSS between older services and newer ones, which are often external companies commissioned to provide stop smoking services.

While newer services are often keen to experiment with new ways of working, older services can find it hard to switch from an abstinence mindset to a harm reduction mindset. After all, vaping is still harmful, even if 95% safer than smoking. That can be hard for someone whose career has been about eliminating all nicotine use.

Objections from medical professionals

The lack of support from doctors is also shocking. At the UK VIA forum, I found it ironic to hear Dr Jessen criticise online influencers with no scientific background for giving out bad health advice when many doctors are doing the same with electronic cigarettes.

One SSS complained to me that they will often spend a lot of time with a smoker overcoming their objections to vaping. The smoker then visits their doctor and gets told they will get popcorn lung if they vape. The next thing the SSS know, their client is smoking again. (FYI, the evidence for vaping leading to popcorn lung is about as strong as the evidence for vaccine denial.)

The Learning Curve

Many in the SSS are worried about the learning curve with vaping. Unfamiliar with vape devices and how they work, they are daunted by the thought of explaining electronic cigarettes. As we shall see, this is one problem the industry could easily solve.

Reaching the right people

As mentioned, SSS are able to reach people the vaping industry can’t. But that’s not always easy. For example, the homeless are often transient, and face the additional challenge of lacking easy access to charging portals.

Key Drivers

While there are barriers, there are also factors driving increased involvement with electronic cigarettes. These include:

Cost Savings

Simply put, a starter kit with e-liquid is cheaper than a single round of NRT. When combined with a discount code for ongoing purchases, many SSS users are happy to make ongoing purchases themselves after being provided with the initial kit and support.

Meeting Key Performance Indicators

Stop Smoking Services have KPIs to meet, such as engaging with a certain proportion of the population a year. A tool which can help drive engagement and success rates is attractive to services.

Another Chance to Help Serial Quitters

Some SSS have clients who they believe will never stop nicotine use. In some areas this includes smokers who are on the poverty line, and who come to the SSS service when they have run out of money to buy tobacco (usually purchased on the black market), in order to gain access to nicotine until their next pay day. Vaping offers SSS a chance to re-engage smokers who have tried every other method of smoking cessation and failed.

Public Health England and Leicester Stop Smoking Service

I don’t think I have spoken to a SSS without Louise Ross being mentioned. Louise Ross, the example of Leicester Stop Smoking services and and Quit Ready of Leicestershire County Council as well as the direction set by Public Health England have all been a key influence in SSS engaging more with electronic cigarettes.

How can the industry help?

Training and support are key. As we’ve seen, SSS staff are usually not familiar with electronic cigarettes, and the industry can help by providing training to SSS staff on the basics of vaping.

Vape shops can also help. Research by Ward et al has found that vape shops can be effective at both diagnosing smoker’s needs and at providing behavioural support. So it makes sense for SSS service to visit shops so they can see how experienced vape professionals interact with smokers. For this to be valuable, of course, the team in the vape shops needs to be experienced, knowledgeable and focussed on analysing and meeting their customers’ needs.

Some SSS may also need guiding with product selection. The industry can help by using a combination of data and experience to steer SSS towards products which are the most effective alternatives to cigarettes for new users.

In Conclusion

Stop Smoking Services are experimenting with vaping, but at present it’s a trickle rather than an avalanche. However, as cost savings start to roll in, and if the massive success rates seen by early adopters continue (66% quit rate when e-cigarettes have been combined with behavioural support), we should see a steady increase in the of electronic cigarettes by SSS. And with SSS reaching people who would never otherwise try vaping, SSS efforts are well deserving of support from the industry.

Article Sources

Working with vape shops, A guide for commissioners and stop smoking services: National Centre for Smoking Cessation and Training (NCSST)

Ross L: What does ‘ecig-friendly’ really mean? CliveBates.com June 2015

Ward E. et alA Qualitative Exploration of the Role of Vape Shop Environments in Supporting Smoking Abstinence, Int J Environ Res Public Health. 2018 Feb 9;15(2). pii: E297. doi: 10.3390/ijerph15020297

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