E-cigarette and vapouriser usage (health and wellbeing needs in South Tyneside)

Introduction

Public Health England has recently published its fourth update on the evidence that underpins policy and regulation of electronic cigarettes and other novel nicotine delivery systems. Electronic cigarettes in the UK have been regulated by the EU Tobacco Products Directive from 20 May 2016. To date over 32,000 e-cigarette and nicotine containing e-liquid products have been registered.
South Tyneside has seen a reduction in its adult smoking prevalence by just over 11% since tobacco legislation was introduced in 2007, equating to around 20,000 fewer smokers. This reduction in prevalence has been achieved through implementing simple but highly cost effective population measures to encourage cessation. These include progressive rises in cigarette price, sustained health promotion campaigns, standardised cigarette packaging, and legislation to make all public and work places smoke-free.
E-cigarettes could be contributing to at least 20,000 successful new quits across the UK per year and therefore the review currently underway to look at the future offer of stop smoking support in South Tyneside will give due consideration to the role of e-cigarettes to engage smokers to quit^[1].

Key issues

The UK Centre for Tobacco and Alcohol and Tobacco Studies recently completed a funded trial^[2] which highlighted:
- E-cigarettes deliver nicotine as well as or better than NRT
- E-cigarettes appear to be genuinely popular forms of NRT
- E-cigarettes appear to work like other forms of NRT
- E-cigarettes are unlikely to carry substantial harms to users, even long term users
- E-cigarettes appear to be helping people to quit smoking who would not otherwise have succeeded and having a measurable population impact
- Stop smoking services can and do support the use of e-cigarettes both within and without the service
- South Tyneside currently has an estimated adult (18+) smoking population of approximately 22,200 (18.5% prevalence rate)
- In 2016/17 the stop smoking service supported 912 smokers to successfully quit at 4 weeks, using a combination of both nicotine replacement therapy and behavioural support
- South Tyneside's quit rate for 16 / 17 was 46%, above that of the national expectation of 35%.
While the service has seen a reduction in the number of people attempting to quit it still has one of the highest rates of access in the country. In 2016 / 17 9.6% of the borough's estimated 18+ smokers attempted a quit through the service. NICE guidelines^[3] recommend that Stop Smoking Services should aim to treat at least 5% of the estimated local population of people who smoke annually.
A recent health equity audit has shown that although there is good service coverage across the Borough there are elements of the population who are not engaging in traditional stop smoking service support. These groups include 18 - 24 year olds and the routine and manual workforce, the latter having a higher prevalence than the general smoking population, at 25.7%.
Many thousands of smokers incorrectly believe that vaping is as harmful as smoking; around 40% of smokers have not even tried an e-cigarette. The accuracy of public perceptions of the relative harmfulness of e-cigarettes vs tobacco cigarettes have worsened over recent years.
Despite some experimentation with these devices among never smokers, e-cigarettes are attracting very few young people who have never smoked into regular use.
E-cigarettes do not appear to be undermining the long-term decline in cigarette smoking in the UK among young people.

High level priorities

Leadership

The Tobacco Control Alliance should form a consensus on the usage of e-cigarettes as a harm reduction technique and an alternative to smoking.

Stop Smoking Services

Trained stop smoking advisers should continue to receive relevant policy and evidence updates in line with the National Centre for Smoking Cessation Training (NCSCT)^[4] and PHE evidence review order to supply advisers and clients with consistent messages around e-cigarettes.

Marketing

There is a need to publicise the current best estimate that using Electronic Cigarettes is around 95% safer than smoking.
Encouraging smokers who cannot or do not want to stop smoking to switch to electronic cigarettes could be adopted as one of the key strategies to reduce smoking related disease and death. Advising that consumers purchase devices from reputable sellers who comply with the Tobacco Regulation Directive^[5].

Those at risk

Vapers are most likely to be either current or ex-smokers. While it is not possible to provide a reliable demographic breakdown around vapers specifically there is an abundance of information around smokers.
Younger people are more likely to be smokers, with tobacco usage peaking in the late 20s. - See Fig 1 Vaping appendix
There is a correlation between deprivation and tobacco consumption. In the most deprived decile in the country over 20% of adults are estimated to smoke, in the most affluent just 12.6% are estimated to smoke. - See Fig 2 Vaping appendix
Anecdotally children and adults are more likely to vape than older people; however it has not been possible to find statistical evidence to support this.
It is possible that there are a proportion of the population that is dual using vapourisers and cigarettes; there could be a missed opportunity to migrate those users to vapourisers alone.

Level of need

While the number of people vaping in Great Britain increased hugely between 2012 and 2017, from 700,000 to 2.9 million, growth has begun to slow with use of e-cigarettes remaining stable since late 2013^[6].
The use of e-cigarettes by adults in the UK has plateaued over the last few years at just under 3 million; around half of these have completely stopped smoking.
Electronic cigarette use among current adult cigarette smokers in Great Britain (2010 - 2017)^[7].- See Fig 3 Vaping appendix
Since 2013 surveys by YouGov have suggested that usage of electronic cigarettes and vapourisers are mainly confined to smokers and ex-smokers. The gap between current and former smokers has been closing, 51% of vapouriser usage in 2016 was by current smokers, compared to 65% in 2013. - See Fig 4 Vaping appendix
There aren't any local prevalence estimates for vapouriser usage in adults; however, national usage in 2016 suggested that 5.6% of the adult population there could be around 6,700 vapers in South Tyneside, 3,400 current smokers, and 3,100 ex-smokers.
The Annual Population survey estimated that 18.4% of South Tyneside adults are current smokers, this equates to around 21,980 adults. That means that 15.5% of current South Tyneside smokers also use an electronic-cigarette or vapouriser.
The What About YOUth (WAY) Survey 2014 / 15 asked 15 year olds if they had ever tried or used electronic cigarettes.
Nationally 18.4% of 15 year-olds said they had tried electronic cigarettes; the North East was significantly higher than this with 19.6%. South Tyneside has a lower, but statistically similar rate of 16.7%.
The 2016 YouGov survey asked current smokers how harmful they thought e-cigarettes were in comparison to traditional cigarettes.
Current Smokers were split into three categories:
- Current e-cigarette user
- Never e-cigarette user
- Ex e-cigarette user
The survey suggests that current e-cigarette users are more likely to understand that e-cigarettes are less harmful than cigarettes, with 70% of those respondents agreeing that e-cigarettes were either less harmful or a lot less harmful than traditional cigarettes.
In contrast less than 40% of smokers that have never tried using an e-cigarette thought they were less harmful than traditional tobacco, while a quarter thought they were even more or equally harmful.
This indicates that there are wide variations in the perceived harm of e-cigarettes, despite public health messages that they are significantly safer than smoking traditional tobacco cigarettes. - See Fig 5 Vaping appendix

Unmet needs

The Health Equity Audit (2018) has highlighted issues with stop smoking service access among 18 - 24 year-olds, while they account for 13% of the borough's smoking population just 8.6% have attempted to quit smoking. People in this cohort are also much less likely to quit, with just 5% of quitters being aged 18 - 24. It is possible that younger smokers would be more likely to attempt a quit using e-cigarettes or vapourisers, however the scope of the HEA did not provide the opportunity to confirm this.
Access is equitable for people from deprived communities.
Lower take up from people from minority ethnic backgrounds.
Men are more likely to quit (higher quit rate) but less likely to access services.
Vaping should be considered a harm reduction technique in current smokers.
Although current stop smoking services support e cigarette use, this could be strengthened by increasing awareness and understanding of the evidence facilitated through a revised training offer. Considering the use of e-learning modules through NCSCT.
There isn't any strong evidence to suggest that vaping is harmful.
Vaping should be considered a harm reduction technique in current smokers.

Projected Need and Demand

There are currently no projections, either locally or nationally, on the usage of vapourisers or electronic cigarettes, although there is increasing emphasis on promoting e cigarettes as an alternative to smoking.
While the number of people using these devices has increased year-on-year growth has begun to slow.
As the number of smokers has declined so has the number of accessing stop smoking services. There is no reason to believe that an increase in e-cigarette usage will lead to a rise in service engagement, it may lead to a further reduction in engagement.

Community assets and services

Stop Smoking services are currently available in the following locations:

25 Pharmacies
22 GP Practices
12 Children's Centres
7 Community Organisations
6 Council Teams
2 Secondary Schools
2 Workplaces

There are several dedicated vape shops in the Borough that will provide advice to customers, a large number who are dual users (smoke and use a vaping device). Although the Council are not in a position to favour individual vaping stores, any stop smoking support messages will include advice to do their research and purchase devices from reputable sellers who are Tobacco Product Directive (TPD) compliant.

Evidence for interventions

PHE Evidence review of e-cigarettes and heated tobacco products 2018, summarises evidence to underpin policy and regulation of e-cigarettes and vaping devices.
The Cochrane review which looked at electronic cigarettes for smoking cessation^[8] (2016), combined results from two studies, involving 662 people, showed that using an e-cigarette containing nicotine increased the chances of stopping smoking in the long term compared to using an e cigarette without nicotine.
There is evidence that school based interventions are effective in reducing uptake and NICE have published a series of recommendations^[9,10] which set out clear guidelines for commissioners. However, the impact of these interventions are considered more effective when delivered as a package of cross cutting tobacco control measures in the community aimed at adults and away from school grounds.
This also applies to e-cigarette usage while pregnant

Views

A recent Health Related Behaviour Questionnaire conducted using a random sample of 2462 pupils in 18 primary schools and 7 secondary schools in South Tyneside in 2017 showed:
- 35% of Year 6 and Year 10 pupils in South Tyneside said their parents/carers smoke
- 86% of Year 8 and 64% of Year 10 pupils said they had never smoked at all
- 29% of Year 10 pupils said that they have at least tried using an e-cigarette
- 23% of Year 6 pupils said that their parents / carers use an e-cigarette
- 22% of Year 10 pupils said that their parents / carers use an e-cigarette.
Stop smoking service providers have had queries around the usage of vapourisers and electronic cigarettes as a quitting aid.
Stop smoking service providers have also had requests from people to help them to quit vaping.
Stop smoking advisors are often unsure of the level of support they should provide, a recent review of the training should improve the advisors knowledge and understanding.

Additional Needs Assessments Required

At this time an Additional Needs Assessment is not required.

Key contacts and references

Carers
Key contact	Wendy Surtees
E-mail	Wendy.Surtees@southtyneside.gov.uk
Job Title	Senior Public Health Advanced Practitioner
Phone Number	0191 424 6581

Last Updated July 2018