Electronic cigarettes (e-cigarettes) allow people to inhale nicotine without exposing the users to tobacco smoke. Although they are not completely risk free, the available evidence shows them to be far less harmful than smoking.
E-cigarettes are effective in helping smokers to quit, especially when combined with behavioural support.
E-cigarettes are not covered by smoke-free legislation and there is no evidence that passive exposure can cause harm other than to people with pre-existing respiratory conditions.
You should base policies about vaping on evidence of relative harm compared with smoking, and e-cigarettes’ role in supporting smokers to quit or stop during their inpatient care. This includes designating areas within the hospital grounds and buildings where e-cigarette use is allowed or prohibited.
Purpose of this advice
This advice only applies to vaping UK-regulated, nicotine-containing products. Vaping illicit substances such as ‘spice’, THC (tetrahydrocannabinol), or black market e-liquids carry unknown risks.
In England, 1 in 3 cigarettes are smoked by a person with a mental health condition, so supporting them to stop smoking must be the overriding priority.
While e-cigarettes offer an effective route to stopping smoking, there are still some risks associated with their use. But evidence suggests they are far less harmful than smoking.
We have based the recommendations on the current scientific understanding of the relative risks and benefits of the use of e-cigarettes and had input from a range of national experts.
We expect NHS trusts and service providers to review local policies and adopt the recommendations unless there are valid evidence-based reasons not to. This might include setting proportionate and justifiable restrictions to improve security and safety in some secure and longer-stay mental health services.
This advice does not apply to heated tobacco products, for which there is currently little independent evidence.
This advice can also support wider NHS trust action for achieving smoke-free status. There should be no new costs to trusts from implementing this advice.
Smoking tobacco remains the largest single cause of preventable death in England. While smoking prevalence in the general population is at an historic low (14.4%), smoking rates in hospital patients average 25% and over 40% of people with serious mental illness (SMI) smoke. The Smoking and Mental Health Partnership reported that smoking prevalence in mental health units was as high as 70%.
Premature mortality rates are more than 3 times higher among people with mental health conditions compared to the general population, with recent analyses suggesting that the gap is widening. Smoking is the main contributing factor for this difference in life expectancy.
The difference between smoking and vaping
E-cigarettes, or ‘vapes’, are devices that deliver an inhalable aerosol by heating a solution (or ‘e-liquid’) that typically contains nicotine, propylene glycol or glycerol, plus flavours. Their use is known as vaping.
Cigarettes rely on the combustion of tobacco which produces far more dangerous substances, including carbon monoxide and tar.
Nicotine, when it is not delivered in tobacco smoke, is safe and well tolerated in healthy adults. This is important when considering how long people might want to vape for, because it is important that people can use nicotine for as long as they need to stay smoke-free. Stopping nicotine use too early can lead to a relapse to smoking.
E-cigarettes have been available since 2004 but did not become popular in the UK until 2011. Prevalence of e-cigarette use has been static at approximately 5% since 2013. It’s now estimated that there are 3.6 million e-cigarette users in Britain. The University College London’s (UCL) Smoking Toolkit Study suggests that they have been the most common aid in quitting smoking for over 5 years.
Current position of leading health organisations on e-cigarettes
The National Institute for Health and Care Excellence’s (NICE) updated guidance on smoking states those healthcare professionals should not discourage the use of e-cigarettes as an aid for quitting smoking.
The Mental Health and Smoking Partnership advise:
To help smokers to stop smoking and stay smoke-free, a more enabling approach to vaping should be considered to make it an easier choice than smoking. Vapers should not be required to use the same space as smokers, as this could undermine their ability to quit and stay smoke-free.
The Care Quality Commission’s brief guide on smoke-free policies in mental health inpatient services recommends:
E-cigarettes should not routinely be treated in the same way as smoking. It is not appropriate to prohibit e-cigarette use in health services as part of smoke-free policies.
The Royal College of Psychiatrists has published guidance on prescribing varenicline and electronic cigarettes to patients with severe mental illness which recommends that psychiatrists tell patients who smoke that e-cigarettes may help them to quit, particularly when used with stop smoking treatments and are safer than continuing to smoke. But it also says that psychiatrists should also encourage patients to avoid e-cigarettes in the long-term where possible, provided this does not lead to a return to smoking.
Most mental health trusts in England allow the use of e-cigarettes and many provide them for free to patients. A survey by Action on Smoking and Health (ASH) (with responses from 45 NHS mental health trusts) reported that:
91% of the mental health trusts that responded allowed some or all inpatients to use e‐cigarettes
47% of the trusts allowed people to use all types of e‐cigarettes
31% of the trusts only allowed the use of non‐rechargeable, disposable devices
42% of the trusts provided e‐cigarettes free to their patients
all but one trust restricted where people could use e‐cigarettes
44% of the trusts allowed the use of e‐cigarettes indoors
76% of the trusts allowed the use of e‐cigarettes in ward courtyards
The evidence on quitting with e-cigarettes
Studies have found e-cigarettes help people to stop smoking and contribute between 50,000 and 70.000 additional quits in England per year. Another study found that among smokers who reported trying to quit, the most successful had used an e-cigarette.
In 2019, a randomised control trial set in English stop smoking services found that combining e-cigarettes with behavioural support could double the chances of successfully quitting smoking tobacco compared to nicotine replacement therapy (NRT) and behavioural support.
Public Health England’s 2019 evidence update looked at stop smoking services data between April 2017 and January 2018. The authors found the highest 4-week quit rates were seen when the quit attempt involved behavioural support from stop smoking adviser and:
- Using a licensed medicine and an e-cigarette one after the other (73%)
- Using a licensed medicine and e-cigarette at the same time (60%)
- Using an e-cigarette on its own (60%)
- People using a licensed medicine by itself or with other licensed medicines (so not using an e-cigarette) had a quit rate of 50%.
American research also shows that people vape for longer than use traditional NRT when trying to quit. The incidence of relapse was lower too (than with NRT).
E-cigarette use avoids the associated higher health risk of smoking. Smokers who see e-cigarettes as harmful are less likely to try e-cigarettes and much less likely to switch completely. And people who smoke and vape who see e-cigarettes as less harmful than cigarettes are more likely to completely switch to vaping and stop smoking than those who view vaping as more harmful.
Recommendations for care
- Provide clear information to both staff and patients about the difference between vaping and smoking and the associated risks of both.
- Encourage patients to stop smoking or to abstain temporarily and offer behavioural support and prescribed smoking medications in support of any quit attempt.
- Ensure patients have access to vaping products and consider whether to provide them proactively to patients who smoke.
- Do not discourage patients using their own e-cigarettes in a quit attempt or when trying to abstain from smoking temporarily (unless an individual risk assessment suggests it is unsafe to do so).
- Nicotine replacement supports temporary abstinence and quitting smoking, so do not rush patients to stop vaping as this may increase the risk of relapse to smoking.
- Where patients are admitted who already vape, allow them to continue to use e-cigarettes. They do not need a stop smoking intervention unless they are also smoking cigarettes.
- NHS trusts that provide stop smoking support should consider offering a wider package of support to the family at home, such as information on referral to local stop smoking services.
- It is an offence to sell a nicotine inhaling product to anyone under the age of 18 or to buy one on their behalf. Public Health England (PHE) does not recommend the use of e-cigarettes by anyone under 18.