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House of Commons Science and Technology Committee E-cigarettes Seventh Report of Session 2017–19 HC 505 EMBARGOED ADVANCE COPY: Not to be published in full, or in part, in any form before 00.01 a.m. on Friday 17 August 2018

E-cigarettes - POLITICO€¦ · 1. E-cigarettes and conventional cigarettes are substantially different products. A lit conventional cigarette contains tobacco and produces carbon

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Page 1: E-cigarettes - POLITICO€¦ · 1. E-cigarettes and conventional cigarettes are substantially different products. A lit conventional cigarette contains tobacco and produces carbon

House of Commons

Science and Technology Committee

E-cigarettes

Seventh Report of Session 2017–19

HC 505

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House of Commons

Science and Technology Committee

E-cigarettes

Seventh Report of Session 2017–19

Report, together with formal minutes relating to the report

Ordered by the House of Commons to be printed 16 July 2018

HC 505Published on 17 August 2018

by authority of the House of Commons

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Science and Technology Committee

The Science and Technology Committee is appointed by the House of Commons to examine the expenditure, administration and policy of the Government Office for Science and associated public bodies.

Current membership

Norman Lamb MP (Liberal Democrat, North Norfolk) (Chair)

Vicky Ford MP (Conservative, Chelmsford)

Bill Grant MP (Conservative, Ayr, Carrick and Cumnock)

Darren Jones MP (Labour, Bristol North West)

Liz Kendall MP (Labour, Leicester West)

Stephen Metcalfe MP (Conservative, South Basildon and East Thurrock)

Carol Monaghan MP (Scottish National Party, Glasgow North West)

Damien Moore MP (Conservative, Southport)

Neil O’Brien MP (Conservative, Harborough)

Graham Stringer MP (Labour, Blackley and Broughton)

Martin Whitfield MP (Labour, East Lothian)

Powers

The Committee is one of the departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the internet via www.parliament.uk.

Publication

Committee reports are published on the Committee’s website at www.parliament.uk/science and in print by Order of the House.

Evidence relating to this report is published on the relevant inquiry page of the Committee’s website.

Committee staff

The current staff of the Committee are: Danielle Nash (Clerk), Yohanna Sallberg (Second Clerk), Dr Harry Beeson (Committee Specialist), Dr Elizabeth Rough (Committee Specialist), Martin Smith (Committee Specialist), Sonia Draper (Senior Committee Assistant), Julie Storey (Committee Assistant), and Sean Kinsey (Media Officer).

Contacts

All correspondence should be addressed to the Clerk of the Science and Technology Committee, House of Commons, London SW1A 0AA. The telephone number for general inquiries is: 020 7219 2793; the Committee’s e-mail address is: [email protected].

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1 E-cigarettes

ContentsSummary 3

1 Introduction 5

Our inquiry 6

2 Reducing Harm 7

E-cigarettes’ comparative lower harm 7

Heat-not-burn tobacco products 10

Flavourings 11

Uncertainty about long-term effects 11

Research 14

3 E-cigarettes and smoking cessation 17

The evidence on smoking cessation 17

Young people and a potential gateway to conventional smoking 18

E-cigarettes as a medically licensed product 19

‘Leicester partnership’ 21

E-cigarettes in mental health facilities 22

E-cigarettes in prisons 25

E-cigarettes in public places 26

4 Regulation 28

The refill strength limit 29

Regulation of health claims 30

Regulation of e-cigarette ingredients 31

Regulation of novel tobacco products 32

Risk-based regulation and taxation 33

Conclusions and recommendations 36

Appendix 1: Analysis of replies from English NHS mental health trusts in response to the Committee’s questions 39

Formal minutes 56

Witnesses 57

Published written evidence 59

List of Reports from the Committee during the current Parliament 62

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3 E-cigarettes

SummaryE-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%—than conventional cigarettes. They lack the tar and carbon monoxide of conventional cigarettes—the most dangerous components. It has also proven challenging to measure the risks from ‘second-hand’ e-cigarette vapour because it is negligible and substantially less than that of conventional cigarettes.

There are uncertainties, nevertheless, especially about any long-term health effects, because the products have not yet had a history of long use. 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, which are substantially more harmful. Existing smokers should be encouraged to give up, but if that is not possible they should switch to e-cigarettes as a considerably less harmful alternative.

To help fill remaining gaps in the evidence on the relative risks of e-cigarettes and heat-not-burn products, the Government should maintain its planned annual ‘evidence review’ on e-cigarettes, and extend it to also cover ‘heat-not-burn’ products—a more recently introduced product which heats rather than combusts tobacco—and support a long-term research programme to be overseen by Public Health England and the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment. The Government should report each year on the state of research in its Tobacco Control Plan, and establish an online hub for making the detailed evidence readily available to the public and to health professionals.

An estimated 2.9 million people in the UK are using e-cigarettes to stop smoking, and tens of thousands are using them to successfully quit smoking each year. Concerns about the risk of e-cigarettes potentially providing a ‘gateway’ into conventional smoking, or that the variety and type of flavours could attract young non-smokers in significant numbers, have not materialised.

A medically licensed e-cigarette could assist smoking cessation efforts by making it easier for medical professionals to discuss and recommend them as a stop smoking treatment with patients. The Government should review with the e-cigarette industry how its systems for approving stop smoking therapies could be streamlined to be able to respond appropriately should e-cigarette manufacturers put forward a product for licensing.

People with mental health issues smoke significantly more than the rest of the population, and could therefore benefit significantly by using e-cigarettes to stop smoking. By encouraging patients in mental health units who are smokers to switch to e-cigarettes as a way out of their cigarette addiction, they could continue to engage in treatment sessions within the facilities, without the interruption of smoking breaks. Some NHS mental health units are allowing unrestricted use of e-cigarettes but it is unacceptable that a third of the 50 English NHS trusts who responded to the Committee’s survey ban them. Three-quarters of NHS trusts were mistakenly concerned about ‘second-

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E-cigarettes 4

hand’ e-cigarette vapour, despite the negligible health risk. NHS England should set a policy of mental health facilities allowing e-cigarette use by patients unless trusts can demonstrate evidence-based reasons for not doing so.

Many businesses, public transport providers and other public places do not allow e-cigarettes in the same way that they prohibit conventional smoking. But, there is no public health (or indeed fire safety) rationale for treating use of the two products the same. There is now a need for a wider debate on how e-cigarettes are to be dealt with in our public places, to help arrive at a solution which at least starts from the evidence rather than misconceptions about their health impacts.

Some aspects of the regulatory system for e-cigarettes appear to be holding back their use as a stop smoking measure. The limit on the strength of refills makes some users have to puff harder to get the nicotine they seek and may put some heavy smokers off persisting with them. The restriction on tank size does not appear to be founded on scientific evidence, and should therefore urgently be reviewed. A prohibition on making claims for the relative health benefits of switching to e-cigarettes means that some who might switch are not getting that message. A ban on advertising ‘tobacco’ products has prevented manufacturers putting information in ‘pack inserts’. The Government should review these regulatory barriers to identify scope for change post-Brexit, including an evidence-based assessment of the case for discontinuing the ban on ‘snus’ oral tobacco.

There should be a shift to a more risk-proportionate regulatory environment; where regulations, advertising rules and tax duties reflect the evidence of the relative harms of the various e-cigarette and tobacco products available. While an evidence-based approach is important in its own right, it also would help bring forward the behaviours that we want as a society—less smoking, and greater use and acceptance of e-cigarettes and novel tobacco products if that serves to reduce smoking rates.

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5 E-cigarettes

1 Introduction1. E-cigarettes and conventional cigarettes are substantially different products. A lit conventional cigarette contains tobacco and produces carbon monoxide, tar and smoke, whilst an e-cigarette does not contain tobacco and heats up its nicotine liquid rather than burning it. E-cigarettes were first introduced to the UK market in 2007 (see Box 1). New rules for nicotine-containing e-cigarettes and refill containers were introduced in May 2016 by the Tobacco and Related Products Regulations 2016,1 implementing the EU Tobacco Products Directive.2 In 2016 it was estimated that 2 million consumers in England had used these products and completely stopped smoking and a further 470,000 were using them as an aid to stop smoking.3

2. In 2016, the Royal College of Physicians concluded that:

Large-scale substitution of e-cigarettes, or other non-tobacco nicotine products, for tobacco smoking has the potential to prevent almost all the harm from smoking in society. Promoting e-cigarettes, [Nicotine Replacement Therapy] and other non-tobacco nicotine products as widely as possible, as a substitute for smoking, is therefore likely to generate significant health gains in the UK.4

The Government published its Tobacco Control Plan in July 2017, advising that e-cigarettes could be an aid for smokers attempting to give up conventional cigarettes, on the basis that “evidence is increasingly clear that e-cigarettes are significantly less harmful to health than smoking tobacco”.5 Public Health England has concluded that “vaping is at least 95% less harmful than smoking”.6

3. There have nevertheless been a number of organisations and commentators that have seen e-cigarettes as a health hazard in their own right. Concerns were raised by the US National Academies of Sciences, Engineering and Medicine earlier this year7 and by the US Surgeon General.8 Some have raised objections to e-cigarettes on the grounds of being exposed to unpleasant second-hand vapour.9 E-cigarettes are banned in many workplaces and in most enclosed public spaces and on public transport.

1 Tobacco and Related Products Regulations (2016)2 EU Tobacco Products Directive (2014)3 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 20174 Nicotine without smoke: Tobacco harm reduction, Royal College of Physicians, 20165 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 20176 Evidence Review of E-cigarettes and Heated Tobacco Products 2018, Public Health England, March 20187 The National Academies of Sciences, Engineering, and Medicine, A Consensus Study Report by the Committee

on the Review of the Health Effects of Electronic Nicotine Delivery Systems (January 2018)8 E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General, The US Surgeon General,

20169 Ian Bardrick (ECG0006); David Bareham and Professor Martin McKee (ECG0039)

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E-cigarettes 6

Our inquiry

4. Against a background of contradictory national policies towards e-cigarettes and disagreement and apparent uncertainty over the health risks, we decided to examine the evidence on the health impacts and on e-cigarettes’ role as a smoking cessation tool. We received over 100 pieces of written evidence, and held five oral evidence sessions between January and May 2018, hearing from 25 witnesses. We are grateful to all those who contributed.

Box 1: A brief overview of e-cigarettes

2007 E-cigarettes are introduced to the UK market

2014 EU Tobacco Products Directive (TPD) comes in to force, covering the bulk of ecigarette regulation in Europe

2016 Tobacco and Related Products Regulations transposes TPD in to UK law—18.4% of adults (age 16+ years) surveyed in the ONS Opinions and Lifestyle Survey had tried an e-cigarette and 5.4% of adults considered themselves current e-cigarette users.

2017 The proportion of ex-smokers who regularly vape has risen from 1.1% in 2012 to 9.5% in 2017

Both the youth and adult data shows smoking prevalence has continued to decline as e-cigarette use has grown. Smoking rates are currently at their lowest recorded levels—15.5% for adults in England, down from 19.9% in 2010, and 7% among 15-year-olds in England, down from 12% in 2010.

Sources: Written evidence from Action on Smoking and Health and Public Health England and MHRA

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7 E-cigarettes

2 Reducing Harm

E-cigarettes’ comparative lower harm

5. Smoking prevalence amongst young people overall is decreasing in the UK, with almost an 8% decrease amongst 18 to 24-year olds since 2011.10 However, there is great disparity between various groups in society. A quarter of those in manual jobs smoke whilst the same number within managerial jobs is one in ten. Men are more likely to smoke compared to women, and those suffering from poor mental health are over represented in these statistics.11 Public Health England, the NHS, the Department of Health and Social Care and NICE are all encouraging smokers of conventional cigarettes to switch to e-cigarettes.12 Public Health England state that vaping presents a “small fraction of the risks of smoking” and that there are substantial health benefits from swapping permanently.13

6. NHS Scotland recently published a statement on e-cigarettes, co-signed by Action on Smoking & Health Scotland, the Royal College of Physicians of Edinburgh and others, stating that although the safety of e-cigarettes cannot be guaranteed due to lack of high quality and longitudinal research, e-cigarettes are “definitely less harmful” compared to cigarettes.14

7. The UK Centre for Tobacco and Alcohol studies assessed the risks of e-cigarettes in comparison to conventional cigarettes:

Sustained inhalation of the multiple components of [e-cigarette] vapour is likely to cause some harm to health, and potential harms include lung cancer, chronic obstructive pulmonary disease, interstitial lung disease and cardiovascular disease. However the concentrations of toxins and particulates in vapour are generally low, and much lower than in tobacco smoke, so the risk of e-cigarette use is likely to be small in relation to tobacco smoking, and may also be small in absolute terms. Recent evidence indicates that smokers who switch to e-cigarettes experience significant falls in exposure to tobacco carcinogens and other toxicants, consistent with a reduction in health risk.15

8. Public Health England report that e-cigarettes are 95% less harmful than conventional cigarettes, although Professor John Newton, Public Health England’s Director of Health Improvement, explained that the figure was not a precise one:

[The figure] originates from a review of the evidence by independent scientists, who were themselves quoting another figure. Our position on the figure is that it is the best available published estimate. It has value. We are trying to convey the extent to which e-cigarettes are likely to be much less harmful than smoking cigarettes. It is a useful figure, but it is not a precise scientific estimate. As the Committee will know very well, it is not

10 Adult smoking habits in Great Britain, The Office for National Statistics, July 201811 Adult smoking habits in Great Britain, The Office for National Statistics, July 201812 The National Institute for Health and Care Excellence13 E-cigarettes and heated tobacco products: evidence review, Public Health England, February 201814 Consensus statement on e-cigarettes, NHS Scotland, 201715 Written evidence submitted by the UK Centre for Tobacco and Alcohol Studies (ECG0031)

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E-cigarettes 8

the sort of issue you can put a single number on. We are trying to convey the extent to which e-cigarettes are likely to be much less harmful than smoking cigarettes.16

9. NHS Smokefree’s campaign material highlights that e-cigarette vapour lacks tar and carbon monoxide—two of the most harmful compounds in tobacco smoke—and carries “a small fraction of the risk of smoking, and can help you quit”.17 The Department of Health and Social Care argued that:

The best thing a smoker can do for their health is to quit smoking. However, the evidence is increasingly clear that e-cigarettes are significantly less harmful to health than smoking tobacco. The government will seek to support consumers in stopping smoking and adopting the use of less harmful nicotine products.18

10. The National Institute for Care and Excellence’s (NICE’s) most recent guidance on e-cigarettes similarly states that although not completely risk free, e-cigarettes are comparatively less harmful than conventional cigarettes.19 Our written evidence likewise emphasised the harm-reducing potential of smokers swapping to e-cigarettes. Action on Smoking and Health stated:

E-cigarettes are substantially less harmful than smoking and the regulatory system now in place is likely to reduce the risks still further. E-cigarettes are now the most popular aid for smokers trying to stop smoking, and are proving effective in helping many smokers to stop smoking.20

The Cochrane Tobacco Addiction Review Group summarised the evidence it had reviewed:

Our findings from independently reviewing the best available evidence on the topic suggest that for existing smokers of conventional cigarettes, switching to electronic cigarettes is likely to lead to significant improvements in health. These findings are based in studies of people who smoked conventional cigarettes, but findings are consonant with findings from the Royal College of Physicians which were based on comparisons of the composition of carcinogens and toxicants in tobacco smoke and vapour from electronic cigarettes.21

11. The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment is currently examining e-cigarettes, and has recently finished work on ‘heat-not-burn’ tobacco products (which heat tobacco without combustion (see paragraph 1)). Professor Harrison from the Committee on Toxicity told us that the main health dangers in a conventional cigarette lie in the combustion of the tobacco:

16 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q359 [Professor Newton]17 NHS Stop Smoking Campaign Stop-tober, October 201718 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 201719 Stop smoking interventions and services, NICE guideline [NG92], March 201820 Written Evidence submitted by Action on Smoking and Health (ECG0071)21 Written evidence submitted by the Cochrane Tobacco Addiction Review Group (ECG0041)

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9 E-cigarettes

Combustion is extremely important. We reviewed that at length, and we found that, overall, there was a 90% to 95% reduction in cancer-causing chemicals. Some disappeared altogether, and some were reduced by only a half.22

Public Health England and the MHRA23 explained that:

Levels of carcinogenic chemicals (including polycyclic aromatic hydrocarbons, tobacco-specific N-nitrosamines, heavy metals and volatile organic compounds are substantially lower in e-cigarettes’ aerosol compared with tobacco smoke. Biomarkers of carcinogen exposures (chemicals detected in the blood or urine of users) are also substantially decreased in current e-cigarette-only users compared with cigarette smokers, and decrease when smokers switch to e-cigarettes.24

12. Professor Newton from Public Health England told us:

We avoid using the word “safe,” because that is a very difficult word to use, but there is no doubt that using an e-cigarette regularly is much less harmful than smoking cigarettes. It is important to get that message across, particularly to smokers.25

The New Zealand Ministry of Health similarly encourages smokers who want to use e-cigarettes to quit smoking to seek the support of local stop smoking services:

Expert opinion is that e-cigarettes are significantly less harmful than smoking tobacco but not completely harmless. A range of toxicants have been found in e-cigarette vapour including some cancer causing agents but, in general, at levels much lower than found in cigarette smoke or at levels that are unlikely to cause harm. Smokers switching to e-cigarettes are highly likely to reduce their health risks and for those around them.26

In Canada e-cigarettes have been legal since 2016, when the Canadian Government amended the Tobacco Act and the Non-smokers’ Health Act to establish a new legislative framework for regulating vaping products in order to address the risks and potential benefits of these products.27

22 Oral evidence taken on 27 February 2018, HC (2017–19) 505, Q185 [Professor Harrison]23 Medicines and Healthcare Products Regulatory Agency24 Written evidence submitted by Public Health England and the Medicines and Healthcare products Regulatory

Agency (ECG0081)25 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q378 [Professor Newton]26 Vaping, smokeless, including heated tobacco, New Zeeland Ministry of Health, October 201727 Parliament of Canada, Bill S-5, an Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make

consequential amendments to other Acts

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E-cigarettes 10

13. We asked Professor David Harrison from the UK Committee on Carcinogenicity of Chemicals in Food, Consumer Products and the Environment about any ‘second-hand’ harm from vaping: He told us:

With e-cigarettes or with heat-not-burn, there is a similar issue. Everything is reduced compared with cigarette smoke, but bystander effects are something to be aware of. One would expect, however, that the dose would be commensurately less than for cigarettes.28

Professor Aveyard from the Cochrane Tobacco Addiction Group also thought that the harm of second-hand vaping was negligible.29 Professor Ricardo Polosa explained that:

It is very well known historically that combustible cigarette smoke is a big cause of diseases, mainly because of side-stream smoke and the smoke that is generated between puffs. An electronic cigarette does not operate on the same principle. It does not have the deadly side-stream smoke and does not generate any smoke or aerosol between operating cycles. Aerosols are emitted by these products only when you exhale. That sets the principle that, on common sense, you will immediately identify that there is less risk just because of that. If you then consider that, as Public Health England and the Royal College of Physicians have already emphasised in their comprehensive reviews, these aerosols are 95% less harmful than common tobacco, you will immediately realise that, from a percentage point of view, the risks will be minuscule.30

Heat-not-burn tobacco products

14. ‘Heat-not-burn’ products contain tobacco which is heated rather than combusted, and is therefore likely to be less harmful compared to conventional cigarettes. The Centre for Tobacco and Alcohol Studies state that the only available data on emissions and safety of heat-not-burn products arises primarily from one of the major tobacco companies, Philip Morris. This research, they argue, therefore needs to be independently validated before it is used to inform policy, but nevertheless pointed to an early evaluation of likely cancer risk which assessed heat-not-burn products to have about 10% of the harm of conventional cigarettes.31

15. The Royal Society for Public Health believed that the lack of independent, high quality research into the “harm profile” of heated tobacco products warrants a regulatory model structured in line with their relative risk as evidence emerges.32 The Department of Health and Social Care similarly stated that there was currently not enough evidence on heat-not-burn products and their relative harmfulness, and that a pragmatic approach to their regulatory framework was appropriate for now.33 Cancer Research UK told us:

28 Oral evidence taken on 27 February 2018, HC (2017–19) 505, Q192 [Professor Harrison]29 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q107 [Professor Aveyard]30 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q7 [Professor Polosa]31 Written evidence submitted by the UK Centre for Tobacco and Alcohol Studies (ECG0031)32 Written evidence submitted by the Royal Society for Public Health (ECG0049)33 Written evidence submitted by the Department of Health (England) (ECG0030)

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11 E-cigarettes

Unlike e-cigarettes, [‘heat-not-burn’] tobacco products are a largely unknown entity, and all of these products are owned by the tobacco industry. There is currently no independent evidence of their safety. We need more evidence, independent from tobacco industry funding or involvement, to determine the level of harm these products may cause, as well as the extent of any potential benefits compared to continued use of tobacco cigarettes.34

The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment highlighted the current uncertainties about any health risks from heat-not-burn products:

The risks associated with use of heat-not-burn tobacco products cannot be quantified due to gaps in the information available and uncertainties in the dose-response relationship of the chemicals and potential adverse health outcomes. In addition, the levels of the different compounds in the aerosol vary compared to the levels in smoke from conventional cigarettes and therefore it is not possible to extrapolate from epidemiological data on smoking risks, particularly given the complexity of the interactions that occur between these compounds in producing adverse health effects.35

Flavourings

16. Some of our evidence expressed a concern about possible risks from e-cigarette liquid flavourings.36 Finland, for example, does not permit flavourings in e-cigarettes at all.37 The British Medical Association believed that flavoured liquids did not cause any acute harm to users, but wanted a long-term assessment to monitor their safety:

Many flavourings used in e-liquid are ‘food safe’, being considered safe when ingested orally, but their safety after heating and inhalation is not established. Given the large numbers of people using flavoured e-liquid without reporting problems, it is unlikely they are having a significant acute impact on the health of users.38

Action on Smoking and Health emphasised the importance of flavourings as part of the appeal of e-cigarettes and possibly also what stopped users from going back to smoking.39 The Cochrane Tobacco Addiction review group called for more research data to be collected from more realistic settings, taking factors such as individual preferences for strength, flavours and devices into account.40

Uncertainty about long-term effects

17. Some have doubts about the long-term safety of e-cigarettes. The US Surgeon General, citing a lack of long-term evidence, could not rule out possible harm from

34 Written evidence submitted by Cancer Research UK (ECG0057)35 Written evidence submitted by the Committee on Toxicity of Chemicals in Food, Consumer Products and the

Environment (ECG0082)36 Written evidence from the Royal Society for Public Health (ECG0049),37 Written evidence submitted by Cancer Research UK (ECG0057)38 Written evidence submitted by the British Medical Association (ECG0037)39 Written Evidence submitted by Action on Smoking and Health (ECG0071)40 Written evidence submitted Cochrane Tobacco Addiction Review Group (ECG0041)

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E-cigarettes 12

e-cigarette ultra-fine particles, flavourings or heavy metals.41 The US National Academies of Sciences, Engineering, and Medicine explained that in the USA “because the efficacy of e-cigarettes to actually reduce harm remains unclear, some have raised concerns about using e-cigarettes for tobacco harm reduction”.42

18. Australia prohibits the sale of nicotine e-cigarettes unless approved as an aid to help people quit smoking and, so far, no e-cigarette has been approved for this purpose.43 The Australian Health, Sport and Aged Care Committee in the Australian House of Representatives concluded that there were two ways of viewing e-cigarette regulation—to take a precautionary approach or a harm-reducing approach. Those arguing for easier access to e-cigarettes, it said, were following a harm-reducing approach, whereas the Committee favoured a continued ban on the basis of the precautionary approach (like the US Surgeon General) until long-term research is able to rule out any long term health consequences.44

19. The Chair of the Australian Committee dissented from his Committee’s report, however, stating that:

In order to assist the millions of smokers struggling to quit tobacco smoking and improve their quality of life, nicotine e-cigarettes should be made available as consumer products. At the same time, regulatory restrictions should be imposed to limit the appeal of e-cigarettes to young people and non-smokers.45

Professor Newton from Public Health England, when giving evidence to the same Committee, told them:

There is this general problem that many of the people who are opposed to e-cigarettes are starting from a position that any smoking is bad and we need to have a firm line. […] We [in the UK] think that, rather than waiting 20 years to get definitive evidence, we have to make the best decision on the evidence that’s available now, and that points us towards cautious use of e-cigarettes.46

And he explained to us:

The Australian situation was different. They had lower smoking rates to begin with when e-cigarettes first appeared. The feeling there was that they

41 E-cigarette Use Among Youth and Young People, United States Surgeon General, U.S. Department of Health and Human Services

42 Consensus Study Report: Public Health Consequences of E-cigarettes, The National Academies of Sciences, Engineering and Medicine, 2018

43 Report on the Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia, The Standing Committee on Health, Aged Care and Sport, The Australian House of Representatives, March 2018

44 Report on the Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia, The Standing Committee on Health, Aged Care and Sport, The Australian House of Representatives, March 2018

45 Chair’s Foreword, Report on the Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia, The Standing Committee on Health, Aged Care and Sport, The Australian House of Representatives, March 2018

46 Oral Evidence taken 18 October 2017, The Standing Committee on Health, Aged Care and Sport, The Australian House of Representatives, Inquiry into the Use and Marketing of Electronic Cigarettes and Personal Vaporisers in Australia

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could continue to control and drive down smoking prevalence without using e-cigarettes. Therefore, in the absence of clear evidence of safety, it was wise to ban them.47

20. Some of those who submitted evidence to our inquiry also highlighted a lack of long-term evidence on the potential harm, if any, from e-cigarette use.48 Some noted that there were very few current vapers who had not previously smoked conventional cigarettes, making comparative studies between vapers and non-vapers difficult to assess.49

21. The Tobacco and Alcohol Research Group at University College London argued, on the other hand, that some research reports have “over-claimed” findings on the harmfulness of e-cigarettes because they have “little or no relevance to prediction of serious illnesses in e-cigarette users”.50 Dr Lion Shahab and Dr Jamie Brown from the UCL Research Group explained that:

A lot of the papers, while written quite correctly, in the press release overstate what has been found. This may be partly because often the papers look at acute and not at chronic effects, and effects that are not very well linked to long-term health outcomes. One of them is arterial stiffness on which a paper was published recently. That was then linked to the fact that ecigarettes cause heart disease. The very same authors also published a paper that showed that, for instance, exercise increased arterial stiffness, so it is very difficult to link that particular marker to long-term health outcomes. That is one of the problems. Another is that often people use unrealistic use conditions. A study looked at the formation of formaldehyde, which is very toxic. […] It is an acrid taste called dry puffing, which is unlikely to occur in real-life conditions. Lastly, often the models used to investigate the effects of ecigarettes are not really relevant to humans—for example, mice models. One big problem is that mice are much more sensitive to nicotine than humans, and often the effects observed in animal studies may just reflect nicotine poisoning rather than the effects of any of the other potentially harmful substances.51

22. Professor Peter Hajek, Professor of Clinical Psychology, Queen Mary University of London, did not believe the uncertainty about any long-term effects would be significant:

We have two ways of looking at it; there is logic and there is data. The logic tells you that most of the chemicals that are dangerous to smokers are absent, or present in very small amounts, in e-cigarettes. As far as we know, none of the chemicals that are specific to e-cigarettes and are not present in smoking poses major health harm. Basically, the data back that up. Recently, there was a detailed paper about kinds of carcinogens, comparing the risk of cancer from smoking and from vaping. That paper took at face value some of the studies on e-cigarettes that actually fry the e-liquid and therefore produce aldehydes, which could be carcinogenic, but even taking

47 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q361 [Professor Newton]48 See for example Written evidence submitted by Pfizer UK (ECG0023),49 Written evidence submitted by the British Lung Foundation (ECG0042)50 Written evidence submitted by University College London, Tobacco and Alcohol Research Group (UTARG)

(ECG0047)51 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q86 [Professor Shahab]

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into account those studies, which do not reflect what vapers are taking in, the conclusion was that the cancer risk is less than 0.5% of the cancer risk from smoking.52

23. Ultimately, whatever any long-term risks there may be from e-cigarettes, not switching from conventional cigarettes also presents its own (very certain) risks in terms of continued conventional smoking-related diseases. Dr Jamie Brown from UCL was clear about how such a balance of risks should be weighed:

Any perceived risk associated with offering reassurance before we have the long-term data [on e-cigarettes] must be balanced against the risk associated with the opportunity cost of failing to inform the millions of people who are currently smoking uniquely dangerous products that e-cigarettes are safer when they believe they are not.53

Research

24. Although the evidence we received has been overwhelmingly that e-cigarettes are much less harmful than conventional cigarettes, new products are constantly being developed; both e-cigarettes and heat-not-burn devices. Research needs to keep abreast of these developments in order to continue to reassure consumers of their relative safety. The Cochrane Tobacco Addiction Review Group told us that more randomized controlled trials were needed, which would compare electronic cigarettes with “alternative pharmacological and behavioural treatments”.54 They stated:

As electronic cigarettes have been used for only a few years, there is little evidence on their safety when used as a long-term or permanent replacement for smoking. As almost all regular use of electronic cigarettes occurs in former or current smokers, interpreting future epidemiological data will be difficult. In the meantime, findings from short- to medium- term studies, studies of biomarkers, and studies of toxicants all suggest electronic cigarettes are significantly less harmful than conventional cigarettes.55

25. The Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment noted that the settings, such as voltage and temperature, on some e-cigarette devices can be modified by the user which, they told us, will result in variations in the composition of the vapour. They explained that the settings on devices used in studies are often not reported in the literature, and that as a result “it will be difficult to establish a worst-case scenario that is representative of human exposure”.56 Professor Aveyard from the Cochrane Review emphasised that “the majority of dangerous compounds present in cigarettes are not there in e-cigarettes”, but:

52 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q5 [Professor Hajek]53 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q90 [Dr Brown]54 Written evidence submitted by Cochrane Tobacco Addiction Review Group (ECG0041)55 Written evidence submitted by Cochrane Tobacco Addiction Review Group (ECG0041)56 Written evidence submitted by the Committee on Toxicity of Chemicals in Food, Consumer Products and the

Environment (ECG0082)

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what we do not have is a cohort of people who have been using ecigarettes for a long time, in order to realise whether there is a true risk in humans. Everything we say is either extrapolation or speculation. There is not a technological fix around that problem; we just do not have people who have used them for 30 or 40 years.57

26. The Department of Health and Social Care told us that to support further independent research and collaboration, the UK E-Cigarette Research Forum, an initiative developed by Cancer Research UK in partnership with PHE and the UK Centre for Tobacco and Alcohol Studies, is “bringing together policy-makers, researchers, practitioners and the NGO community to discuss the emerging evidence and knowledge gaps about e-cigarettes”. The Department pointed out that the group has asked it “to contribute suggestions for further areas of e-cigarette research to help develop improvements in policy to achieve the Tobacco Control Plan aims”.58 The Department is also running an annual evidence review on e-cigarettes, through Public Health England, which will look at the latest evidence on “adult and youth prevalence, safety, effectiveness for quitting and perceptions of harmfulness, addictiveness of nicotine and a section on heat-not-burn tobacco products”.59

27. There is clear evidence that e-cigarettes are substantially less harmful than conventional cigarettes. Public Health England estimate e-cigarettes as 95% less harmful, although the evidence available does not currently allow a precise figure to be determined. E-cigarettes lack the tar and carbon monoxide of conventional cigarettes—the most dangerous components of conventional cigarettes—which are produced by combustion. Some potentially harmful components are present in both products, such as heavy metals, but at substantially lower levels in e-cigarettes. Researchers have found it almost impossible to measure the risks from ‘second-hand’ e-cigarette vapour because any potentially harmful compounds released into the surrounding area are so negligible.

28. More recently introduced ‘heat-not-burn’ products—producing nicotine from tobacco but without the combustion—have been estimated to be around 90% less harmful than conventional cigarettes, although there is a lack of independent research to validate this claim.

29. There are uncertainties, nevertheless, especially about any long-term health effects of e-cigarettes, because the products have not yet had a history of long use. The studies needed to guarantee the safety of e-cigarettes are inevitably frustrated by the absence of a population of e-cigarette users who have never smoked conventional cigarettes before taking up vaping. 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, which are substantially more harmful than e-cigarettes. 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.

57 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q87 [Professor Aveyard]58 Written evidence submitted by the Department of Health (England) (ECG0030)59 Written evidence submitted by the Department of Health (England) (ECG0030)

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30. To help fill remaining gaps in the evidence on the relative risks of e-cigarettes and heat-not-burn products, the Government should maintain its planned annual ‘evidence review’ on e-cigarettes and extend it to also cover heat-not-burn products. It should support a long-term research programme, to be overseen by Public Health England and the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment, to ensure that health-related evidence is not dependent solely on the tobacco industry or the manufacturers of e-cigarettes. That PHE/COT research should include examining health risks arising from the flavourings added to e-cigarettes. The Government should report each year on the state of research in its Tobacco Control Plan, and establish an online hub for making the detailed evidence readily available to the public and to health professionals.

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3 E-cigarettes and smoking cessation

The evidence on smoking cessation

31. The Tobacco Control Plan reported that in 2016 there were 470,000 people using e-cigarettes as a way to stop smoking conventional cigarettes.60 The Department of Health and Social Care estimates that e-cigarettes contribute to between 16,000 and 22,000 people successfully quitting smoking each year who would not otherwise have done so had they used nicotine replacement therapies or willpower alone.61 Professor Paul Aveyard from the Cochrane Review highlighted that e-cigarettes are a popular alternative to other smoking cessation tools.62 Professor John Newton from Public Health England similarly told us:

E-cigarettes are the most popular quitting aid among smokers. Whatever we think of the evidence on their effectiveness, smokers are choosing to use e-cigarettes much more widely than other available forms, such as nicotine patches and nicotine-containing gums. There is no doubt that they are popular among smokers. The first step to being an effective aid is that they have to be used by smokers. That is very much in their favour. We have recognised that by introducing references to e-cigarettes in our campaigns.

32. Professor Newton recognised gaps in the evidence on the effectiveness of e-cigarettes as a smoking cessation tool, but said that this should not detract from their already apparent usefulness:

There is a lack of hard, randomised control-trial evidence of their effectiveness in cessation, but the evidence from observational studies, which are quite convincing, is that many smokers have used e-cigarettes to quit—and to quit completely, not just for dual use. We need to continue to build the evidence base. At the same time, we need to be clear that this is for smokers, particularly those who have tried to quit before. If they have not tried an e-cigarette, they should try an e-cigarette, because that might be their route out of smoking.63

Action on Smoking and Health similarly highlighted both the benefits of e-cigarettes as a stop smoking route and the need for further research on their effectiveness as a cessation aid.64 The Royal Society for Public Health noted that although e-cigarettes appear to be successful as a cessation tool, especially when combined with behavioural support, more “high quality research” is needed.65

33. One of the difficulties in undertaking research to assess their effectiveness is that some people continue to smoke conventional cigarettes, albeit fewer, at the same time—cutting down rather than giving up completely.66 This means that some studies which have claimed that e-cigarettes hamper smoking cessation have been based on observations

60 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 201761 Written evidence submitted by the Department of Health (England) (ECG0030)62 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q92 [Professor Aveyard]63 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q394 [Professor Newton]64 Written Evidence submitted by Action on Smoking and Health (ECG0071)65 Written evidence submitted by the Royal Society for Public Health (ECG0049)66 Written evidence submitted by Pfizer UK (ECG0023)Written evidence submitted by ASH Scotland (ECG0011)

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that e-cigarette users still describe themselves as “smokers”.67 The UCL Research Group also argued that claims that e-cigarettes could reduce smoking cessation rates did not tally with the significant increases seen in the number of conventional smokers quitting in the UK and the US.68

The British Medical Association concluded:

Although the data in favour of the effectiveness of e-cigarettes as a cessation aid is not conclusive, given the quality of the studies, the overall picture—at present—is that they do play a helpful role in helping people to stop smoking.69

The UK Centre for Tobacco and Alcohol Studies argued that e-cigarettes, as an alternative consumer product to tobacco rather than a medical therapy like other nicotine replacements products, had allowed them to reach more people. They believed, in that context, that this gave e-cigarettes a better result overall: “A low efficacy treatment used by large numbers of smokers will generate more quitters than a high efficacy treatment used by a small minority”.70

34. Heat-not-burn products, the Centre for Tobacco and Alcohol Studies suggested, may also have a role in helping those smokers to quit who do not find e-cigarettes a solution:

The role of heat-not-burn products is, thus, far from clear: if more toxic than e-cigarettes and no more effective and acceptable to smokers as smoking substitutes, then their role is likely to be limited. If more effective however, or (for example) as a result of being more similar in taste and experience to tobacco cigarettes, heat-not-burn products are able to appeal to sectors of the smoking population who find e-cigarettes ineffective or otherwise unacceptable, then they may offer a public health benefit despite their relative hazard.71

Young people and a potential gateway to conventional smoking

35. One of the concerns that has been raised about e-cigarettes has been a fear that they could appeal to young people and potentially act as a ‘gateway’ to conventional smoking. The evidence we received, however, has not shown this to be the case. Research undertaken by the Association for Young People’s Health found that the proportion of young people ‘experimenting’ with e-cigarettes ranged between an eighth and a quarter of young people, but that regular use by secondary school children was limited to about 1%, and those children generally engaged in smoking behaviour.72

36. Professor Peter Hajek of Queen Mary University nevertheless cautioned:67 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q394 [Professor Newton]68 Written evidence submitted by University College London, Tobacco and Alcohol Research Group (UTARG)

(ECG0047)69 Written evidence submitted by the British Medical Association (ECG0037)70 Written evidence submitted by the UK Centre for Tobacco and Alcohol Studies (ECG0031)71 Written evidence submitted by the UK Centre for Tobacco and Alcohol Studies (ECG0031)72 Key Data on Young People 2017, Association for Young People’s Health 2017, 2017. See also Written evidence

submitted by The Association for Young People’s Health (AYPH), The Royal College of General Practitioners’ (RCGP) Adolescent Health Group, The Royal College of Paediatrics and Child Health (RCPCH), The Royal Pharmaceutical Society (RPS), and The Young People’s Health Special Interest Group of the RCPCH (YPHSIG) (ECG0093)

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We need to keep an eye on it, because somebody will figure out what you need to add to e-cigarettes to make them more addictive to non-smokers. At the moment, non-smokers do not progress to daily vaping; it is really difficult. If they do, they often vape nicotine-free, just for some kind of flavour and behaviour. There would be a very legitimate concern if we saw large numbers of young people who have never smoked becoming daily vapers, but you would be hard pushed to find anybody.73

Public Health England and the MHRA similarly concluded:

British youth experiment with e-cigarettes but regular use is rare and very largely confined to young people who have smoked. There is some evidence that young people who have vaped but never smoked are more likely subsequently to smoke but there is no evidence that this relationship is causal. The UK has good data on this issue from surveys.74

37. There remain some gaps in the evidence about how effective e-cigarettes are as a stop smoking tool in comparison to other nicotine replacement therapies. Nevertheless, an estimated 2.9 million people in the UK are using e-cigarettes, and tens of thousands are using them to successfully quit smoking each year. Concerns about the risk of e-cigarettes potentially providing a ‘gateway’ into conventional smoking have not materialised to any significant degree. Similarly, the risk of the variety and type of flavours being attractive to young non-smokers, who would be drawn into e-cigarette use, also appears to be negligible.

E-cigarettes as a medically licensed product

38. While many conventional smokers have taken up vaping, some of our witnesses believed that more would do so if an e-cigarette was approved for medical use, and thereby able to be prescribed by a doctor. They saw advantages in two ways. Firstly, a medically licensed product would enable health professionals to feel able to recommend e-cigarettes as a smoking cessation tool, knowing that the device and liquid had been tested and approved by the Medicines and Healthcare products Regulatory Agency (MHRA). Professor Newton from Public Health England told us:

We would like to see a medicinally licensed product because […] it would send a stronger message about relative safety, and it would also provide another avenue and help smoking cessation services to use e-cigarettes more. We think there would be considerable advantages if there was a medically licensed product.75

39. Deborah Arnott from Action on Smoking and Health similarly told us:

We have doctors saying to us all the time, “If we had products that we could prescribe and that were licensed, we would feel much more comfortable.” They would be effective on prescription and highly cost-effective. There have

73 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q29 [Professor Hajek]74 Written evidence submitted by Public Health England and the Medicines and Healthcare products Regulatory

Agency (ECG0081)75 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q426 [Professor Newton]

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been criticisms, with people asking why they should be on prescription. These are cheap products that are highly effective in helping smokers to quit. It would be reassuring to consumers, as well as to the medical profession.76

The Royal Society for Public Health stressed the importance of smoking cessation advisors being able to provide information, with assurance, to smokers:

Research has shown that perceptions of harm can indeed inhibit the use of e-cigarettes among smokers, and this barrier will only be exacerbated if the concerns of the public go unaddressed. Responsible messaging could help to counteract this threat, for example highlighting that smoking cessation services are advised to support smokers who choose to quit using e-cigarettes.77

40. A licensed product could also provide the basis for a doctor-patient relationship that could extend over the period needed to give up smoking, and help overcome some smokers’ reluctance to swap to e-cigarettes because of cost considerations. Several studies show that smokers receiving specialised cessation assistance through their GP are more likely to stop successfully.78 The initial start-up cost of e-cigarettes, Hazel Cheeseman from Action on Smoking and Health explained, may stop some people from swapping to vaping:

Although for most people using an electronic cigarette is cheaper than continuing to smoke, there is a group of people, particularly people with mental health conditions, for whom there is a barrier to entry—an initial cost that you have to meet. For somebody on a low income, that is quite a risk to take, potentially, if you are not sure that the product will work for you. Having something on prescription can help to ease that risk for people. It will also lock people into a relationship with medical professionals and quit services, which we know can significantly improve people’s chances of quitting successfully. Having something on prescription would be a benefit for both of those reasons. For groups that are vulnerable, have high levels of addiction and face lots of barriers to quitting, a prescription product could be really valuable.79

41. As we discuss in Chapter 4, the regulation of e-cigarettes currently prohibits claims being made for their harm-reduction properties. Dr Ian Hudson from MHRA noted that medicines’ licensing would allow such health claims to be made:

Gum, patches and so on have smoking cessation or harm-reduction claims, and those can be promoted as such. The advertising restrictions would be different. They would be able to promote a bit more in relation to the claims for medicines available on prescription […] if these were authorised as ‘medicines’.80

76 Oral evidence taken on 27 March 2018, HC (2017–19) 505, Q299 [Deborah Arnott]77 Written evidence submitted by the Royal Society for Public Health (ECG0049)78 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 201779 Oral evidence taken on 27 March 2018, HC (2017–19) 505, Q300 [Hazel Cheeseman]80 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q422 [Dr Hudson]

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We heard, however, that the MHRA medical authorisation process was itself a barrier. Dr Ian Jones from Japan Tobacco International told us:

The concern that we have, other than the cost, is mainly about the time. These products are innovating and changing so fast—if you run for a medicinal licence approval, you essentially freeze the product at the start, and you have to have the same product at the end. By that time, particularly in today’s environment, the other products have evolved so fast that your product is out of date by the time you reach the other end.81

MHRA highlighted that as a “relatively new” product, it would take longer to go through the generation of the evidence for a ‘medicine’ and through the review process.82

42. Action on Smoking and Health argued for a shorter licensing period to make it a more attractive route for e-cigarette producers to take, and to ensure there were more medically licensed e-cigarettes on the market:

There are precedents for adopting a less restrictive approach, in particular in the area of nicotine regulation. Until nicotine replacement therapy was liberalised in 2005, NRT products were licensed for a maximum of 12 weeks. In 2005 this was extended for some products to a year, and in 2009 the MHRA approved a ‘harm reduction’ extension to the license of the nicorette inhalator without a limit to duration of use. This was on the basis that, “it had become widely accepted that there were no circumstances in which it was safer to smoke than to use NRT.” The Commission went on to say that there was a need for further research and data collection to assess long term safety and agreed that the holder of the market authorization “should be asked to provide a robust risk management plan that would satisfactorily address the outstanding issues”.83

‘Leicester partnership’

43. Leicester City Council’s “e-cigarette friendly” smoking cessation service was highlighted in our inquiry as a model for others to follow. They actively encourage those interacting with patients to recommend e-cigarettes as a stop smoking tool, provide online resources describing experiences of individual smokers who have switched to e-cigarettes, and in some cases supply a free e-cigarette ‘start-up’ kit. The Council emphasises the importance of also providing behavioural support to increase the chances of quitting permanently.84 Leicester City Council told us:

Our advice to those stopping smoking with e-cigarettes is that it is their choice whether they continue to vape—the nicotine they get from their vaporiser could be exactly what stops them relapsing to smoking, and it’s the smoke that kills. The key difference that we see among service users who have switched to vaping though is their increased confidence in their determination never to smoke again. Most have tried many, many times

81 Oral evidence taken on 27 February 2018, HC (2017–19) 505, Q176 [Dr Jones]82 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q423 [Dr Hudson]83 Written evidence submitted by Action on Smoking and Health ECG0071.84 Stop Smoking Leicester website

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before, with medicinal products, or by willpower alone, and have relapsed to smoking. Vaping has made a difference that has taken them (and often their families) by surprise.85

44. Leicester City Council told us about their experience of allowing them in mental health facilities (which we discuss below):

Even highly dependent smokers such as those with poor mental health, and homeless people, are doing really well with vaping. Nursing staff in the mental health wards who were initially sceptical about vaping have been pleasantly surprised at how much easier it has been for their patients who have started using a vaporiser to manage their nicotine needs.86

45. The Minister called the public health team running the Council initiative “a trailblazing group” who were “achieving good things”.87

46. A medically licensed e-cigarette could assist smoking cessation efforts by making it easier for medical professionals to discuss and recommend them as a stop smoking treatment with patients. It would also make it easier for claims to be explicitly made about their harm-reduction relative to conventional smoking, which regulations currently prevent (Chapter 4). The Government should review with MHRA and the e-cigarette industry how its systems for approving stop smoking therapies could be streamlined; to be able to respond appropriately should manufacturers put forward a product for licensing.

E-cigarettes in mental health facilities

47. The Government’s Tobacco Control Plan highlights the need to tackle the much higher rate of smoking among those with mental illness. It reports that 40% of adults with mental illness smoke,88 compared with 16% of the general population.89 The Mental Health and Smoking Partnership told us that:

While people with a mental health condition are as motivated to quit smoking as other smokers they are less likely to be successful. As a consequence, while the rates of smoking in the general population have fallen steadily over the last few decades, the same rate of progress is not apparent for people with a mental health condition, with almost no decline recorded.90

The Tobacco Control Plan states that “Smoking causes premature death, disability and poverty and if we do not reduce smoking prevalence among this group [with mental illness], we will have failed to reduce inequalities”.91

85 Written evidence submitted by Leicester City Council (ECG0022)86 Written evidence submitted by Leicester City Council (ECG0022)87 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q441 [Steve Brine MP]88 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 201789 Adult smoking habits in the UK: 2016, Office for National Statistics, 201790 Written evidence submitted by Mental Health and Smoking Partnership (ECG0060)91 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 2017

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48. The Plan sets out the Government’s goal for all sites providing mental health inpatient services to be smoke-free by 2018. The document states that:

People with mental health conditions have an equal right to be asked whether they smoke. They need to be offered effective methods to quit smoking or reduce harm as part of their care plan and there is an urgent clinical need to improve the support they receive. In some instances, healthcare staff will escort patients on and away from hospital grounds to smoke. This practice is outdated. It reduces the resources available to deliver clinical care and causes direct harm to patients.92

The Mental Health and Smoking Partnership told us that e-cigarettes could play a role in reducing smoking in this group because some evidence indicated that e-cigarettes are seen as more acceptable to people with mental health conditions than other forms of support. They concluded, however, that:

There are barriers to access of e-cigarettes for people with a mental health condition and this includes the policies in NHS settings, attitudes and understanding of health care professionals, false perceptions of harm among smokers with a mental health condition and barriers to entry such as cost of devices.93

49. Heather Thomson from Nottinghamshire Healthcare NHS Foundation Trust told us that restricting patients to specific areas within facilities where they can vape may be counter-productive:

We do not want to make patients become more isolated than they were. If one e-cigarette lasts as long as 30 cigarettes and somebody who is a 40-a-day smoker usually can use it only in their room, we may find that they have even less interaction. We want to encourage them to be a part of activities that are going on. If vaping during an activity enables them to remain focused and within that activity, that is part of their therapeutic recovery and is a good thing.94

While the Care Quality Commission’s (CQC) guidance for its inspectors asks them not to challenge smoke-free policies, it does emphasise how such policies can be mitigated for patients affected:

CQC inspections should not challenge smoke-free policies, including bans on tobacco smoking in mental health inpatient services (for example, by raising such policies as an unwarranted ‘blanket restriction’). Instead, focus should be paid on whether such a ban is mitigated by adequate advice and support for smokers to stop or temporarily abstain from smoking with the assistance of behavioural support, and a range of stop smoking medicines and/or e-cigarettes. Inspections should also consider whether alternative activities are in place and promoted, including regular access to outside areas.95

92 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 201793 Written Evidence submitted by Mental Health and Smoking Partnership (ECG0060)94 Oral evidence given 16 April 2018 HC (2017–19) 505 Q280 [Heather Thomson]95 Brief guide: Smokefree policies in mental health inpatient services, Care Quality Commission, 2017.

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Encouragingly, it states that a ban on e-cigarettes without “cogent justification” can be criticised as effectively being an unwarranted ‘blanket restrictions’.96

50. We decided to directly survey all English NHS mental health trusts (see Appendix 1), and found that a third of the 50 NHS trusts that responded banned e-cigarettes within their facilities (three failed to respond—Cumbria Partnership NHS Foundation Trust, Greater Manchester West Mental Health NHS Foundation Trust, and Hertfordshire Partnership University NHS Foundation Trust). Some of these NHS trusts stated that e-cigarette use was allowed in designated shelters outside, along with conventional smoking, whilst others designated the facility’s entire estate as smoke-free including for e-cigarettes. Amongst the NHS trusts which allowed e-cigarettes indoors, this was generally in designated areas, to make sure that those patients, staff and visitors who did not wish to be exposed to the vapour could avoid it. Three-quarters of NHS trusts were concerned about ‘second-hand’ e-cigarette vapour despite evidence that it presents negligible, if any, health risks (Chapter 2), and some NHS trusts reported that staff had complained about the smell. Some NHS trusts allowed only certain types of e-cigarettes, usually ‘tamper proof’ models, which had been approved by the NHS trust. Heather Thomson, Smokefree Lead, Nottinghamshire Healthcare NHS Foundation Trust, emphasised possible difficulties caused by not having a consistent approach across NHS trusts, which could mean that e-cigarettes approved by one site were not permitted in another, or that e-cigarettes were stocked in some retail outlets but not others.97

51. Hazel Cheeseman from Action on Smoking Health emphasised a need for “some central guidance and policy in relation to ecigarettes and smoke-free policies, and greater investment in the training of mental health staff”.98 Professor Newton from Public Health England highlighted the importance of evidence-based local decision-making in this area:

We have provided guidance to NHS trusts, including mental health trusts, and to employers on the basis on which they should produce their own policies. We think that there is value in individual organisations developing their own policies, based on a general understanding of the evidence, because they are more likely to know what their particular circumstances are. I agree with you that it seems unlikely that an overall ban [on e-cigarettes] is the right approach, given the evidence.99

52. Heather Thomson believed that a central policy from NHS England would, nevertheless, be beneficial:

It would be very useful to have some central guidance, because there is an anxiety about bringing in something that, in years to come, may prove to have been harmful. However, we need to balance that against the fact that we absolutely know the harms that are associated with smoking. Anything that allays those fears and lays the foundations will be useful.100

96 Brief guide: Smokefree policies in mental health inpatient services, Care Quality Commission, 2017.97 Oral evidence taken on 27 March 2018, HC (2017–19) 505, Q284 [Heather Thomson]98 Oral evidence taken on 27 March 2018, HC (2017–19) 505, Q334 [Hazel Cheeseman]99 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q373 [Professor Newton]100 Oral evidence taken on 27 March 2018, HC (2017–19) 505, Q262 [Heather Thomson]

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NHS Providers recognised “the potential value of national guidance from NHS England to support NHS mental health services in permitting the use of e-cigarettes”, but cautioned that:

[A policy would] need to be sufficiently flexible and allow trusts to incorporate the guidance in an individually tailored way as part of personalised care planning, as well as to manage their permissions as to where e-cigarettes can be used on the trust’s premises. We would also maintain that the cost of using e-cigarettes services remains with the service user and not the trust, unless such a time comes that e-cigarettes are prescribed by the NHS.101

E-cigarettes in prisons

53. In the prison estate, like mental health NHS trusts, a conventional smoking ban is being rolled out across England. The difference however is that e-cigarettes and vaping devices are made available for purchase within the entire prison estate whilst only in some mental health facilities. E-cigarettes had been brought into some prisons on a trial basis in 2014. In 2015 the then Minister for Prisons and Probation told the Justice Committee:

Our steps to date [towards a smoke-free prison service] include the recent and highly successful roll out of electronic cigarettes to all prisons. These are available in every prison shop and offer a comparable alternative to traditional tobacco products in cost terms.102

54. Michelle Jarman-Howe, Executive Director of Public Sector Prisons South, told us that the policy was working well:

At the point at which the [prison] service introduced no smoking, offenders could access disposable e-cigarettes through the offender canteen system on closed sites in the public sector. Later, in October 2017, we also enabled offenders to access rechargeable vaping facilities. That proved to be far more popular.103

55. Smoking cessation is a particular challenge in mental health. People with mental health issues smoke significantly more than the rest of the population and, as the Government warns, if we do not reduce smoking prevalence among this group, “we will have failed to reduce inequalities”. Patients in mental health units who are smokers would benefit from using e-cigarettes to help them stop smoking conventional cigarettes whilst also encouraging them to engage with treatments within the facilities, because they can continue to engage in treatment sessions, when as smokers they would have to leave. Some NHS mental health units are allowing unrestricted use of e-cigarettes—Nottinghamshire Healthcare NHS Foundation Trust is an exemplar—but it is unacceptable that a third of mental health NHS trusts still ban e-cigarettes within their facilities. Three-quarters of NHS trusts are mistakenly concerned about ‘second-hand’ e-cigarette vapour, despite evidence that it presents a negligible health risk.

101 Written evidence submitted by NHS Providers (ECG0109)102 Letter from Prisons Minister Andrew Selous to Robert Neill MP, Chairman of the Justice Select Committee

regarding smoking in prisons, 29 September 2015.103 Oral evidence taken on 27 March 2018, HC (2017–19) 505, Q233 [Michelle Jarman-Howe]

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56. We are concerned that NHS England declined our invitation to give evidence on how it was working to encourage innovative solutions, such as e-cigarettes, to battle the worryingly high numbers of smokers amongst those with poor mental health. NHS England stated that it was unable to provide a representative to put in front of the Committee. NHS England explained that there was no one responsible centrally with “oversight” of e-cigarette policies amongst NHS mental health trusts, nor did NHS England do anything centrally to enforce any type of policy approach. NHS England should take a strong leadership role in ensuring that everything is done to reduce the numbers of smokers amongst those with poor mental health, as smoking is the single largest cause of premature mortality within this group. We also find it very concerning that there is not a dedicated person within NHS England responsible for implementing the Government’s Tobacco Control Plan. NHS England should as a matter of urgency ensure that such a position is created.

57. NHS England should set a clear central NHS policy on e-cigarettes in mental health facilities 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 issue e-cigarette guidance to all NHS mental health trusts to ensure that they understand the physical and mental health benefits for their patients.

E-cigarettes in public places

58. Although e-cigarettes are significantly less harmful than conventional cigarettes, and are helping people to stop smoking, they are generally prohibited in closed spaces including workplaces, restaurants and on public transport. Vapers are typically shown to outside ‘smoking areas’ to vape next to a conventional smoker, which could be counter-productive for those attempting to stay away from cigarettes while trying to quit smoking. John Dunne from the UK Vaping Industry Association compared making vapers stand with smokers as “putting an alcoholic in a bar: It just does not make sense”.104

59. Smoking has been banned in closed public spaces and many workplaces to protect non-smokers from the effects of second-hand smoke, and in some cases to reduce fire-risk, but it appears that the same logic is being used to prevent e-cigarette vaping. Yet, as we discussed in Chapter 2, second-hand vapour does not cause harm. Professor Newton from Public Health England pointed to another more basic factor potentially involved, noting that while “there is no evidence that exposure to the vapour of e-cigarettes is harmful, […] some people do not necessarily like it”.105

60. Many businesses, public transport providers and owners of other public places do not allow e-cigarettes in the same way that they prohibit conventional smoking. There is some hostility towards the use of e-cigarettes in public areas, if only because some bystanders find its vapour unpleasant. As we have described in this Report, there is no public health rationale for treating use of the two products the same. Indeed, forcing vapers to use the same ‘smoking shelters’ as conventional smokers could undermine their efforts to quit. There is now a need for a wider debate on how e-cigarettes are to be dealt with in our public spaces, to help arrive at a solution which at least starts from the evidence rather than misconceptions about their health impacts. A liberalisation of

104 Oral evidence taken on 9 May 2018, HC (2017–19) 505, Q554 [John Dunne]105 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q401 [Professor Newton]

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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).

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4 Regulation61. E-cigarettes are regulated under the UK Tobacco and Related Products Regulations 2016 (TRP Regulation),106 which implemented the EU’s Tobacco Products Directive.107 Because the regulations are connected with trade, it is largely a reserved matter and the Department of Health and Social Care transposed the regulations on behalf of Northern Ireland, Scotland and Wales. The EU Directive:

• Sets minimum standards for the safety and quality of all e-cigarettes and liquid refill containers;

• Requires that information is provided to consumers so that they can make informed choices; and

• Requires that children are protected from starting to use ‘tobacco’ products.108

It leaves national governments to stipulate and control:

• smoke-free environments;

• domestic advertising;

• domestic sales;

• age restrictions;

• nicotine-free cigarettes; and

• flavourings of e-cigarettes.109

62. E-cigarettes and e-liquids are subject to a notification scheme, for which the Medicines and Healthcare products Regulatory Agency (MHRA) is the competent authority in the UK. This system is intended to ensure standards that:

• require child-resistant and tamper-evident packaging;

• provide protection against breakage and leakage;

• ban certain ingredients (including certain colourings, caffeine and taurine);

• require that devices deliver a consistent dose of nicotine under normal conditions; and

• limit liquid tank and cartridges to no more than 2ml in volume and 20mg/ml in nicotine strengths.110

106 The Tobacco and Related Products Regulations 2016107 The Tobacco Products Directive (2014/40/EU)108 The Tobacco Products Directive (2014/40/EU)109 The Tobacco Products Directive (2014/40/EU)110 The Tobacco and Related Products Regulations 2016

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63. The Department of Health and Social Care regarded the e-cigarette regulatory framework as “proportionate”. The EU and national regulations, they told us, have enabled them:

[…] to introduce measures to regulate e-cigarettes to reduce the risk of harm to children and protect against any risk of re-normalisation of tobacco use, provide assurance on relative safety for users, and provide legal certainty for businesses. This has enabled the UK to implement standards and consistency. There are a few exceptions in terms of UK domestic law and it is right for each UK country to decide on those matters. For example, in Scotland there are powers to introduce domestic legislation banning domestic advertising of e-cigarettes. This is a matter for the Scottish Parliament.111

64. The Scottish Government has made provision, through the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016, to restrict the advertising of vapour products through secondary legislation, though this is not yet in place. This would require retailers selling ‘nicotine vapour product’, or e-cigarettes, to register on a tobacco retailer register. It would also restrict domestic advertising and promotions and bans staff under the age of 18 from selling tobacco and ‘nicotine vapour products’.112 In 2015–16, the Welsh Government attempted to go further and introduce stricter controls on the use of e-cigarettes in public places and, like Scotland, introduce a national register for tobacco and nicotine retailers.113 Its Bill was defeated in the Welsh Assembly.

65. Many of our witnesses identified problems with the regulatory system in four main areas: the 20mg/ml maximum nicotine refill limit, a size restriction on the tank, a block on advertising e-cigarettes’ relative harm-reduction potential, and the notification scheme for e-cigarette ingredients, as we discuss below.

The refill strength limit

66. The Centre for Addictive Behaviours Research at London South Bank University told us that the 20 mg/ml nicotine limit for e-cigarette refills was not evidence-based and was actually counter-productive:

Vapers using higher nicotine e-liquid concentrations have been compelled to switch to lower nicotine concentrations since the introduction of the [EU Directive]. This upper limit is arbitrary and is not based on empirical evidence. In fact, it may increase harm if smokers cannot achieve the nicotine delivery they need to supress cravings for tobacco, which in turn may dis-incentivise switching to electronic cigarettes and expose high nicotine-dependent smokers, willing to switch to e-cigarettes, to greater risks of relapse.114

111 Written evidence submitted by the Department of Health (England) (ECG0030)112 Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016113 First minister dismisses e-cigs ban plan in health bill, BBC News, 22 May 2015114 Written evidence submitted by London Southbank University and the University of East London (ECG0018)

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Sarah Jakes from the New Nicotine Alliance similarly told us, in regard to the size of the tank size restriction, that:

There is no scientific basis at all for the 2 ml tank limit and 10 ml bottle limit. Speaking for consumers, they make things fiddlier and the bottles are easier to lose. It is generally inconvenient and there is no possible gain from it.115

Regulation of health claims

67. Under the current EU tobacco regulations, there are restrictions on how e-cigarettes and tobacco products can be advertised and where. The detailed rules are determined by the Committee on Advertising Practice for non-broadcast media and by the UK Code of Broadcast Advertising for broadcast media. The Advertising Standards Authority, who regulate and monitor advertisements, told us:

The [Department of Health and Social Care] took a minimal approach to implementing the advertising prohibitions in the [EU tobacco directive]. The legal prohibitions emanating from the Directive and the TRP Regulation apply only to ads which promote (directly or indirectly) certain types of products (those which are unlicensed and which contain nicotine) and only in some media channels. In general terms the prohibited media channels are those which have a cross-EU-border effect. The result is that a nicotine-containing e-cigarette may be lawfully advertised on an outdoor poster, in a leaflet and in the cinema. However, the same ad would be illegal on television and radio and in magazines and newspapers.116

68. Health claims in advertising can only be made about a product which has a medical licence from the MHRA,117 but the Advertising Standards Authority is reviewing whether health claims should be allowed when promoting e-cigarettes.118 We were told that 27 representations made to the consultation had been in favour of allowing health claims for e-cigarette advertising, and six for the retention of the current legislation.119

69. The UK Centre for Tobacco and Alcohol Studies argued that due to currently restrictive advertising rules, there is a lack of clear guidance on the relative harms of e-cigarettes and conventional cigarettes. This, they believed, contributes to a common misconception among smokers who have never used an e-cigarette that they are no less harmful.120 Fraser Cropper from the Independent Vape Trade Industry Association explained that e-cigarette manufacturers wanted to make claims only about the products’ relatively lower harm compared with conventional cigarettes:

To tie a hand behind our back and not allow us to be able to promote our products, to seize even more of those smokers out of the hands of the tobacco businesses, does not make sense. We are in a regulated space; we

115 Oral evidence taken on 9 May 2018, HC (2017–19) 505, Q504 [Sarah Jakes]116 Written evidence submitted by the Advertising Standards Authority (ECG0015)117 Written evidence submitted by the Advertising Standards Authority (ECG0015)118 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q387 [Mr Morrison]119 E-cigarette advertising consultation, the Advertising Standards Authority, September 2017120 Written evidence submitted by the UK Centre for Tobacco and Alcohol Studies (ECG0031)

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are protecting our consumers because of that. It should, therefore, also allow for confidence that we can continue to deliver those products and services in an ethical and responsible way.121

Vaping does not make anybody better per se; it significantly reduces the risk of what a smoker is exposed to. It is a relative health claim. It is not a health claim in the singular sense that it makes somebody better.122

70. One way of targeting information about the relative harm reduction of e-cigarettes at existing smokers, rather than more broadly, would be through ‘pack inserts’ placed in conventional cigarette cartons. Dr Moira Gilchrist from Philip Morris International told us that:

We are very interested in ensuring we have the opportunity to have targeted communications to smokers. We are not interested in broad communication opportunities; we are interested in attracting the right users—smokers who would otherwise continue to use cigarettes. Pack inserts in conventional cigarette packs are one example of that. Unfortunately, we cannot do that here in the United Kingdom, because of the laws that exist. We believe that that would be a tremendous opportunity to talk only to smokers, to tell them about the existence of new smoke-free products. That would be a very simple thing to do here in the United Kingdom that would allow marketing to exactly the right audience and not to the wrong audience.123

71. Dr Tim Baxter from the Department of Health and Social Care told us that, in relation to ‘pack inserts’ in conventional cigarette packs, “there is not a single UK phone number for helping people to stop smoking, so that is an issue. We cannot use inserts. We do effectively use the pack to give various messages, with graphic health warnings.”124

Regulation of e-cigarette ingredients

72. Whilst the MHRA includes all nicotine containing e-cigarette products in its notification scheme for obtaining product approval, non-nicotine containing products such as nicotine-free vaping liquids fall outside of the approval process.125 Dr Grant O’Connell from Fontem Ventures noted that there is a blacklist of ingredients which are not allowed, and took issue with the less rigorous approach of the notification process for products which do not contain nicotine:

The issue regarding whether some liquids already contain these chemicals is that in the absence of product standards, particularly around testing methods, you are comparing apples with pears. There is not one standard method. One lab will use method A and one will use method B, so you might not detect the chemical. We agree that strict enforcement of product standards is absolutely essential. We believe that that would form the basis of a bespoke regulatory framework for these products.126

121 Oral evidence taken on 9 May 2018, HC (2017–19) 505, Q547 [Mr Cropper]122 Oral evidence taken on 9 May 2018, HC (2017–19) 505, Q544 [Mr Cropper]123 Oral evidence taken on 27 February 2018, HC (2017–19) 505, Q152 [Dr Gilchrist]124 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q491 [Dr Baxter]125 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q405 [Dr Hudson]126 Oral evidence taken on 27 February 2018, HC (2017–19) 505, Q164 [Dr O’Connell]

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Dr Ian Jones from Japan Tobacco International wanted non-nicotine containing liquids to be tested in the same way as nicotine containing liquids:

Consumers are still inhaling the vapour from these liquids. We are also seeing—I believe, in the UK—what are called ‘short fills’, where consumers buy a small bottle of nicotine-containing liquid and add it to an unregulated bottle of zero-nicotine flavoured liquid. For me, as a scientist, that is a concern, because we do not know what is in that zero-nicotine flavoured liquid combination. Based on the principles of consumer protection, I think that zero-nicotine liquids should be regulated in the same way.127

73. Dr Ian Hudson, Chief Executive of the MHRA, wrote to us:

The [MHRA] is aware of concern in the industry that products that do not contain nicotine when sold could potentially include harmful ingredients as they do not fall under scope TRP Regulation. MHRA is collaborating with the Department of Health and Public Health England, who are carrying out research into the safety of e-cigarette products. Together with the compliance work undertaken by Trading Standards and trade bodies, this research will provide clearer view of the risks of these products.128

When subsequently he gave evidence to us, he elaborated:

We are doing a number of things. One of them is to work with the Chartered Trading Standards Institute in relation to the sampling of products, such that they can be tested, and to confirm that they comply with the regulations and notifications—and also to ensure that there are no banned substances in there.129 […] We cannot test directly, but we are working with trading standards to do a pilot of testing, to ensure compliance.130

Regulation of novel tobacco products

74. The regulatory system is also being applied to new products in two areas: ‘heat-not-burn’ products (Chapter 2) and ‘snus’. ‘Snus’, a Scandinavian non-combustible tobacco product inserted under the user’s lip, is currently illegal in the UK under the EU Tobacco Products Directive. The same directive does however make an exception for the product to be produced and sold in Sweden:

Given the general prohibition of the sale of tobacco for oral use in the Union, the responsibility for regulating the ingredients of tobacco for oral use, which requires in-depth knowledge of the specific characteristics of this product and of its patterns of consumption, should, in accordance with the principle of subsidiarity, remain with Sweden, where the sale of this product is permitted pursuant to Article 151 of the Act of Accession of Austria, Finland and Sweden.131

127 Oral evidence taken on 27 February 2018, HC (2017–19) 505, Q156 [Dr Jones]128 Letter from Dr Ian Hudson, Medicines and Healthcare products Regulatory Agency (ECG0103)129 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q408 [Dr Hudson]130 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q409 [Dr Hudson]131 Tobacco Products Directive (2014/40/EU)

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Swedish Match, a company which develops, manufactures and sells tobacco alternatives including Snus, recently challenged the ban on the product in British courts, arguing that new scientific data had shown it to be less harmful than cigarettes. The Advocate General of the European Courts of Justice has judged that the ban outside Sweden remains valid, and the Court will make a ruling in the coming months.132

75. Professor Peter Hajek of Queen Mary University told us that snus’ use in Scandinavia provided useful data on the health impact of nicotine from long-term users of nicotine replacement treatments:

It is not a huge sample, but it is very reassuring. We have a huge population of data from Sweden and Norway on people who use snus, which is a nicotine-containing tobacco product. There is no sign of an increase in cancer that is linked to nicotine. There are some pancreatic cancer concerns, but there are nitrosamines in those products; the concerns are not nicotine linked. Smoking-linked lung cancer is gone. The same applies to heart disease. […] I do not think we have any evidence of nicotine being that harmful.133

76. We wrote to the then Health Secretary, Jeremy Hunt MP, about the UK Government’s position on the Swedish Match case at the European Court of Justice including its support for maintaining the ban on snus. In response, he set out the grounds of the Government’s continued support for the ban:

It is worth noting that there are strongly diverging views in terms of the evidence on the health risks of snus—with significant concerns in Norway and Sweden about the impact of the use of snus, particularly by young people and pregnant women. Where such controversy exists, our view is that a ban constitutes a proportionate response. However, the primary objective of the UK government was not to secure the continued prohibition of snus, but to seek to protect the principle of proportionality on which it is based.134

When we subsequently asked the Health Minister, Steve Brine MP, whether he could see a case for an end to the ban on snus in the UK post-Brexit, he replied: “No—but I have an open mind”.135

Risk-based regulation and taxation

77. The University of Otago, New Zealand, has argued for a differentiated risk-proportionate regulatory framework for e-cigarettes, heat-not-burn products and conventional cigarettes “to ensure the least harmful products are the most affordable, accessible and appealing to smokers, while the most harmful smoked tobacco products are the least affordable, accessible and appealing to both smokers and young people at risk of starting to smoke”.136 Their framework would involve abolishing excise duty and taxation of e-cigarettes, except potentially for a level deemed to be required to deter young people from starting.

132 Written evidence submitted by the UK Centre for Tobacco and Alcohol Studies (ECG0031)133 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q25 [Professor Hajek]134 Letter from the Secretary of State, Department of Health and Social Care (ECG0095)135 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q477 [Steve Brine MP]136 ‘Smoke, heat or vapour? Ideas for risk-proportionate regulation to make World Smokefree Day irrelevant by

2025’, The University of Otago, New Zealand, March 2018

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78. The Government’s Tobacco Control Plan states that, once the UK has left the EU, tobacco regulation will have to “reflect the new environment in which tobacco control will be delivered”.137 The current regulations will be reviewed and the legislation will be re-assessed, including the regulatory framework around e-cigarettes.138 ASH recommended a review of the various regulations post-Brexit.139 Health Minister Steve Brine MP told us:

On the question of post-Brexit and whether Brexit gives us more room for manoeuvre, unquestionably yes. That is a bit of “take back control” that I do not remember seeing on any buses, but it is a fact that we would have more room for manoeuvre.140

79. Some of our witnesses nevertheless raised a concern about needing to ensure that vaping products were only advertised to adults, and preferably only to existing conventional cigarette smokers. Although currently the proportion of young people using e-cigarettes is very small (Chapter 3), the Association for Young People’s Health believed that e-cigarettes are marketed to young people, and were concerned that “young people, who are early adopters of all new technologies may be attracted to use e-cigarettes whether or not they already smoke”.141

80. Currently, e-cigarettes are not subject to excise duty in the UK, unlike conventional cigarettes, heat-not-burn and other tobacco-containing products.142 Dr Lion Shahab from UCL believed that taxation could play an important part in encouraging smokers to switch from conventional smoking to less harmful alternatives including e-cigarettes.143

81. Some aspects of the regulatory system for e-cigarettes appear to be holding back their use as a stop smoking measure. The limit on the strength of refills means that some users have to puff harder to get the nicotine they seek and may put some heavy smokers off persisting with e-cigarettes. The tank size restriction does not seem to be founded on any scientific rationale. A prohibition on making claims for the relative health benefits of switching to e-cigarettes from conventional cigarettes means that some who might switch are not getting that message. A ban on advertising ‘tobacco’ products, has prevented manufacturers putting ‘pack insert’ information about e-cigarettes in cigarette cartons. The Government, together with the ASA and the MHRA, should review all these regulatory anomalies and, to the extent that EU directives do not present barriers, publish a plan for addressing these in the next annual Tobacco Control Plan.

82. The level of taxation on smoking-related products should directly correspond to the health risks that they present, to encourage less harmful consumption. Applying that logic, e-cigarettes should remain the least-taxed and conventional cigarettes the most, with heat-not-burn products falling between the two.

83. The Government should conduct a review of regulations on e-cigarettes and novel tobacco products which are currently applied under EU legislation, to identify scope for change post-Brexit, including an evidence-based review of the case for discontinuing 137 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 2017138 Towards a Smokefree Generation - A Tobacco Control Plan for England, Department of Health, 2017139 Action on Smoking and Health (ECG0071)140 Oral evidence taken on 24 April 2018, HC (2017–19) 505, Q481 [Steve Brine MP]141 Written evidence submitted by the Association for Young People’s Health (ECG0093)142 Tax on shopping and services, HMRC143 Oral evidence taken on 9 January 2018, HC (2017–19) 505, Q97 [Dr Lion Shahab MP]

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35 E-cigarettes

the ban on ‘snus’ oral tobacco. This should be part of a wider shift to a more risk-proportionate regulatory environment; where regulations, advertising rules and tax/duties reflect the evidence on the relative harms of the various e-cigarette and tobacco products available. While an evidence-based approach is important in its own right, it also may help bring forward the behaviours that we want as a society—less smoking, and greater use and acceptance of e-cigarettes and novel tobacco products if that serves to reduce smoking rates.

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E-cigarettes 36

Conclusions and recommendations

Reducing Harm

1. There is clear evidence that e-cigarettes are substantially less harmful than conventional cigarettes. Public Health England estimate e-cigarettes as 95% less harmful, although the evidence available does not currently allow a precise figure to be determined. E-cigarettes lack the tar and carbon monoxide of conventional cigarettes—the most dangerous components of conventional cigarettes—which are produced by combustion. Some potentially harmful components are present in both products, such as heavy metals, but at substantially lower levels in e-cigarettes. Researchers have found it almost impossible to measure the risks from ‘second-hand’ e-cigarette vapour because any potentially harmful compounds released into the surrounding area are so negligible. (Paragraph 27)

2. More recently introduced ‘heat-not-burn’ products—producing nicotine from tobacco but without the combustion—have been estimated to be around 90% less harmful than conventional cigarettes, although there is a lack of independent research to validate this claim. (Paragraph 28)

3. There are uncertainties, nevertheless, especially about any long-term health effects of e-cigarettes, because the products have not yet had a history of long use. The studies needed to guarantee the safety of e-cigarettes are inevitably frustrated by the absence of a population of e-cigarette users who have never smoked conventional cigarettes before taking up vaping. 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, which are substantially more harmful than e-cigarettes. 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. (Paragraph 29)

4. To help fill remaining gaps in the evidence on the relative risks of e-cigarettes and heat-not-burn products, the Government should maintain its planned annual ‘evidence review’ on e-cigarettes and extend it to also cover heat-not-burn products. It should support a long-term research programme, to be overseen by Public Health England and the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment, to ensure that health-related evidence is not dependent solely on the tobacco industry or the manufacturers of e-cigarettes. That PHE/COT research should include examining health risks arising from the flavourings added to e-cigarettes. The Government should report each year on the state of research in its Tobacco Control Plan, and establish an online hub for making the detailed evidence readily available to the public and to health professionals. (Paragraph 30)

E-cigarettes and smoking cessation

5. There remain some gaps in the evidence about how effective e-cigarettes are as a stop smoking tool in comparison to other nicotine replacement therapies. Nevertheless, an estimated 2.9 million people in the UK are using e-cigarettes, and tens of thousands are using them to successfully quit smoking each year. Concerns about

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37 E-cigarettes

the risk of e-cigarettes potentially providing a ‘gateway’ into conventional smoking have not materialised to any significant degree. Similarly, the risk of the variety and type of flavours being attractive to young non-smokers, who would be drawn into e-cigarette use, also appears to be negligible. (Paragraph 37)

6. A medically licensed e-cigarette could assist smoking cessation efforts by making it easier for medical professionals to discuss and recommend them as a stop smoking treatment with patients. It would also make it easier for claims to be explicitly made about their harm-reduction relative to conventional smoking, which regulations currently prevent (Chapter 4). The Government should review with MHRA and the e-cigarette industry how its systems for approving stop smoking therapies could be streamlined; to be able to respond appropriately should manufacturers put forward a product for licensing. (Paragraph 46)

7. Smoking cessation is a particular challenge in mental health. People with mental health issues smoke significantly more than the rest of the population and, as the Government warns, if we do not reduce smoking prevalence among this group, “we will have failed to reduce inequalities”. Patients in mental health units who are smokers would benefit from using e-cigarettes to help them stop smoking conventional cigarettes whilst also encouraging them to engage with treatments within the facilities, because they can continue to engage in treatment sessions, when as smokers they would have to leave. Some NHS mental health units are allowing unrestricted use of e-cigarettes—Nottinghamshire Healthcare NHS Foundation Trust is an exemplar—but it is unacceptable that a third of mental health NHS trusts still ban e-cigarettes within their facilities. Three-quarters of NHS trusts are mistakenly concerned about ‘second-hand’ e-cigarette vapour, despite evidence that it presents a negligible health risk. (Paragraph 55)

8. We are concerned that NHS England declined our invitation to give evidence on how it was working to encourage innovative solutions, such as e-cigarettes, to battle the worryingly high numbers of smokers amongst those with poor mental health. NHS England stated that it was unable to provide a representative to put in front of the Committee. NHS England explained that there was no one responsible centrally with “oversight” of e-cigarette policies amongst NHS mental health trusts, nor did NHS England do anything centrally to enforce any type of policy approach. NHS England should take a strong leadership role in ensuring that everything is done to reduce the numbers of smokers amongst those with poor mental health, as smoking is the single largest cause of premature mortality within this group. We also find it very concerning that there is not a dedicated person within NHS England responsible for implementing the Government’s Tobacco Control Plan. NHS England should as a matter of urgency ensure that such a position is created. (Paragraph 56)

9. NHS England should set a clear central NHS policy on e-cigarettes in mental health facilities 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 issue e-cigarette guidance to all NHS mental health trusts to ensure that they understand the physical and mental health benefits for their patients. (Paragraph 57)

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E-cigarettes 38

10. Many businesses, public transport providers and owners of other public places do not allow e-cigarettes in the same way that they prohibit conventional smoking. There is some hostility towards the use of e-cigarettes in public areas, if only because some bystanders find its vapour unpleasant. As we have described in this Report, there is no public health rationale for treating use of the two products the same. Indeed, forcing vapers to use the same ‘smoking shelters’ as conventional smokers could undermine their efforts to quit. There is now a need for a wider debate on how e-cigarettes are to be dealt with in our public spaces, to help arrive at a solution which at least starts from the evidence rather than misconceptions about their health impacts. 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). (Paragraph 60)

Regulation

11. Some aspects of the regulatory system for e-cigarettes appear to be holding back their use as a stop smoking measure. The limit on the strength of refills means that some users have to puff harder to get the nicotine they seek and may put some heavy smokers off persisting with e-cigarettes. The tank size restriction does not seem to be founded on any scientific rationale. A prohibition on making claims for the relative health benefits of switching to e-cigarettes from conventional cigarettes means that some who might switch are not getting that message. A ban on advertising ‘tobacco’ products, has prevented manufacturers putting ‘pack insert’ information about e-cigarettes in cigarette cartons. The Government, together with the ASA and the MHRA, should review all these regulatory anomalies and, to the extent that EU directives do not present barriers, publish a plan for addressing these in the next annual Tobacco Control Plan. (Paragraph 81)

12. The level of taxation on smoking-related products should directly correspond to the health risks that they present, to encourage less harmful consumption. Applying that logic, e-cigarettes should remain the least-taxed and conventional cigarettes the most, with heat-not-burn products falling between the two (Paragraph 82)

13. The Government should conduct a review of regulations on e-cigarettes and novel tobacco products which are currently applied under EU legislation, to identify scope for change post-Brexit, including an evidence-based review of the case for discontinuing the ban on ‘snus’ oral tobacco. This should be part of a wider shift to a more risk-proportionate regulatory environment; where regulations, advertising rules and tax/duties reflect the evidence on the relative harms of the various e-cigarette and tobacco products available. While an evidence-based approach is important in its own right, it also may help bring forward the behaviours that we want as a society—less smoking, and greater use and acceptance of e-cigarettes and novel tobacco products if that serves to reduce smoking rates. (Paragraph 83)

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39 E-cigarettes

Ap

pen

dix

1: A

nal

ysis

of

rep

lies

fro

m E

ng

lish

NH

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enta

l hea

lth

tru

sts

in r

esp

on

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o t

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esti

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sEm

ail s

ent

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alf

of

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] In

th

eir

rep

ort

, Pu

blic

Hea

lth

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gla

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als

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s th

at “

Som

e h

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rust

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ns

hav

e b

ann

ed t

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use

of

EC [

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hic

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ay d

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rop

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atel

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fect

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re d

isad

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tag

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kers

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ld t

her

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re li

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ath

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om

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atis

tics

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ho

w m

enta

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ng

lan

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ith

E-c

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s an

d u

se in

th

eir

faci

litie

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I wo

uld

be

gra

tefu

l if

you

co

uld

pro

vid

e th

e fo

llow

ing

info

rmat

ion

to

th

e C

om

mit

tee:

1. H

ave

you

ban

ned

th

e u

se o

f el

ectr

on

ic c

igar

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s in

yo

ur

faci

litie

s?

2. If

yo

u b

an o

r re

stri

ct t

he

use

of

e-c

igar

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s, d

o y

ou

hav

e an

y p

lan

s to

rev

iew

th

at p

osi

tio

n g

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th

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vice

fro

m P

ub

lic H

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ng

lan

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id y

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co

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th

e h

arm

red

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tial

of

e-c

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s co

mp

ared

to

co

nve

nti

on

al c

igar

ette

s in

yo

ur

dec

isio

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re y

ou

co

nce

rned

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ny

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nd

-han

d h

arm

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by

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po

nse

s fr

om

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sts

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esti

on

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tio

n 4

Cam

den

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d

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gto

n N

HS

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nd

atio

n T

rust

No

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bel

ieve

th

at e

cig

aret

tes

can

be

a va

luab

le a

lter

nat

ive

to s

mo

kin

g t

ob

acco

an

d a

s su

ch h

elp

ful t

o t

ho

se o

n o

ur

in-

pat

ien

t ac

ute

war

ds

and

on

lon

ger

sta

y re

hab

ilita

tio

n w

ard

s b

y re

du

cin

g t

hei

r fr

ust

rati

on

at

no

t b

ein

g a

ble

to

sm

oke

, re

du

cin

g a

sso

ciat

ed a

gg

ress

ion

on

th

e w

ard

s an

d t

he

risk

s o

f h

idd

en s

mo

kin

g a

rtic

les

wh

ich

may

sta

rt fi

res.

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bel

ieve

th

ey m

ay

sup

po

rt in

div

idu

als

in s

top

pin

g s

mo

kin

g

tob

acco

. To

su

pp

ort

th

is w

e ar

e p

rovi

din

g

som

e e

cig

aret

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for

peo

ple

to

try

ou

t an

d if

th

ey fi

nd

th

ey a

re a

n a

ccep

tab

le a

lter

nat

ive

to t

ob

acco

th

en t

hey

can

pu

rch

ase.

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ou

ld b

e o

f h

elp

if s

om

e o

f th

ese

pro

du

cts

cou

ld b

e p

resc

rib

ed in

th

e fu

ture

.

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E-cigarettes 40

NH

S Tr

ust

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esti

on

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tio

n 2

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esti

on

3Q

ues

tio

n 4

No

rth

Eas

t Lo

nd

on

NH

S Fo

un

dat

ion

Tru

st

Yes

Yes

, we

are

curr

entl

y g

oin

g t

hro

ug

h a

p

rocu

rem

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pro

cess

an

d h

ave

iden

tifi

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a ta

mp

er p

roo

f, s

ing

le u

se e

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te t

hat

w

ou

ld b

e ap

pro

pri

ate

for

use

on

ou

r m

enta

l h

ealt

h in

pat

ien

t w

ard

s. W

e h

ave

con

sult

ed

hea

lth

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d s

afet

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lleag

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, ser

vice

use

r g

rou

ps

and

sto

p s

mo

kin

g c

olle

agu

es in

re

ach

ing

th

is d

ecis

ion

.

Yes

, we

did

We

are

and

to

th

at e

nd

pat

ien

ts w

ill b

e ab

le t

o u

se t

hem

in o

pen

/gar

den

are

as

of

war

ds

bu

t n

ot

in r

oo

ms

wh

ere

oth

er

pat

ien

ts w

ou

ld b

e su

bje

cted

to

th

e va

po

ur.

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are

loo

kin

g a

t a

sin

gle

use

ci

gar

ette

to

elim

inat

e th

e ri

sk p

ose

d b

y ch

arg

ing

. We

are

on

ly c

on

sid

erin

g t

amp

er

evid

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e ci

gar

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s to

elim

inat

e th

e ri

sk

of

dru

gs

bei

ng

intr

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uce

d t

o t

he

pro

du

ct.

Ber

ksh

ire

Hea

lth

care

NH

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un

dat

ion

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st

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po

licy

is k

ept

un

der

rev

iew

an

d in

th

e lig

ht

of

the

gro

win

g e

vid

ence

rel

atin

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o

e-c

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s an

d t

he

rece

nt

info

rmat

ion

p

ub

lish

ed b

y Pu

blic

Hea

lth

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gla

nd

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e D

rug

an

d A

lco

ho

l Lea

d a

t Pr

osp

ect

Park

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spit

al

is r

evis

itin

g t

he

po

ssib

ility

of

E-ci

gar

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s as

an

alt

ern

ativ

e fo

rm o

f n

ico

tin

e re

pla

cem

ent.

Sh

e h

as r

ecen

tly

bee

n in

to

uch

wit

h a

Lo

nd

on

Men

tal H

ealt

h t

rust

th

at h

as

succ

essf

ully

intr

od

uce

d E

-cig

aret

tes

and

has

ar

ran

ged

to

go

an

d v

isit

th

is t

rust

(in

Mar

ch)

to s

ee h

ow

th

is is

pra

ctic

ally

imp

lem

ente

d

and

ass

oci

ated

ris

ks

man

aged

. A s

up

plie

r h

as

also

ag

reed

to

sen

d s

om

e sa

mp

les

and

th

ere

are

pla

ns

to u

nd

erta

ke a

fo

cus

gro

up

wit

h

pat

ien

ts.

Wh

en t

he

Smo

ke F

ree

Polic

y w

as fi

rst

intr

od

uce

d, t

he

Tru

st c

on

sid

ered

th

e u

se o

f E-

cig

aret

tes

as a

mea

ns

of

har

m r

edu

ctio

n

as a

n a

lter

nat

ive

to s

mo

kin

g b

ut

at t

he

tim

e as

th

ere

was

litt

le, i

f an

y ev

iden

ce

that

su

pp

ort

ed t

he

use

of

e-c

igar

ette

s as

a

relia

ble

an

d s

afe

alte

rnat

ive

form

of

nic

oti

ne

rep

lace

men

t, a

dec

isio

n w

as m

ade

to b

an t

he

use

of

E-ci

gar

ette

s an

d a

dec

isio

n t

aken

to

o

ffer

oth

er n

ico

tin

e re

pla

cem

ent

op

tio

ns

to

pat

ien

ts a

dm

itte

d t

o t

he

war

ds.

Issu

es r

elat

ing

to

sec

on

d h

and

har

m w

ill

be

con

sid

ered

as

par

t o

f th

e re

view

of

the

Smo

ke F

ree

Polic

y an

d t

he

use

of

E-C

igar

ette

s.

Sou

th L

on

do

n a

nd

M

aud

lsey

NH

S Fo

un

dat

ion

Tru

st

No

. Th

e SL

aM s

mo

ke f

ree

po

licy,

wh

ich

was

la

un

ched

on

1st

Oct

ob

er 2

014

reco

gn

ises

th

e p

ote

nti

al b

enefi

ts f

or

smo

kers

to

be

able

to

use

e-c

igar

ette

s as

par

t o

f th

eir

har

m-r

edu

ctio

n o

r q

uit

pla

n. W

e su

pp

ort

al

l e-c

igar

ette

use

, an

d a

re c

om

mit

ted

to

mak

ing

e-c

igar

ette

s af

ford

able

an

d

acce

ssib

le.

Yes

, ou

r p

olic

y w

as in

form

ed b

y th

e av

aila

ble

ev

iden

ce a

s w

ell a

s co

llab

ora

tio

n w

ith

ou

r se

rvic

e u

ser,

car

er a

nd

sta

ff g

rou

ps–

all w

ere

keen

to

fin

d a

way

to

acc

om

mo

dat

e th

is n

ew

tech

no

log

y.

N/A

No

, bu

t w

e d

o p

lace

wh

at w

e b

elie

ve

to b

e re

aso

nab

le r

estr

icti

on

s o

n w

her

e e

-cig

aret

tes

can

be

use

d w

ith

in t

he

ho

spit

al e

nvi

ron

men

t. F

or

exam

ple

, ou

t o

f re

spec

t fo

r o

ther

s w

e d

o n

ot

sup

po

rt

vap

ing

in s

har

ed s

pac

es (

such

as

din

ing

ar

eas

and

lou

ng

es),

or

in t

her

apeu

tic

sess

ion

s.

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41 E-cigarettes

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Bra

dfo

rd D

istr

ict

Car

e N

HS

Fou

nd

atio

n T

rust

The

use

of

E ci

gs

wit

hin

Bra

dfo

rd D

istr

ict

NH

S C

are

Fou

nd

atio

n T

rust

is c

urr

entl

y u

nd

er

revi

ew. I

nit

ially

ou

r tr

ust

did

no

t su

pp

ort

th

e u

se o

f E

cig

aret

tes

du

e to

us

bei

ng

o

ne

of

the

firs

t tr

ust

s to

go

sm

oke

fre

e.

At

that

po

int

ther

e w

as v

ery

littl

e su

pp

ort

fo

r th

e u

se o

f E

Cig

aret

tes.

Ho

wev

er d

ue

to t

he

curr

ent

advi

ce a

nd

evi

den

ce t

his

is

no

w u

nd

er r

evie

w. T

he

tru

st is

cu

rren

tly

revi

ewin

g t

he

use

of

the

E ci

g a

s a

pla

tfo

rm

to r

edu

ce s

mo

kin

g. T

her

e h

as b

een

a w

ealt

h

of

info

rmat

ion

fro

m p

ub

lic h

ealt

h E

ng

lan

d

reg

ard

ing

th

e u

se o

f el

ectr

on

ic c

igar

ette

s an

d w

e ar

e w

ork

ing

wit

h a

mu

lti-

agen

cy

app

roac

h in

clu

din

g s

top

sm

oki

ng

ser

vice

s re

gar

din

g t

he

use

of

thes

e w

ith

in h

osp

ital

g

rou

nd

s.

Cu

rren

tly

the

tru

st is

rev

iew

ing

its

po

licy

and

is

co

nsu

ltin

g o

n t

he

use

of

e ci

gar

ette

s. A

n

agre

emen

t w

as m

ade

by

the

tru

st w

ou

ld b

e lo

oki

ng

at

e ci

gar

ette

s o

nly

to

be

use

d in

o

pen

sp

aces

, th

is w

ou

ld in

clu

de

cou

rtya

rd

area

s. T

he

tru

st w

ou

ld d

isco

ura

ge

thei

r u

se

in c

on

fin

ed a

nd

ind

oo

r sp

aces

.

The

use

of

e ci

gar

ette

s as

alw

ays

bee

n o

n t

he

fore

fro

nt

of

dec

isio

n m

akin

g, t

her

e h

as b

een

co

nsi

der

able

dis

cuss

ion

aro

un

d t

he

po

ten

tial

b

enefi

ts/ h

arm

in r

elat

ion

to

co

nve

nti

on

al

cig

aret

tes.

Info

rmat

ion

fro

m p

ub

lic h

ealt

h

Eng

lan

d h

as s

up

po

rted

th

e p

ote

nti

al u

se o

f th

em in

red

uci

ng

/ sto

pp

ing

sm

oki

ng

. Th

ere

has

als

o b

een

co

nsi

der

able

deb

ate

of

the

dif

fere

nt

typ

es o

f el

ectr

on

ic c

igar

ette

s, t

hes

e b

ein

g p

re fi

lled

, dis

po

sab

le o

r th

e ta

nk

typ

e ci

gar

ette

s, c

on

cern

s h

ave

bee

n h

igh

ligh

ted

ar

ou

nd

th

e u

se o

f ill

egal

su

bst

ance

s in

th

e re

filla

ble

ele

ctro

nic

cig

aret

te t

ypes

.

Ther

e ar

e co

nce

rns

exp

ress

ed b

y so

me

gro

up

s re

gar

din

g a

ny

po

ten

tial

har

m

fro

m s

eco

nd

han

d v

apo

ur.

Th

ere

con

tin

ues

to

be

revi

ews

into

th

e p

ote

nti

al

har

m o

f th

is. T

he

tru

st d

oes

ack

no

wle

dg

e th

at t

her

e ar

e so

me

con

cern

s an

d t

his

h

as s

up

po

rted

th

e id

ea o

f el

ectr

on

ic

cig

aret

tes

on

ly b

ein

g u

sed

in o

uts

ide

spac

es.

Lan

cash

ire

Car

e N

HS

Fou

nd

atio

n

Tru

st

LCFT

’s n

ico

tin

e m

anag

emen

t p

olic

y al

low

s th

e u

se o

f d

isp

osa

ble

e-c

igar

ette

s b

y se

rvic

e u

sers

on

in-p

atie

nt

war

ds

sub

ject

to

a r

isk

asse

ssm

ent.

Th

is is

bec

ause

alt

ho

ug

h n

ico

tin

e re

pla

cem

ent

ther

apy

(NR

T)

is a

vaila

ble

an

d a

ctiv

ely

pro

mo

ted

, we

reco

gn

ise

that

fo

r so

me

peo

ple

e-c

igar

ette

s ar

e h

elp

ful

in m

anag

ing

th

eir

nic

oti

ne

add

icti

on

an

d

sto

pp

ing

sm

oki

ng

. We

on

ly a

llow

th

e u

se

of

dis

po

sab

le e

-cig

aret

tes

bec

ause

of

the

mis

use

ris

ks

asso

ciat

ed w

ith

refi

llab

le

e-c

igar

ette

s, a

nd

th

e sa

fety

ris

ks

asso

ciat

ed

wit

h b

atte

ry o

per

ated

e-c

igar

ette

s.

E-ci

gar

ette

s ca

nn

ot

be

use

d b

y st

aff

or

visi

tors

. Th

is is

bec

ause

we

do

no

t w

ish

to

re

-n

orm

alis

e sm

oki

ng

in p

ub

lic p

lace

s. A

llow

ing

th

e u

se o

f e

-cig

aret

tes

in p

ub

lic a

reas

wo

uld

al

so m

ake

it h

ard

er t

o im

ple

men

t th

e sm

oke

fr

ee r

equ

irem

ent;

fro

m a

dis

tan

ce it

is h

ard

to

kn

ow

if s

om

eon

e is

sm

oki

ng

a t

ob

acco

ci

gar

ette

or

an e

-cig

aret

te. W

e n

eed

to

mak

e it

eas

y fo

r st

aff

to a

dh

ere

to t

he

po

licy

and

b

ein

g c

lear

th

at s

mo

kin

g b

ehav

iou

r in

an

y p

ub

lic s

pac

e is

no

t al

low

ed d

oes

th

is.

We

con

sid

er o

ur

po

siti

on

to

be

com

pat

ible

w

ith

Pu

blic

Hea

lth

En

gla

nd

’s a

dvi

ce a

nd

re

view

ou

r p

olic

ies

and

pro

ced

ure

s w

hen

n

ew a

dvi

ce o

r g

uid

ance

is p

ub

lish

ed.

The

dec

isio

n t

o a

llow

e-c

igar

ette

use

by

inp

atie

nt

serv

ice

use

rs, s

ub

ject

to

a r

isk

asse

ssm

ent,

was

tak

en f

ollo

win

g; a

su

rvey

of

staf

f an

d s

ervi

ce u

sers

, a p

ilot

of

e-c

igar

ette

u

se in

tw

o a

reas

of

the

tru

st, a

nd

th

e PH

E g

uid

ance

.

This

co

nce

rn, a

nd

a c

on

cern

th

at t

he

lon

g-t

erm

hea

lth

imp

act

of

e-c

igar

ette

s is

un

kno

wn

, was

rai

sed

by

staf

f an

d

serv

ice

use

rs in

th

e su

rvey

. Giv

en P

HE’

s ad

vice

it w

as d

ecid

ed t

o a

llow

th

e u

se

of

dis

po

sab

le e

-cig

aret

tes

for

inp

atie

nt

serv

ice

use

rs s

ub

ject

to

a r

isk

asse

ssm

ent.

Esse

x Pa

rtn

ersh

ip

Un

iver

siti

es N

HS

Tru

st

Yes

ori

gin

ally

as

par

t o

f o

ur

app

roac

h

follo

win

g a

dvi

ce f

rom

Ph

arm

acy.

No

te t

he

form

er S

ou

th E

ssex

Tru

st w

ent

smo

ke f

ree

in 2

009

Yes

we

are

revi

ewin

g a

nd

will

like

ly a

llow

e

cig

aret

tes

in o

ur

revi

sio

n o

f p

olic

yY

es w

e d

id b

ut

was

ori

gin

ally

bas

ed o

n

licen

sin

g a

nd

per

ceiv

ed fi

re r

isk

sN

ot

curr

entl

y as

we

wo

uld

no

t su

pp

ort

w

ith

in o

ur

bu

ildin

g o

nly

ou

tsid

e

EMBARGOED ADVANCE COPY: Not to

be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

Page 46: E-cigarettes - POLITICO€¦ · 1. E-cigarettes and conventional cigarettes are substantially different products. A lit conventional cigarette contains tobacco and produces carbon

E-cigarettes 42

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Bla

ck C

ou

ntr

y Pa

rtn

ersh

ip N

HS

Fou

nd

atio

n T

rust

Elec

tro

nic

Cig

aret

tes

can

on

ly b

e u

sed

in

the

des

ign

ated

sm

oki

ng

sh

elte

rs w

hic

h a

re

situ

ated

ou

tsid

e th

e b

uild

ing

.

We

are

wo

rkin

g t

ow

ard

s a

smo

ke f

ree

Tru

st.

E-ci

gar

ette

s ar

e u

nd

er r

evie

w in

lig

ht

of

this

an

d t

he

advi

ce f

rom

Pu

blic

Hea

lth

En

gla

nd

This

is p

art

of

the

mo

ve t

o a

sm

oke

fre

e Tr

ust

.Th

is is

par

t o

f th

e m

ove

to

a s

mo

ke f

ree

Tru

st.

Ch

esh

ire

and

W

irra

l Par

tner

ship

N

HS

Fou

nd

atio

n

Tru

st

In o

ur

inp

atie

nt

faci

litie

s ye

s, n

ot

in o

ur

com

mu

nit

y se

rvic

es.

We

revi

ew t

his

po

siti

on

sev

eral

tim

es a

yea

r an

d c

on

stan

tly

revi

ew in

form

atio

n r

elat

ing

to

e-c

igar

ette

s.

Yes

Yes

Tees

, Esk

an

d

Wea

r V

alle

y N

HS

Fou

nd

atio

n T

rust

The

Tru

st d

evel

op

ed a

sm

oke

free

Nic

oti

ne

Man

agem

ent

Polic

y (d

ated

Mar

ch 2

016)

in

pre

par

atio

n t

o g

o f

ully

sm

oke

free

on

9

Mar

ch 2

016.

Th

is p

olic

y is

cu

rren

tly

un

der

re

view

bu

t th

e o

rig

inal

ver

sio

n is

att

ach

ed

(ap

pen

dix

1).

TEW

V f

ully

su

pp

ort

th

e u

se o

f al

l mo

del

s o

f e

-cig

aret

tes/

Vap

es T

rust

wid

e ex

cep

t w

ith

in

the

Fore

nsi

c se

rvic

e w

her

e th

e d

ecis

ion

was

ta

ken

no

t to

allo

w t

hes

e d

ue

to t

he

po

ten

tial

ri

sks

for

thei

r in

div

idu

al s

ervi

ce u

sers

. In

th

e o

rig

inal

Po

licy

(Mar

ch 2

016)

bo

th fi

rst

and

se

con

d g

ener

atio

n e

-cig

s/va

pes

wer

e al

low

ed

for

use

bu

t fo

llow

ing

co

nsu

ltat

ion

th

e th

ird

g

ener

atio

n t

ank

mo

del

s w

ere

also

allo

wed

fo

r u

se. A

ll re

char

gea

ble

mo

del

s ar

e al

low

ed

follo

win

g in

div

idu

al r

isk

asse

ssm

ents

. Th

e re

vise

d P

olic

y w

ill r

eflec

t th

is in

form

atio

n. I

n

add

itio

n w

e h

ave

pro

vid

ed e

-cig

aret

te/v

apes

g

uid

ance

fo

r TE

WV

sta

ff (

app

end

ix 2

).

The

Tru

st h

as a

lso

mad

e av

aila

ble

fre

e d

isp

osa

ble

e-c

igar

ette

s to

all

inp

atie

nts

ove

r th

e ag

e o

f 18

yea

rs a

nd

th

e C

risi

s te

am/1

36

Suit

e st

aff

can

als

o a

cces

s th

ese

for

serv

ice

use

rs a

t th

e ea

rlie

st o

pp

ort

un

ity

to h

elp

al

levi

ate

nic

oti

ne

wit

hd

raw

al. T

hes

e h

ave

bee

n w

ell r

ecei

ved

an

d a

re r

ead

ily a

vaila

ble

(o

ther

th

an F

ore

nsi

c se

rvic

e) T

rust

wid

e.

TEW

V c

urr

entl

y h

as n

o r

estr

icti

on

s o

ther

th

an in

th

e Fo

ren

sic

serv

ice.

Th

e Tr

ust

o

rig

inal

ly a

llow

ed t

he

dis

po

sab

le a

nd

re

char

gea

ble

mo

del

s to

be

use

d b

ut

in

Oct

ob

er 2

017

tan

k/r

eser

voir

mo

del

s w

ere

also

ap

pro

ved

fo

r u

se. R

isk

asse

ssm

ents

are

ca

rrie

d o

ut

for

the

rech

arg

eab

le m

od

els.

Th

e Tr

ust

off

er f

ree

dis

po

sab

le e

-cig

aret

tes

on

ad

mis

sio

n a

nd

wo

rk is

on

go

ing

to

loo

k at

th

e p

oss

ibili

ty t

o p

rovi

de

free

rec

har

gea

ble

m

od

els

in t

he

nea

r fu

ture

fo

llow

ing

d

iscu

ssio

n d

uri

ng

th

e N

ico

tin

e M

anag

emen

t St

eeri

ng

Gro

up

in J

anu

ary

2018

.

Yes

, TE

WV

fu

lly c

on

sid

ered

th

e h

arm

re

du

ctio

n p

ote

nti

al h

ence

th

e ch

oic

e to

al

low

th

eir

use

Tru

st w

ide.

Ap

pen

dix

3 is

th

e A

SH 7

15 B

riefi

ng

pap

er w

hic

h w

as o

ne

of

a n

um

ber

of

gu

idan

ce w

hic

h s

up

po

rted

th

e Tr

ust

’s s

tan

ce o

n u

se o

f e

-cig

aret

tes.

Prio

r to

go

ing

sm

oke

free

so

me

war

d

staf

f w

ere

con

cern

ed a

bo

ut

the

sid

e ef

fect

s fr

om

th

e va

pe

in b

edro

om

s. T

he

Nic

oti

ne

Man

agem

ent

team

lin

ked

wit

h

PHE,

FR

ESh

l an

d o

ther

nat

ion

al b

od

ies

to p

rovi

de

any

evid

ence

fo

r st

aff

on

an

y ri

sks

or

con

cern

s w

ith

th

eir

use

. Fo

llow

ing

im

ple

men

tati

on

of

the

Polic

y an

d s

ervi

ce

use

r/st

aff

use

of

e-c

igar

ette

s n

o f

urt

her

st

aff

con

cern

s h

ave

bee

n r

aise

d a

nd

e

-cig

aret

tes

are

op

enly

use

d t

hro

ug

ho

ut

the

Tru

st. E

-cig

aret

tes

can

be

use

d in

si

ng

le o

ccu

pan

cy b

edro

om

s o

r o

uts

ide

bu

t n

ot

in c

om

mu

nal

are

as. T

he

tan

k m

od

els

are

rest

rict

ed t

o u

se o

uts

ide

as

they

hav

e th

e p

ote

nti

al t

o a

ctiv

ate

fire

al

arm

s.

Som

erse

t Pa

rtn

ersh

ip N

HS

Fou

nd

atio

n T

rust

No

. We

are

allo

win

g t

he

use

of

no

n-

rech

arg

eab

le, d

isp

osa

ble

, e-c

igar

ette

s. If

p

atie

nts

are

ad

mit

ted

wit

ho

ut

such

dev

ices

w

e w

ill s

up

ply

a m

axim

um

of

3 e

-cig

aret

tes

free

of

char

ge

if t

he

pat

ien

t d

oes

no

t w

ish

to

use

NR

T

We

hav

e n

ot

ban

ned

e-c

igar

ette

s b

ut

will

re

view

th

e u

se o

f ‘t

ank’

e-c

igar

ette

s as

th

e ev

iden

ce o

f sa

fe u

se is

dev

elo

ped

Yes

Yes

. Wit

h d

isp

osa

ble

e-c

igar

ette

s w

e ar

e aw

are

of

the

po

ten

tial

fo

r th

e b

atte

ries

to

be

ing

este

d. W

ith

‘ta

nk’

e-c

igar

ette

s th

ere

is t

he

po

ten

tial

fo

r o

ther

su

bst

ance

s to

be

smo

ked

.

EMBARGOED ADVANCE COPY: Not to

be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

Page 47: E-cigarettes - POLITICO€¦ · 1. E-cigarettes and conventional cigarettes are substantially different products. A lit conventional cigarette contains tobacco and produces carbon

43 E-cigarettes

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Suss

ex P

artn

ersh

ip

NH

S Fo

un

dat

ion

Tr

ust

No

, we

hav

e n

ot

ban

ned

th

e u

se o

f el

ectr

on

ic c

igar

ette

s in

ou

r fa

cilit

ies.

We

curr

entl

y al

low

firs

t g

ener

atio

n d

isp

osa

ble

m

od

els.

We

are

curr

entl

y re

view

ing

th

is a

nd

th

e p

oss

ibili

ty t

o e

xpan

d t

he

ran

ge

of

e-c

igar

ette

s to

sec

on

d g

ener

atio

n a

nd

ex

plo

rin

g t

he

use

of

rech

arg

eab

le o

nes

, w

hils

t re

cog

nis

ing

th

e n

atio

nal

ale

rt.

Yes

we

did

co

nsi

der

th

e h

arm

red

uci

ng

p

ote

nti

al o

f e

-cig

aret

tes

to c

on

ven

tio

nal

ci

gar

ette

s in

ou

r d

ecis

ion

mak

ing

.

We

hav

e n

o e

vid

ence

to

su

pp

ort

th

is a

t p

rese

nt

bu

t w

e re

mai

n o

pen

an

d c

on

tin

ue

to m

on

ito

r th

is e

vid

ence

an

d g

uid

ance

fr

om

pu

blic

hea

lth

.

Dev

on

Par

tner

ship

N

HS

Fou

nd

atio

n

Tru

st

No

, an

ag

reed

bra

nd

is a

llow

ed in

ou

tsid

e ar

eas

and

bed

roo

ms.

N/A

Yes

Som

e st

aff

hav

e ra

ised

th

is, s

tati

ng

th

at a

s re

sear

ch h

as n

ot

yet

bee

n d

on

e,

we

can

no

t kn

ow

if t

her

e is

a r

isk

of

‘sec

on

dar

y va

pin

g.’

The

e ci

gar

ette

s w

e w

ill a

llow

pro

du

ce v

ery

littl

e va

po

ur.

Der

bys

hir

e H

ealt

hca

re N

HS

Fou

nd

atio

n T

rust

E-ci

gar

ette

s h

ave

bee

n b

ann

ed f

or

use

by

pat

ien

ts a

nd

als

o b

y vi

sito

rs o

n o

ur

gro

un

ds.

Th

e in

itia

l dec

isio

n w

as t

aken

ow

ing

to

la

ck o

f ev

iden

ce r

egar

din

g t

he

lon

ger

ter

m

effe

cts

and

mo

re im

po

rtan

tly

the

po

ten

tial

ri

sk t

o m

enta

l hea

lth

pat

ien

ts. T

he

latt

er

is o

win

g t

o t

he

po

ten

tial

alt

ern

ativ

e u

ses

of

the

flu

ids

or

ind

eed

th

e p

rod

uct

itse

lf

reg

ard

ing

sel

f-h

arm

or

har

m t

o o

ther

peo

ple

. H

ow

ever

, fo

llow

ing

ext

ensi

ve b

ench

mar

kin

g

and

fee

db

ack

fro

m p

atie

nts

an

d s

taff

we

hav

e re

cen

tly

com

men

ced

a t

rial

of

e-b

urn

ers

wh

ich

are

sin

gle

use

e-c

igar

ette

s w

hic

h d

o

no

t h

ave

to b

e re

char

ged

an

d h

ave

pro

ved

le

ss o

f a

risk

to

MH

pat

ien

ts. T

hes

e h

ave

succ

essf

ully

bee

n in

tro

du

ced

in a

nu

mb

er o

f M

H H

osp

ital

s an

d s

ecu

re u

nit

s. A

s th

e tr

ial

on

ly c

om

men

ced

aft

er C

hri

stm

as it

is t

oo

ea

rly

to a

sses

s th

e su

cces

s o

r o

ther

wis

e.

E-b

urn

ers

are

clas

sed

as

nic

oti

ne

rep

lace

men

t b

y PH

an

d t

his

was

par

t o

f th

e d

ecis

ion

to

in

tro

du

ce t

hem

.

Yes

–mai

nly

har

m t

o s

taff

fro

m a

git

ated

p

atie

nts

. Als

o f

eed

bac

k fr

om

sta

ff a

nd

p

atie

nts

.

Too

ear

ly t

o r

evie

w. W

e ar

e o

nly

allo

win

g

the

e-b

urn

ers

to b

e u

sed

ou

tsid

e an

d N

OT

on

war

ds

or

oth

er e

ncl

ose

d s

pac

es.

No

rfo

lk a

nd

Su

ffo

lk N

HS

Fou

nd

atio

n T

rust

No

, we

are

enco

ura

gin

g t

he

use

of

e-c

igar

ette

s as

an

alt

ern

ativ

e to

bu

rnt

tob

acco

on

th

e p

rem

ises

bu

t o

utd

oo

rs

We

un

der

stan

d a

nd

su

pp

ort

PH

E p

osi

tio

n

that

e-c

igar

ette

s ar

e 95

% s

afer

th

an b

urn

t to

bac

co

We

do

, th

at’s

wh

y w

e su

pp

ort

use

of

e-c

igar

ette

sW

e ar

e n

ot

allo

win

g u

se o

f e

-cig

aret

tes

ind

oo

rs f

or

this

rea

son

, un

til t

he

hea

lth

ri

sks

are

bet

ter

un

der

sto

od

EMBARGOED ADVANCE COPY: Not to

be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

Page 48: E-cigarettes - POLITICO€¦ · 1. E-cigarettes and conventional cigarettes are substantially different products. A lit conventional cigarette contains tobacco and produces carbon

E-cigarettes 44

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Co

ven

try

and

W

arw

ick

shir

e Pa

rtn

ersh

ip N

HS

Fou

nd

atio

n T

rust

Smo

kin

g t

ob

acco

is n

ot

per

mit

ted

in a

ny

par

t o

f an

y Tr

ust

pro

per

ty. A

s th

e Tr

ust

is a

no

sm

oki

ng

org

anis

atio

n s

taff

are

no

t al

low

ed

to s

mo

ke o

r va

pe

e-c

igar

ette

s d

uri

ng

pai

d

wo

rkin

g t

ime.

Th

eref

ore

sta

ff a

re n

ot

per

mit

ted

to

vap

e e

-cig

aret

tes

on

Tru

st

pro

per

ty (

insi

de

or

ou

tsid

e in

ou

r g

rou

nd

s).

This

res

tric

tio

n a

lso

ap

plie

s to

ou

t-p

atie

nts

an

d v

isit

ors

.

We

do

allo

w e

-cig

aret

tes

for

in-p

atie

nts

w

ho

are

res

ista

nt

to “

Qu

it”

or

nic

oti

ne

rep

lace

men

t th

erap

y [N

RT

] p

rod

uct

s, in

lin

e w

ith

th

e Tr

ust

’s N

RT

gu

idan

ce. T

he

use

o

f e

-cig

aret

tes

is p

erm

itte

d f

or

ou

r m

enta

l h

ealt

h in

-pat

ien

ts in

th

e g

ard

ens

/ fre

sh a

ir

area

s, a

nd

, fo

llow

ing

clin

ical

ris

k as

sess

men

t an

d c

are

pla

n, t

he

pat

ien

t’s

ow

n b

edro

om

. A

pp

rop

riat

e ar

eas

are

iden

tifi

ed lo

cally

.

We

hav

e n

o p

lan

s to

rev

iew

sta

ff u

se o

f e

-cig

aret

tes

wit

hin

tru

st p

rop

erti

es (

eith

er

insi

de

or

ou

tsid

e). W

e h

ave

rece

ntl

y re

view

ed

and

re

-co

nfi

rmed

ou

r st

ance

on

ban

nin

g

refi

llab

le r

e-u

sab

le e

-cig

aret

te’s

by

in-

pat

ien

ts.

Yes

. Th

ere

wer

e in

itia

l eth

ical

an

d s

afet

y co

nce

rns

abo

ut

allo

win

g p

atie

nts

acc

ess

to a

nd

th

e u

se o

f e

-cig

aret

tes

wit

hin

ou

r se

rvic

es. T

hes

e w

ere

deb

ated

as

par

t o

f ag

reei

ng

ou

r ab

ove

po

siti

on

. We

con

sid

ered

th

e h

arm

red

uct

ion

po

ten

tial

to

ou

t-w

eig

h

any

po

ten

tial

har

m.

Yes

. Du

e to

co

nce

rns

abo

ut

“sec

on

d

han

d”

e-c

igar

ette

vap

ou

r an

d a

lso

bei

ng

se

en t

o n

orm

alis

e th

e sm

oki

ng

of

tob

acco

, u

se o

f e

-cig

aret

te’s

was

res

tric

ted

to

o

uts

ide

op

en d

efin

ed s

pac

es o

r a

pat

ien

t’s

ow

n-b

edro

om

(al

l ou

r b

edro

om

s ar

e si

ng

le o

ccu

pan

cy).

No

rth

amp

ton

shir

e H

ealt

hca

re N

HS

Fou

nd

atio

n T

rust

No

. Th

e Tr

ust

dec

isio

n w

as t

o p

erm

it t

he

use

o

f E-

cig

aret

tes

and

vap

es, s

ub

ject

to

a r

isk

asse

ssm

ent.

Vap

es a

nd

E-c

igar

ette

s ar

e o

nly

p

erm

itte

d in

th

e g

ard

en a

reas

. We

hav

e a

sup

ply

of

dis

po

sab

le E

-cig

aret

tes

on

eac

h

war

d a

vaila

ble

to

pat

ien

ts f

or

the

firs

t 4

8 h

ou

rs o

f ad

mis

sio

n. P

atie

nts

can

bri

ng

in

thei

r o

wn

E-c

igar

ette

s o

r va

pes

.

We

hav

e n

ot

ban

ned

th

em, b

ut

ou

r d

ecis

ion

to

per

mit

th

eir

use

will

be

revi

ewed

p

erio

dic

ally

.

Yes

we

did

, ad

dit

ion

ally

we

con

sid

ered

th

e fa

ct t

hat

th

ey a

re “

the

nex

t b

est

thin

g”

and

w

ou

ld h

elp

pat

ien

t w

ho

are

str

ug

glin

g w

ith

n

ico

tin

e w

ith

dra

wal

.

The

po

ten

tial

fo

r se

con

d-h

and

har

m

has

bee

n c

on

sid

ered

, th

e Tr

ust

to

ok

the

dec

isio

n t

o a

llow

th

eir

use

on

th

e b

asis

th

at if

evi

den

ce is

rel

ease

d t

hat

su

gg

ests

d

etri

men

tal s

eco

nd

-han

d h

arm

th

e d

ecis

ion

will

be

revi

ewed

.

Sou

th

Staf

ford

shir

e an

d S

hro

psh

ire

Hea

lth

care

NH

S Fo

un

dat

ion

Tru

st

Yes

, un

til D

ecem

ber

201

7–n

ow

per

mit

ted

in

des

ign

ated

are

as o

nly

Posi

tio

n r

evie

wed

in 2

017,

fo

llow

ing

PH

E p

osi

tio

n c

han

ge

Yes

No

–ap

art

fro

m s

taff

/pat

ien

ts p

refe

ren

ce

and

imp

act

on

sm

ell o

f p

rod

uct

s

2get

her

NH

S Fo

un

dat

ion

Tru

stN

o. E

-cig

aret

tes

can

be

use

d in

ou

tsid

e sp

aces

on

ly; h

ow

ever

, we

may

co

nsi

der

ch

ang

ing

th

e p

olic

y in

du

e co

urs

e.

We

do

no

t b

an t

he

use

of

e-c

igar

ette

s;

ho

wev

er, o

ur

po

licy

is u

nd

er c

on

stan

t re

view

Yes

we

did

, usi

ng

wh

at in

form

atio

n t

her

e w

as a

vaila

ble

at

the

tim

e.

We

are

awar

e th

at e

-cig

aret

tes

del

iver

a

hig

her

leve

l of

nic

oti

ne

com

par

ed t

o

con

ven

tio

nal

NR

T p

rod

uct

s, a

nd

th

is f

avo

urs

o

ur

clie

nt

gro

up

du

e to

th

eir

hea

vy s

mo

kin

g

leve

ls.

We

wo

uld

co

nsi

der

an

y ad

vice

fro

m

Pub

lic H

ealt

h E

ng

lan

d. C

urr

entl

y w

e ad

voca

te t

he

use

du

e to

th

e d

ram

atic

ally

re

du

ced

ris

k o

f e

-cig

aret

tes

com

par

ed t

o

con

ven

tio

nal

cig

aret

tes.

The

situ

atio

n is

bei

ng

co

nst

antl

y re

view

ed.

Sou

th W

est

Yo

rksh

ire

Part

ner

ship

NH

S Fo

un

dat

ion

Tru

st

Ou

r cu

rren

t p

olic

y fo

r a

smo

ke-f

ree

envi

ron

men

t d

oes

incl

ud

e a

ban

on

th

e u

se

of

elec

tro

nic

cig

aret

tes

in o

ur

faci

litie

s.

The

po

licy

is c

urr

entl

y u

nd

er r

evie

w a

nd

d

ue

to b

e am

end

ed b

y Ju

ne

2018

. Th

is w

ill

spec

ifica

lly t

ake

into

acc

ou

nt

the

advi

ce f

rom

Pu

blic

hea

lth

En

gla

nd

We

will

be

con

sid

erin

g t

he

har

m r

edu

ctio

n

po

ten

tial

of

e-c

igar

ette

s in

th

e fo

rmu

lati

on

o

f o

ur

up

dat

ed p

olic

y.

Ther

e ar

e co

nsi

der

able

co

nce

rns

abo

ut

the

po

ten

tial

fo

r se

con

d-h

and

har

m

cau

sed

by

e-c

igar

ette

s an

d t

hes

e w

ill

nee

d t

o b

e m

itig

ated

ag

ain

st w

ith

in o

ur

up

dat

ed p

olic

y.

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be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

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45 E-cigarettes

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Leic

este

rsh

ire

Part

ner

ship

NH

S Tr

ust

We

allo

w t

he

use

of

elec

tro

nic

cig

aret

tes

wit

hin

des

ign

ated

are

as b

oth

insi

de

and

o

uts

ide

faci

litie

s.

We

are

con

tin

ual

ly r

evie

win

g t

he

use

of

e-c

igar

ette

s w

ith

in o

ur

faci

litie

sY

esN

o–c

urr

ent

evid

ence

do

es n

ot

sug

ges

t th

at t

her

e is

an

y se

con

d h

and

har

m.

Leed

s an

d Y

ork

Pa

rtn

ersh

ip N

HS

Fou

nd

atio

n T

rust

Cu

rren

tly

e-c

igar

ette

s ar

e n

ot

ban

ned

bu

t th

ere

is d

esig

nat

ed o

uts

ide

area

s fo

r p

atie

nts

an

d t

he

use

of

e-c

igar

ette

s. T

his

is w

ith

in t

he

con

text

of

hea

lth

pro

mo

tio

nal

ad

vice

an

d

the

off

er o

f n

ico

tin

e re

pla

cem

ent

ther

apy.

The

app

roac

h t

o im

pro

vin

g p

hys

ical

hea

lth

o

f m

enta

l hea

lth

pat

ien

ts is

un

der

co

nst

ant

revi

ew a

nd

th

e u

se o

f e

-cig

aret

tes

will

be

par

t o

f th

at; s

ee r

esp

on

se t

o q

ues

tio

n 1

–we

do

no

t cu

rren

tly

ban

.

Yes

This

will

be

kep

t u

nd

er r

evie

w a

s fu

rth

er

evid

ence

bec

om

es a

vaila

ble

on

sec

on

d-

han

d h

arm

bu

t is

mit

igat

ed b

y th

e d

esig

nat

ed s

mo

kin

g a

reas

bei

ng

ou

tsid

e at

pre

sen

t.

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be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

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E-cigarettes 46

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Cen

tral

an

d N

ort

h

Wes

t Lo

nd

on

NH

S Fo

un

dat

ion

Tru

st

No

, we

hav

e n

ot

ban

ned

th

em. S

ervi

ce u

sers

ar

e ab

le t

o u

se e

-cig

aret

tes

that

are

of

the

dis

po

sab

le, n

on

-rec

har

gea

ble

var

iety

in t

hei

r ro

om

s an

d o

uts

ide.

Ho

wev

er, w

e d

o r

estr

ict

thei

r u

se–w

e as

k th

at t

hey

are

no

t u

sed

in

com

mu

nal

are

as a

s so

me

serv

ice

use

rs a

nd

st

aff

hav

e o

bje

cted

to

pas

sive

inh

alat

ion

of

vap

ou

r.

We

hav

e re

cen

tly

revi

ewed

th

e Tr

ust

’s

po

siti

on

an

d h

ave

agre

ed t

hat

e-c

igar

ette

ve

nd

ing

mac

hin

es a

re t

o b

e p

rovi

ded

in in

-p

atie

nt

faci

litie

s. S

ervi

ce u

sers

will

be

able

to

pu

rch

ase

e-c

igar

ette

s if

th

ey s

o c

ho

ose

. Th

e re

view

of

the

use

of

e-c

igar

ette

s h

as

bee

n o

ng

oin

g o

ver

a co

nsi

der

able

per

iod

of

tim

e, a

s ev

iden

ce h

as b

een

mad

e av

aila

ble

. Th

e Pu

blic

Hea

lth

En

gla

nd

gu

idan

ce w

as

par

t o

f th

at e

vid

ence

, bu

t w

e w

ere

alre

ady

revi

ewin

g t

he

Tru

st p

osi

tio

n p

rio

r to

its

pu

blic

atio

n.

Alt

ho

ug

h e

-cig

aret

tes

are

pu

blic

ised

as

less

h

arm

ful t

han

cig

aret

tes,

th

ere

are

gap

s in

th

e ev

iden

ce b

ase

aro

un

d lo

ng

-ter

m b

enefi

ts

and

har

ms

wh

ich

sh

ou

ld b

e ad

dre

ssed

wh

en

enco

ura

gin

g t

hei

r u

se w

ith

th

e g

ener

al

pu

blic

.

In li

ne

wit

h N

ICE

gu

idan

ce, t

hat

lice

nse

d

nic

oti

ne

con

tain

ing

pro

du

cts

sho

uld

be

use

d

pri

mar

ily f

or

tho

se w

ish

ing

to

sto

p s

mo

kin

g,

e-c

igar

ette

s sh

ou

ld n

ot

be

reco

mm

end

ed a

s th

ese

are

no

t ye

t lic

ense

d w

ith

th

e M

edic

ines

an

d H

ealt

hca

re p

rod

uct

s R

egu

lato

ry A

gen

cy.

This

is a

sit

uat

ion

th

at w

ill c

han

ge

this

ye

ar a

nd

th

e Tr

ust

will

fu

lly r

evie

w t

he

use

o

f e

-cig

aret

tes

on

ce a

lice

nse

d p

rod

uct

is

avai

lab

le.

It is

rec

og

nis

ed t

hat

pat

ien

ts w

ith

men

tal

hea

lth

pro

ble

ms

suff

er d

isp

rop

ort

ion

atel

y h

igh

leve

ls o

f h

arm

fro

m s

mo

kin

g a

nd

hav

e lo

w q

uit

rat

es o

n s

tan

dar

d s

mo

kin

g c

essa

tio

n

app

roac

hes

. Tra

nsi

tio

n t

o e

-cig

aret

tes

may

b

e o

f b

enefi

t fo

r th

is g

rou

p, a

nd

sh

ou

ld b

e ac

tive

ly e

nco

ura

ged

as

on

e p

art

of

a h

arm

re

du

ctio

n a

pp

roac

h. T

his

sh

ou

ld b

e ai

med

p

arti

cula

rly

at t

ho

se w

ho

hav

e tr

ied

an

d

faile

d e

xist

ing

ap

pro

ach

es in

clu

din

g N

RT

and

o

ther

sm

oki

ng

ces

sati

on

med

icat

ion

s, o

r ar

e u

nw

illin

g t

o t

ry t

hem

.

We

advi

se t

hat

pre

scri

pti

on

of

Nic

oti

ne

Rep

lace

men

t Th

erap

y (N

RT

) o

r m

edic

atio

n

such

as

Var

enic

line,

plu

s p

sych

olo

gic

al

sup

po

rt, i

s th

e p

refe

rred

firs

t ch

oic

e o

f tr

eatm

ent

for

nic

oti

ne

add

icti

on

/su

pp

ort

ing

sm

oke

rs in

a s

mo

ke-f

ree

envi

ron

men

t.

Ho

wev

er, w

e re

cog

nis

e th

at m

any

fin

d

e-c

igar

ette

s h

elp

ful a

nd

un

der

stan

d t

hat

, if

peo

ple

ch

oo

se t

o u

se t

hem

, th

ey a

re li

kely

to

b

e le

ss h

arm

ful t

han

co

nve

nti

on

al c

igar

ette

s (t

he

smo

ke f

rom

wh

ich

co

nta

ins

tar

and

m

any

toxi

ns)

.

Stro

ng

vie

ws

are

hel

d b

y b

oth

sta

ff a

nd

se

rvic

e u

sers

. Wh

ilst

smo

kers

fin

d t

hem

a

use

ful o

pti

on

, oth

ers

hav

e ex

pre

ssed

co

nce

rns

abo

ut

the

risk

s o

f p

assi

ve

inh

alat

ion

an

d a

dve

rse

pu

blic

ity

- th

ere

hav

e b

een

man

y co

nfl

icti

ng

art

icle

s in

th

e m

edia

ab

ou

t co

nd

itio

ns

said

to

po

ssib

ly

be

cau

sed

or

exac

erb

ated

by

e-c

igar

ette

va

po

ur

(eg

‘po

pco

rn lu

ng

’). T

his

res

ult

s in

co

nfu

sio

n. I

n o

ur

op

inio

n t

he

mai

n

con

cern

is t

he

effe

cts

of

usi

ng

of

foo

d

flav

ou

rin

gs

in v

apo

rise

d f

orm

to

en

ter

the

lun

g. T

his

is s

om

eth

ing

wh

ich

litt

le is

kn

ow

n a

bo

ut

and

rep

rese

nts

th

e la

rges

t p

ote

nti

al r

isk

fro

m ‘p

assi

ve v

apin

g’ i

n o

ur

op

inio

n.

The

Tru

st s

tan

ce is

th

at if

a s

ervi

ce u

ser

cho

ose

s to

use

e-c

igar

ette

s to

qu

it/

abst

ain

fro

m t

hei

r sm

oki

ng

hab

it, t

hey

sh

ou

ld b

e en

cou

rag

ed t

o u

se t

hem

as

a to

ol,

rath

er t

han

mer

ely

as a

rep

lace

men

t,

and

be

sup

po

rted

to

gra

du

ally

wea

n

them

selv

es o

ff e

-cig

aret

tes.

EMBARGOED ADVANCE COPY: Not to

be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

Page 51: E-cigarettes - POLITICO€¦ · 1. E-cigarettes and conventional cigarettes are substantially different products. A lit conventional cigarette contains tobacco and produces carbon

47 E-cigarettes

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Surr

ey a

nd

B

ord

ers

Part

ner

ship

NH

S Fo

un

dat

ion

Tru

st

We

hav

e n

ot

ban

ned

th

e u

se o

f e

-cig

aret

tes

bu

t o

ur

po

licy

is a

bo

ut

ban

nin

g a

ll u

se

of

tob

acco

pro

du

cts

on

ou

r p

rem

ises

. We

actu

ally

pro

vid

e e

-lit

es f

or

free

fo

r o

ur

inp

atie

nts

as

par

t o

f th

e ce

ssat

ion

pro

cess

.

N/A

Yes

th

is is

was

fu

lly c

on

sid

ered

wh

en

des

ign

ing

ou

r C

are

2qu

it p

rog

ram

me

and

d

ecid

ed t

o n

ot

ban

e-c

igar

ette

s, b

ut

to f

ocu

s o

n t

he

ban

nin

g o

f to

bac

co p

rod

uct

s an

d

thei

r u

se o

n o

ur

pre

mis

es. W

e al

so e

nsu

red

th

at p

eop

le h

ad s

uffi

cien

t ac

cess

to

NR

T an

d

full

scre

enin

g w

as t

akin

g p

lace

on

ad

mis

sio

n

to e

nsu

re t

hat

all

peo

ple

wh

o s

mo

ke r

ecei

ve

bri

ef a

dvi

ce o

n q

uit

tin

g a

nd

su

pp

ort

wh

ere

req

uir

ed.

Yes

we

revi

ewed

th

is a

nd

th

e an

xiet

ies

abo

ut

po

ssib

le u

nkn

ow

n r

isk

s to

bo

th

staf

f an

d p

eop

le u

sin

g s

ervi

ces

and

as

a re

sult

we

ban

ned

th

e u

se o

f e

-cig

aret

tes

in c

om

mu

nal

are

as o

r in

war

d s

leep

ing

b

ays.

Peo

ple

are

on

ly p

erm

itte

d t

o u

se

thes

e in

th

eir

sin

gle

bed

roo

ms

and

/or

gar

den

s. W

e al

so c

on

sid

ered

th

e ri

sk o

f th

e va

pin

g s

mo

ke a

ctiv

atin

g fi

re a

larm

s an

d w

e to

ok

step

s to

mit

igat

e th

ese

Wes

t Lo

nd

on

M

enta

l Hea

lth

N

HS

Tru

st

No

. Ho

wev

er, w

e h

ave

ban

ned

ele

ctro

nic

ci

gar

ette

s p

urc

has

ed o

uts

ide

of

the

un

it

du

e to

po

ten

tial

fire

ris

ks

and

th

e in

abili

ty

to m

on

ito

r th

e co

nte

nts

of

them

. We

sell

a b

ran

d o

f el

ectr

on

ic c

igar

ette

th

at h

as b

een

ac

cep

ted

as

‘saf

e’. I

n t

wo

sit

es t

hes

e ar

e so

ld

fro

m a

ven

din

g m

ach

ine,

in o

ne

furt

her

sit

e th

ey a

re s

old

dir

ectl

y fr

om

th

e w

ard

s.

We

curr

entl

y h

ave

no

pla

ns

to b

an o

r re

stri

ct

the

use

of

app

rove

d E

-cig

aret

tes

sold

on

-si

te. T

he

ECig

s w

e se

ll o

n s

ite

are

sold

fo

r £3

w

hic

h is

co

nsi

der

ably

ch

eap

er t

han

ret

ail

sho

ps

on

th

e h

igh

str

eet.

Cu

rren

tly

we

do

n

ot

hav

e an

y p

lan

s to

allo

w o

ther

Eci

gs

du

e to

th

e p

ote

nti

al fi

re r

isk

s an

d t

he

inab

ility

to

m

on

ito

r th

e co

nte

nts

of

them

.

Yes

we

did

. Hen

ce, t

he

acti

ve p

rom

oti

on

of

ECig

s in

ad

dit

ion

to

a r

ang

e o

f N

RT

pro

du

cts

wh

en t

he

Tru

st im

ple

men

ted

th

e sm

oke

-fre

e p

olic

y in

Jan

uar

y 20

16. P

rio

r to

intr

od

uci

ng

a

tru

st w

ide

ban

on

sm

oki

ng

we

mad

e th

e d

ecis

ion

to

allo

w t

he

use

of

elec

tro

nic

ci

gar

ette

s (n

ot

in w

ard

s co

mm

un

al a

reas

) as

a

har

m r

edu

ctio

n in

terv

enti

on

. In

ad

dit

ion

w

e p

ut

in p

lace

a c

om

pre

hen

sive

sm

oki

ng

ce

ssat

ion

str

ateg

y an

d in

terv

enti

on

s.

Res

earc

h h

as s

o f

ar s

ho

wn

th

e p

ote

nti

al

seco

nd

han

d h

arm

is m

inim

al. H

ow

ever

, w

e en

cou

rag

e th

ese

to o

nly

be

use

d in

th

e p

atie

nt’

s o

wn

bed

roo

m t

o m

inim

ise

any

dis

com

fort

or

har

m t

o o

ther

pat

ien

ts,

staf

f an

d v

isit

ors

. Giv

en c

urr

ent

evid

ence

an

d t

he

fact

th

at e

lect

ron

ic c

igar

ette

s ca

nn

ot

be

use

d in

co

mm

un

al a

reas

we

do

no

t h

ave

any

sig

nifi

can

t co

nce

rns

reg

ard

ing

sec

on

d-h

and

har

m c

ause

d b

y el

ectr

on

ic c

igar

ette

s.

Co

rnw

all

Part

ner

ship

NH

S Fo

un

dat

ion

Tru

st

Yes

We

are

curr

entl

y re

view

ing

ou

r p

olic

yY

esY

es

Bar

net

, En

fiel

d

and

Har

ing

ey

Men

tal H

ealt

h

NH

S Tr

ust

No

, we

hav

e ac

tive

ly e

nco

ura

ged

th

em a

s p

art

of

sup

po

rtin

g o

ur

smo

kefr

ee p

olic

y si

nce

17.

1.17

(an

d s

ince

201

5 in

ou

r fo

ren

sic

un

it)

and

hav

e p

rovi

ded

th

em t

o s

ervi

ce

use

rs o

urs

elve

s in

em

erg

ency

(in

ad

dit

ion

to

p

rovi

din

g N

RT

in a

ran

ge

of

form

s); i

n o

ther

ci

rcu

mst

ance

s w

e m

ake

it p

oss

ible

fo

r th

em

to p

urc

has

e e

-cig

aret

tes

on

ho

spit

al p

rem

ises

o

r en

cou

rag

e re

lati

ves

to b

rin

g t

hem

in.

We

also

en

cou

rag

e th

e u

se o

f va

pes

on

ou

r p

rem

ises

, no

tin

g t

hat

dis

po

sab

le e

-cig

aret

tes

are

no

t su

ffici

ent

for

all s

ervi

ce u

sers

to

hel

p

them

to

man

age

wit

ho

ut

cig

aret

tes.

Pro

toco

l at

tach

ed. W

e h

ave

no

ted

th

ou

gh

th

at v

apes

ca

n s

et o

ff s

mo

ke a

larm

s in

co

nfi

ned

sp

aces

o

r w

hen

use

d d

elib

erat

ely

to d

o s

o, s

o w

e h

ave

had

to

lim

it t

hei

r u

se in

cer

tain

war

d

area

s.

N/A

Yes

as

abo

veN

ot

real

ly. A

few

peo

ple

hav

e ra

ised

it,

bo

th o

n h

ealt

h a

nd

nu

isan

ce g

rou

nd

s b

ut

mai

nly

du

e to

th

e fi

re a

larm

issu

e. B

ut

we

sup

po

rt w

ard

man

ager

s to

lim

it v

ape

use

in a

reas

wh

ere

it c

ause

s a

nu

isan

ce.

This

has

no

t p

reve

nte

d w

ides

pre

ad u

se o

f e

-cig

aret

tes.

EMBARGOED ADVANCE COPY: Not to

be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

Page 52: E-cigarettes - POLITICO€¦ · 1. E-cigarettes and conventional cigarettes are substantially different products. A lit conventional cigarette contains tobacco and produces carbon

E-cigarettes 48

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Avo

n a

nd

W

iltsh

ire

Men

tal H

ealt

h

Part

ner

ship

NH

S Tr

ust

We

hav

e im

ple

men

ted

a s

mo

ke f

ree

po

licy.

Pa

tien

ts a

nd

sta

ff a

re n

ot

per

mit

ted

to

sm

oke

insi

de

the

bu

ildin

gs.

Ser

vice

use

rs

can

use

ap

pro

ved

eB

urn

s an

d V

apes

in t

he

gro

un

ds

away

fro

m t

he

war

d.

The

Tru

st c

on

tin

ual

ly r

evie

ws

imp

lem

enta

tio

n o

f th

e p

olic

y in

clu

din

g t

he

rece

nt

advi

ce f

rom

PH

E. W

e al

so n

eed

to

co

nsi

der

oth

er f

acto

rs w

hic

h w

ou

ld r

equ

ire

the

rep

lace

men

t o

f o

ur

curr

ent

fire

det

ecti

on

sy

stem

s if

eB

urn

an

d V

apin

g w

ere

to b

e p

erm

itte

d in

sid

e.

The

risk

an

d b

enefi

ts w

ere

con

sid

ered

in

pre

par

ing

th

e cu

rren

t p

olic

yTh

e Tr

ust

is c

on

cern

ed r

egar

din

g

seco

nd

-han

d h

arm

incl

ud

ing

th

e n

eed

s o

f n

on

-sm

oke

rs in

rel

atio

n t

o t

he

smo

ke

fro

m v

apes

. We

will

co

nti

nu

e to

mo

nit

or

the

emer

gin

g e

vid

ence

reg

ard

ing

th

e u

se

of

thes

e d

evic

es a

nd

ad

op

t b

est

pra

ctic

e w

her

ever

po

ssib

le.

No

rth

Wes

t B

oro

ug

hs

Hea

lth

care

NH

S Fo

un

dat

ion

Tru

st

Wh

en t

he

Tru

st o

rig

inal

ly c

om

mit

ted

to

b

eco

min

g s

mo

kefr

ee in

th

e su

mm

er o

f 20

16, a

dec

isio

n w

as m

ade

to n

ot

allo

w

elec

tro

nic

cig

aret

tes

wit

hin

ou

r m

enta

l h

ealt

h in

pat

ien

t u

nit

s. A

t th

e ti

me,

th

ere

wer

e co

nce

rns

reg

ard

ing

th

e sa

fety

of

thes

e d

evic

es a

nd

th

e p

ote

nti

al a

sso

ciat

ed r

isk

s fo

r p

atie

nts

an

d s

taff

. Th

eref

ore

at

this

p

oin

t, t

hey

wer

e n

ot

incl

ud

ed w

ith

in t

he

po

licy

as a

tre

atm

ent

op

tio

n. H

ow

ever

a

furt

her

rev

iew

was

un

der

take

n 1

2 m

on

ths

late

r as

loca

l in

telli

gen

ce a

nd

pat

ien

t/ca

rer

feed

bac

k su

gg

este

d a

dem

and

fo

r th

ese

pro

du

cts,

as

man

y p

atie

nts

has

use

d t

hem

b

efo

re a

dm

issi

on

. Th

e lic

ense

d N

ico

tin

e R

epla

cem

ent

Ther

apy

pro

du

cts

wer

e n

ot

acce

pte

d b

y al

l pat

ien

ts, s

o w

e lo

oke

d a

t th

e le

ast

rest

rict

ive

pra

ctic

e in

rel

atio

n t

o

pro

visi

on

of

nic

oti

ne

rep

laci

ng

pro

du

cts

for

men

tal h

ealt

h in

-pat

ien

ts w

ith

in t

he

Tru

st.

Wit

h t

he

ben

efit

of

shar

ed e

xper

ien

ces

fro

m

oth

er T

rust

s an

d t

akin

g in

to c

on

sid

erat

ion

th

e ev

iden

ce r

evie

w (

McN

eill

et a

l, 20

15)

com

mis

sio

ned

by

Pub

lic H

ealt

h E

ng

lan

d,

a d

ecis

ion

was

tak

en t

o a

llow

on

e sp

ecifi

c b

ran

d o

f d

isp

osa

ble

e-c

igar

ette

s as

a

nic

oti

ne

dep

end

ency

tre

atm

ent

op

tio

n.

We

com

men

ced

pro

vid

ing

th

e ch

oic

e o

f N

ico

tin

e R

epla

cem

ent

Ther

apy

or

dis

po

sab

le

e-c

igar

ette

s in

Dec

emb

er 2

017.

We

do

allo

w t

he

use

of

e-c

igar

ette

s as

o

utl

ined

in q

ues

tio

n 1

an

d h

ave

seen

in

crea

sed

co

mp

lian

ce w

ith

ou

r sm

oke

fre

e p

olic

y as

a r

esu

lt.

Yes

. We

also

to

ok

into

co

nsi

der

atio

n t

he

revi

ew o

f u

nd

erp

inn

ing

evi

den

ce (

McN

eill

et a

l, 20

15)

com

mis

sio

ned

by

Pub

lic H

ealt

h

Eng

lan

d.

Yes

. We

will

co

nti

nu

e to

mo

nit

or

this

an

d

ensu

re w

e d

eliv

er o

ur

serv

ices

in li

ne

wit

h

nat

ion

al e

vid

ence

bas

e an

d b

est

pra

ctic

e.

EMBARGOED ADVANCE COPY: Not to

be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

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49 E-cigarettes

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Ken

t an

d M

edw

ay

NH

S an

d S

oci

al

Car

e Pa

rtn

ersh

ip

Tru

st

(Ext

ract

s fr

om

th

eir

smo

kefr

ee

po

licy)

On

ly d

isp

osa

ble

dev

ices

wit

h p

refi

lled

ca

rtri

dg

es m

ay b

e u

sed

(se

e A

pp

end

ix B

).

Rec

har

gea

ble

dev

ices

of

this

typ

e ar

e n

ot

per

mit

ted

du

e to

th

e ri

sks

asso

ciat

ed w

ith

ch

arg

ing

. E-c

igar

ette

use

is o

nly

per

mit

ted

fo

r p

atie

nts

, vis

ito

rs a

nd

co

ntr

acto

rs in

d

esig

nat

ed a

reas

e.g

. ho

spit

al g

rou

nd

s an

d

cou

rtya

rds,

bu

t n

ot

in c

om

mu

nal

ind

oo

r ar

eas

or

bed

roo

ms.

N/A

E-ci

gar

ette

s ar

e b

atte

ry p

ow

ered

dev

ices

th

at d

eliv

er n

ico

tin

e vi

a in

hal

ed v

apo

r.

Sin

ce e

- ci

gar

ette

s d

o n

ot

con

tain

to

bac

co

and

are

no

t b

urn

t, t

hey

do

no

t re

sult

in

the

inh

alat

ion

of

cig

aret

te s

mo

ke t

hey

are

th

eref

ore

reg

ard

ed b

y m

ost

exp

erts

as

mu

ch

safe

r d

eliv

ery

dev

ices

fo

r n

ico

tin

e. T

his

do

es

no

t m

ean

th

at t

hey

are

co

mp

lete

ly s

afe,

bu

t th

ey a

re e

nvi

sag

ed t

o b

e m

uch

less

har

mfu

l th

an c

igar

ette

s.

E-ci

gar

ette

use

sh

ou

ld o

nly

be

per

mit

ted

in

dis

cret

e p

lace

s an

d n

ever

be

per

mit

ted

in

are

as w

her

e p

atie

nts

an

d s

taff

co

ng

reg

ate.

Mer

sey

Car

e N

HS

Fou

nd

atio

n T

rust

We

hav

e n

ot

ban

ned

th

e u

se o

f e

-cig

aret

tes

and

are

fo

llow

ing

th

e ad

vice

fro

m P

HE

and

th

e C

QC

ab

ou

t th

eir

ben

efits

to

su

pp

ort

se

rvic

e u

sers

wh

o a

re d

epen

den

t o

n n

ico

tin

e.

E-ci

gar

ette

s ar

e in

th

e re

per

toir

e o

f N

ico

tin

e R

epla

cem

ent

Ther

apie

s w

e su

pp

ort

fo

r th

e p

eop

le w

ho

use

ou

r se

rvic

es.

We

hav

e cu

rren

tly

ban

ned

th

e u

se o

f e

-cig

aret

tes

in o

ur

Hig

h S

ecu

re S

ervi

ce,

wh

ich

is c

on

sist

ent

wit

h t

he

oth

er t

wo

HSS

Tr

ust

s. H

ow

ever

, we

are

mee

tin

g t

o r

evie

w

this

dec

isio

n t

o c

lari

fy t

he

clin

ical

, ris

k an

d/o

r se

curi

ty g

rou

nd

s w

hic

h in

form

th

is d

ecis

ion

. W

e m

ay a

lso

rev

iew

th

e d

ecis

ion

in t

he

ligh

t o

f se

rvic

e u

sers

’ exp

erie

nce

in u

sin

g

e-c

igar

ette

s in

ou

r m

ediu

m a

nd

low

sec

ure

se

rvic

es o

r if

oth

er a

pp

rop

riat

e p

rod

uct

s b

eco

me

avai

lab

le.

The

Tru

st c

on

sid

ered

, an

d is

su

pp

ort

ive

of,

th

e h

arm

red

uci

ng

po

ten

tial

of

e-c

igar

ette

s an

d r

eco

gn

ises

th

ey m

ay b

e o

f as

sist

ance

to

en

able

so

me

smo

kers

to

mo

ve a

way

fro

m

usi

ng

har

mfu

l bu

rnt

tob

acco

to

war

ds

a cl

ean

er f

orm

of

nic

oti

ne

del

iver

y, a

nd

may

u

ltim

atel

y h

elp

th

em t

o g

ive

up

sm

oki

ng

in

the

lon

ger

ter

m if

th

ey m

ake

this

dec

isio

n.

In a

dd

itio

n, t

he

Tru

st s

tro

ng

ly s

up

po

rts

serv

ice

use

rs’ c

ho

ice

and

pre

fere

nce

s in

th

eir

reco

very

, an

d o

ur

serv

ice

use

rs in

form

ed

us

that

hav

ing

e-c

igar

ette

s as

an

ava

ilab

le

op

tio

n w

ou

ld a

llow

th

em t

o m

ake

po

siti

ve

imp

rove

men

ts in

bo

th t

hei

r p

hys

ical

an

d

psy

cho

log

ical

wel

l-b

ein

g. W

e co

nsi

der

co

llab

ora

tio

n a

nd

ch

oic

e to

be

an e

ssen

tial

co

mp

on

ent

of

ou

r le

ast

rest

rict

ive

and

co

-p

rod

uce

d a

pp

roac

h t

o c

are

wit

hin

th

e Tr

ust

.

The

Tru

st w

ill c

on

tin

ue

to r

evie

w it

s p

osi

tio

n o

n e

-cig

aret

tes,

incl

ud

ing

if

any

risk

s ar

e id

enti

fied

in f

utu

re a

s n

ew

evid

ence

an

d g

uid

ance

em

erg

es. T

his

w

ill in

clu

de

reg

ula

r re

view

s, a

s it

wo

uld

an

y o

ther

new

asp

ect

of

pra

ctic

e an

d

care

, to

en

sure

th

e Tr

ust

, its

sta

ff a

nd

th

e p

eop

le w

e se

rve

are

kep

t fu

lly in

form

ed

by

con

tem

po

rary

fin

din

gs

and

saf

ety

info

rmat

ion

so

th

at w

e co

nti

nu

e to

su

pp

ort

bes

t p

ract

ice

and

saf

e ca

re in

th

is

dev

elo

pin

g a

rea.

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ed in

full,

or in part

,

in any f

orm befo

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018

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E-cigarettes 50

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Do

rset

Hea

lth

care

U

niv

ersi

ty N

HS

Fou

nd

atio

n T

rust

No

N/A

Yes

We

bel

ieve

th

e p

ote

nti

al f

or

har

m

red

uct

ion

th

rou

gh

su

pp

ort

ing

th

e u

se o

f e

-cig

aret

tes

to f

ar o

utw

eig

h a

ny

con

cern

s re

gar

din

g e

xpo

sure

to

sec

on

dh

and

va

po

ur.

Th

e N

CSC

T’s

Elec

tro

nic

cig

aret

tes

bri

efin

g in

dic

ates

th

at “

som

e st

ud

ies

hav

e fo

un

d t

race

s o

f to

xica

nts

in

seco

nd

han

d v

apo

ur,

bu

t at

su

ch lo

w

leve

ls t

hat

th

ey d

o n

ot

po

se a

hea

lth

ri

sk t

o b

ysta

nd

ers.

Th

ere

is n

o e

vid

ence

th

at s

eco

nd

han

d v

apo

ur

is d

ang

ero

us

to

oth

ers;

ho

wev

er, i

t h

elp

s to

be

resp

ectf

ul

wh

en u

sin

g e

-cig

aret

tes

aro

un

d o

ther

s,

esp

ecia

lly n

on

-sm

oke

rs.”

We

hav

e ta

ken

th

is e

vid

ence

into

co

nsi

der

atio

n in

ou

r sm

oke

free

po

licy.

We

do

ask

ou

r p

atie

nts

an

d s

taff

no

t to

use

e-c

igar

ette

s in

co

mm

un

al s

pac

es li

mit

ing

su

ch e

xpo

sure

an

d n

orm

alis

atio

n o

f th

eir

use

.

Sou

ther

n H

ealt

h

NH

S Fo

un

dat

ion

Tr

ust

No

, we

enco

ura

ge

thei

r u

se.

We

on

ly r

estr

ict

the

use

of

som

e m

od

els

of

e-c

igar

ette

fo

r re

aso

ns

of

fire

saf

ety.

Yes

, bas

ed o

n s

tro

ng

res

earc

h e

vid

ence

of

har

m r

edu

ctio

n.

No

, bu

t w

e d

isco

ura

ge

use

in s

har

ed a

reas

so

as

to n

ot

affe

ct o

ther

s at

all.

Tavi

sto

ck a

nd

Po

rtm

an N

HS

Fou

nd

atio

n T

rust

Yes

we

hav

e b

ann

ed t

he

use

of

elec

tro

nic

ci

gar

ette

s in

ou

r fa

cilit

ies

afte

r ca

refu

l co

nsi

der

atio

n. W

e ar

e an

ou

t -p

atie

nt

faci

lity

and

th

e m

ajo

rity

of

ou

r p

atie

nts

are

ch

ildre

n,

you

ng

peo

ple

an

d f

amili

es. O

ur

pat

ien

ts a

re

on

ou

r p

rem

ises

fo

r sh

ort

per

iod

s to

att

end

o

ut

-pat

ien

t ap

po

intm

ents

. We

ban

ned

th

e u

se o

f el

ectr

on

ic c

igar

ette

s as

we

did

no

t w

ish

ou

r yo

un

g p

atie

nts

an

d f

amili

es t

o s

ee

pat

ien

ts, s

taff

or

visi

tors

usi

ng

an

y fo

rm o

f ci

gar

ette

wh

ich

mig

ht

imp

ly o

ur

con

do

nin

g

this

beh

avio

ur

Yes

, ou

r sm

oke

fre

e p

olic

y (M

ay 2

017)

will

b

e re

view

ed in

May

201

8 o

n t

he

bas

is o

f an

up

dat

ed r

evie

w o

f cu

rren

t ev

iden

ce

incl

ud

ing

PH

E ad

vice

.

Yes

, we

did

an

d w

e en

cou

rag

e an

d s

up

po

rt

staf

f an

d p

atie

nts

to

tak

e u

p in

terv

enti

on

s to

sto

p o

r re

du

ce s

mo

kin

g t

ob

acco

th

rou

gh

ap

pro

pri

ate

mea

ns

incl

ud

ing

sw

itch

ing

to

el

ectr

on

ic c

igar

ette

s as

a s

ub

stan

tial

ly s

afer

al

tern

ativ

e fo

r w

hen

th

ey a

re n

ot

on

Tru

st

pre

mis

es.

Yes

.

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ed in

full,

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,

in any f

orm befo

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. on Frid

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018

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51 E-cigarettes

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

No

ttin

gh

amsh

ire

Hea

lth

care

NH

S Fo

un

dat

ion

Tru

st

Staf

f an

d v

isit

ors

–yes

.

Pati

ents

–Yes

in t

he

Tru

st’s

Fo

ren

sic

Serv

ice

Div

isio

n

No

in t

he

Tru

st’s

Lo

cal P

artn

ersh

ip D

ivis

ion

(i

n-p

atie

nt

men

tal h

ealt

h u

nit

s]. U

se is

re

stri

cted

to

just

on

e ty

pe

of

dis

po

sab

le

e-c

igar

ette

cal

led

E-b

urn

du

e to

un

iqu

e sa

fety

fea

ture

s an

d t

he

fact

th

at n

um

ero

us

oth

er T

rust

s an

d s

om

e p

riso

ns

are

allo

win

g

thei

r u

se.

Yes

ou

r p

osi

tio

n w

ill b

e u

nd

er c

on

stan

t re

view

an

d d

ecis

ion

s w

ill b

e m

ade

acco

rdin

g

to g

uid

ance

an

d t

he

emer

gin

g e

vid

ence

-b

ase.

Yes

We

are

gu

ided

by

PHE

advi

ce, 2

016

“th

e co

nst

itu

ents

of

cig

aret

te s

mo

ke t

hat

h

arm

hea

lth

–in

clu

din

g c

arci

no

gen

s–ar

e ei

ther

ab

sen

t in

e-c

igar

ette

vap

ou

r o

r, if

p

rese

nt,

th

ey a

re m

ost

ly a

t le

vels

mu

ch

low

er t

han

5%

of

smo

kin

g d

ose

(m

ost

ly

bel

ow

1%

an

d f

ar b

elo

w s

afet

y lim

its

for

occ

up

atio

nal

exp

osu

re)”

Cam

bri

dg

esh

ire

and

Pet

erb

oro

ug

h

NH

S Fo

un

dat

ion

Tr

ust

In o

ur

faci

litie

s w

e d

o n

ot

per

mit

th

e u

se o

f el

ectr

on

ic c

igar

ette

s in

do

ors

. We

do

allo

w

the

use

of

elec

tro

nic

cig

aret

tes

amo

ng

se

rvic

e u

sers

in w

ard

gar

den

s an

d a

llow

st

aff

mem

ber

s to

use

ele

ctro

nic

cig

aret

tes

ou

tdo

ors

du

rin

g b

reak

tim

es.

On

1 O

cto

ber

201

7 C

PFT

ban

ned

sm

oki

ng

an

d t

he

use

of

all e

lect

ron

ic c

igar

ette

s an

d

vap

ori

sers

on

ou

r p

rem

ises

. Th

is p

olic

y w

as

amen

ded

in D

ecem

ber

201

7 to

allo

w f

or

the

use

of

elec

tro

nic

cig

aret

tes

and

vap

ori

sers

in

ou

tdo

or

area

s in

lig

ht

of

feed

bac

k fr

om

st

aff

on

ou

r w

ard

s. T

he

dec

isio

n t

o a

llow

th

e u

se o

f el

ectr

on

ic c

igar

ette

s an

d v

apo

rise

rs in

o

utd

oo

r ar

eas

was

refl

ecti

ve o

f th

e ev

iden

ce

and

rec

om

men

dat

ion

s p

rese

ntl

y av

aila

ble

fr

om

Pu

blic

Hea

lth

En

gla

nd

. Th

e C

PFT

Smo

ke

Free

po

licy

will

be

mo

nit

ore

d a

nd

am

end

ed

as a

dd

itio

nal

evi

den

ce b

eco

mes

ava

ilab

le.

The

har

m r

edu

ctio

n p

ote

nti

al o

f el

ectr

on

ic

cig

aret

tes

was

a f

acto

r in

ou

r d

ecis

ion

to

al

low

ele

ctro

nic

cig

aret

tes

and

vap

ori

sers

on

o

ur

gro

un

ds.

As

no

ted

ab

ove

, th

e Tr

ust

will

co

nti

nu

ally

mo

nit

or

ou

r Sm

oke

Fre

e Po

licy

as

add

itio

nal

evi

den

ce b

eco

mes

ava

ilab

le f

rom

Pu

blic

Hea

lth

En

gla

nd

aro

un

d t

he

risk

s an

d

ben

efits

of

elec

tro

nic

cig

aret

te u

se.

At

the

mo

men

t th

ere

is n

o e

vid

ence

to

su

gg

est

that

ele

ctro

nic

cig

aret

tes

or

vap

ori

sers

cau

se h

arm

to

no

n-u

sers

. As

we

hav

e re

stri

cted

th

e u

se o

f el

ectr

on

ic

cig

aret

tes

and

vap

ori

sers

to

ou

tdo

or

area

s o

nly

we

do

no

t cu

rren

tly

hav

e an

y co

nce

rns

aro

un

d t

he

po

ten

tial

fo

r se

con

dar

y h

arm

to

ser

vice

use

rs o

r st

aff.

W

e w

elco

me

up

dat

es f

rom

Pu

blic

Hea

lth

En

gla

nd

aro

un

d t

he

seco

nd

-han

d r

isk

s o

f el

ectr

on

ic c

igar

ette

s as

res

earc

h in

th

is

fiel

d p

rog

ress

es.

Sou

th W

est

Lon

do

n a

nd

St

Geo

rge’

s M

enta

l H

ealt

h N

HS

Tru

st

SWLS

TG N

HS

Tru

st h

as a

do

pte

d a

n in

teri

m

E-ci

gar

ette

Pro

toco

l to

su

pp

ort

pat

ien

ts

to m

anag

e th

eir

nic

oti

ne

dep

end

ence

w

hils

t h

osp

ital

ised

. Pat

ien

ts w

ish

ing

to

u

se e

-cig

aret

tes

as p

art

of

thei

r n

ico

tin

e m

anag

emen

t p

rog

ram

me

can

bri

ng

/pu

rch

ase

the

bra

nd

of

thei

r ch

oic

e as

lon

g a

s th

ose

are

d

isp

osa

ble

an

d n

on

-rec

har

gea

ble

e-c

igar

ette

d

evic

es. P

atie

nts

are

allo

wed

to

use

e

-cig

aret

tes

in d

esig

nat

ed a

reas

of

the

war

ds

i.e. t

hei

r in

div

idu

al b

edro

om

s an

d c

ou

rtya

rds

bu

t sh

ou

ld r

efra

in f

rom

vap

ing

at

ind

oo

r co

mm

un

al a

reas

. Th

e p

roto

col p

roh

ibit

s th

e u

se o

f e

-cig

aret

tes

in a

ny

oth

er a

reas

of

the

Tru

st g

rou

nd

s an

d/o

r b

uild

ing

s. E

-cig

aret

tes

use

by

ou

tpat

ien

ts, s

taff

an

d v

isit

ors

is

curr

entl

y p

roh

ibit

ed a

cro

ss T

rust

pre

mis

es.

We

are

curr

entl

y re

view

ing

ou

r ex

isti

ng

e

-cig

aret

te p

roto

col t

o e

nsu

re t

hat

it

is in

lin

e w

ith

th

e n

ew P

HE

and

NIC

E re

com

men

dat

ion

s. H

ow

ever

, we

also

tak

e in

to c

on

sid

erat

ion

th

e n

eed

s an

d v

iew

s o

f o

ur

serv

ice

use

rs, c

arer

s an

d s

taff

.

Des

pit

e th

e lim

ited

evi

den

ce o

n t

he

lon

g

term

hea

lth

eff

ects

of

e-c

igar

ette

s, t

her

e’s

bee

n s

om

e ev

iden

ce t

hat

vap

ing

is 9

5% le

ss

har

mfu

l th

an s

mo

kin

g. O

ur

inp

atie

nts

are

b

ein

g p

rofe

ssio

nal

ly s

up

po

rted

to

man

age

thei

r n

ico

tin

e d

epen

den

ce w

ith

th

e m

eth

od

o

f th

eir

cho

ice

wh

eth

er t

his

is N

RT

or

dis

po

sab

le e

-cig

aret

tes.

We

com

bin

e ei

ther

m

eth

od

wit

h b

ehav

iou

ral s

up

po

rt.

We

hav

e co

nsi

der

ed t

he

very

few

ev

iden

ce o

f th

e ef

fect

s o

f se

con

d-h

and

va

pin

g o

n b

ysta

nd

ers

wh

ich

do

es n

ot

sup

po

rt t

his

po

ssib

ility

bu

t al

so d

oes

no

t en

tire

ly d

ism

iss

the

po

ten

tial

eff

ects

. H

ence

, ou

r b

alan

ced

dec

isio

n t

o a

llow

th

e u

se o

f e

-cig

aret

tes

in o

pen

-air

are

as i.

e.

cou

rtya

rds

bu

t n

ot

in c

om

mu

nal

ind

oo

r ro

om

s.

EMBARGOED ADVANCE COPY: Not to

be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

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E-cigarettes 52

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Bir

min

gh

am a

nd

So

ilhu

ll M

enta

l H

ealt

h N

HS

Fou

nd

atio

n T

rust

E-ci

gar

ette

s u

se o

r ‘v

apin

g’ m

ust

occ

ur

on

ly

ou

tsid

e, a

t n

o t

ime

insi

de

any

bu

ildin

gs.

This

[e

-cig

aret

te p

olic

y] is

cu

rren

tly

un

der

a

revi

ew w

ith

ou

r Sm

oki

ng

Ste

erin

g G

rou

p.

The

e-c

igar

ette

sec

tio

n is

par

t o

f th

at r

evie

w

and

in p

arti

cula

r th

e d

isp

osa

ble

an

d r

e-

char

gea

ble

item

s.

Yes

Yes

Lin

coln

shir

e Pa

rtn

ersh

ip N

HS

Fou

nd

atio

n T

rust

In li

ne

wit

h L

inco

lnsh

ire

Part

ner

ship

NH

S Fo

un

dat

ion

Tru

st (

LPFT

) Sm

oke

Fre

e Pr

emis

es

Polic

y (a

ttac

hed

), w

e ad

her

e to

th

e fo

llow

ing

g

uid

ance

:

Res

tric

tio

ns

on

usa

ge

of

e-c

igar

ette

s o

n L

PFT

Tru

st P

rem

ises

• E-

cig

aret

tes

can

on

ly b

e u

sed

in o

uts

ide

area

s aw

ay f

rom

exi

ts a

nd

en

tran

ces.

Th

ey

sho

uld

no

t b

e u

sed

in p

roxi

mit

y to

oth

er

peo

ple

wh

o c

ho

ose

no

t to

use

th

em.

• E-

cig

aret

tes

sho

uld

on

ly b

e re

char

ged

usi

ng

ap

pro

ved

dev

ices

an

d m

eth

od

s. R

ech

arg

ing

sh

ou

ld b

e u

nd

er t

he

sup

ervi

sio

n o

f st

aff

wit

hin

a s

pec

ific

des

ign

ated

saf

e ch

arg

ing

ar

ea a

way

fro

m s

ou

rces

of

ign

itio

n a

nd

ac

cele

ran

ts s

uch

as

oxy

gen

su

pp

lies.

On

ce

rech

arg

ing

is c

om

ple

te t

he

dev

ice

sho

uld

be

pro

mp

tly

dis

con

nec

ted

an

d r

etu

rned

to

saf

e st

ora

ge.

• St

aff

sho

uld

be

awar

e th

at fi

re r

isk

s w

hils

t re

char

gin

g e

-cig

aret

tes

rela

te la

rgel

y to

:-

- U

se o

f in

corr

ect

or

mal

fun

ctio

nin

g c

har

ger

- B

atte

ry d

efec

ts o

r o

vert

igh

ten

ing

of

the

bat

tery

- O

verc

har

gin

g o

f th

e p

rod

uct

.

• E-

cig

aret

tes

con

tain

bat

teri

es a

nd

mu

st b

e d

isp

ose

d o

f in

a d

esig

nat

ed b

in a

s el

ectr

on

ic

was

te.

LPFT

has

no

t b

ann

ed E

-cig

aret

tes.

Ou

r cu

rren

t LP

FT S

mo

ke F

ree

Prem

ises

Po

licy

is s

ched

ule

d f

or

revi

ew in

Ju

ne

/Ju

ly 2

018.

W

e w

ill r

eap

pra

ise

ou

r p

osi

tio

n a

t th

is

tim

e, t

akin

g in

to a

cco

un

t PH

E g

uid

ance

an

d w

e w

ill c

on

tin

ue

to w

ork

clo

sely

wit

h

ou

r ex

per

ts b

y ex

per

ien

ce, c

arer

s an

d s

taff

to

en

sure

ou

r p

olic

ies

are

evid

ence

bas

ed,

rob

ust

an

d u

sab

le.

Ou

r vi

sio

n a

t LP

FT is

to

mak

e a

dif

fere

nce

to

th

e liv

es o

f p

eop

le w

ith

men

tal h

ealt

h

and

lear

nin

g d

isab

iliti

es. T

o p

rom

ote

re

cove

ry a

nd

qu

alit

y o

f lif

e th

rou

gh

ef

fect

ive,

inn

ova

tive

an

d c

arin

g s

ervi

ces.

W

e en

cou

rag

e sm

oki

ng

ces

sati

on

an

d h

arm

re

du

ctio

n t

hro

ug

h t

he

use

an

d a

vaila

bili

ty

of

nic

oti

ne

rep

lace

men

t th

erap

y. W

e su

pp

ort

th

e u

se o

f E-

cig

aret

tes

rath

er t

han

co

nve

nti

on

al c

igar

ette

s.

The

evid

ence

bas

e is

sti

ll lim

ited

an

d

pro

du

cts

are

chan

gin

g r

apid

ly. A

t LP

FT w

e su

pp

ort

th

e b

elie

f th

at E

-cig

aret

tes

are

less

har

mfu

l th

an c

on

ven

tio

nal

cig

aret

tes

and

we

will

su

pp

ort

ou

r p

atie

nts

at

ever

y st

age

of

thei

r sm

oki

ng

ces

sati

on

jou

rney

.

EMBARGOED ADVANCE COPY: Not to

be publish

ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

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53 E-cigarettes

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Oxf

ord

Hea

lth

N

HS

Fou

nd

atio

n

Tru

st

We

hav

e b

ann

ed t

hem

on

ou

r in

pat

ien

t w

ard

s at

th

e m

om

ent.

We

hav

e re

view

ed t

his

dec

isio

n–i

n li

gh

t o

f th

e ad

vice

an

d n

ew p

rod

uct

s th

at a

re n

ow

av

aila

ble

. Pla

n is

th

at w

e w

ill p

ilot

use

wit

h

a p

arti

cula

r b

ran

d o

f e

cig

aret

tes.

We

are

wo

rkin

g w

ith

pat

ien

ts o

n t

his

pilo

t. T

he

Pilo

t w

ill b

e ac

tive

wit

hin

th

e n

ext

cou

ple

of

mo

nth

s w

ith

sh

ort

cyc

le b

efo

re r

olli

ng

ou

t ac

ross

all

inp

atie

nt

area

s.

Wh

en t

he

init

ial d

ecis

ion

was

mad

e to

ban

e

-cig

aret

tes

ther

e w

as n

o g

uid

ance

ava

ilab

le.

At

the

tim

e th

ere

was

co

nce

rn a

bo

ut

safe

ty

of

the

mo

del

s av

aila

ble

.

Ho

wev

er w

ith

th

e in

tro

du

ctio

n o

f sa

fe

mo

del

s to

use

on

war

ds,

th

e ad

vice

fro

m

pu

blic

hea

lth

an

d t

he

fact

th

at o

ur

pat

ien

ts

are

aski

ng

fo

r th

em h

as m

ean

t th

at w

e h

ave

revi

site

d o

ur

dec

isio

n a

nd

are

ab

ou

t to

em

bar

k o

n a

sh

ort

pilo

t in

on

e o

f o

ur

low

se

cure

war

ds

wit

h t

he

aim

to

ro

ll o

ut

acro

ss

all s

ervi

ces.

Smo

kin

g c

essa

tio

n—

enco

ura

gin

g t

hei

r u

se a

s a

pro

ven

aid

to

sto

p s

mo

kin

g.

We

do

no

t b

elie

ve t

hat

th

ere

will

be

an

incr

easi

ng

ris

k o

f se

con

d h

and

har

m t

o

pat

ien

ts b

y u

se o

f e

-cig

aret

tes.

They

are

haz

ard

ou

s w

aste

an

d n

eed

to

be

dis

po

sed

of

safe

ly b

ut

we

hav

e p

lan

s in

p

lace

to

en

sure

th

at t

his

hap

pen

s.

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ed in

full,

or in part

,

in any f

orm befo

re 00

.01 a.m

. on Frid

ay 17

August 2

018

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E-cigarettes 54

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

Pen

nin

e C

are

NH

S Fo

un

dat

ion

Tru

stTh

e Tr

ust

do

es n

ot

hav

e a

ban

on

th

e u

se

of

elec

tro

nic

cig

aret

tes,

th

ey a

re h

ow

ever

re

stri

cted

. Th

ey c

ann

ot

curr

entl

y b

e u

sed

in

sid

e Tr

ust

Bu

ildin

gs.

Th

is in

clu

des

Inp

atie

nt

war

ds.

The

Tru

st is

cu

rren

tly

con

sid

erin

g it

s p

osi

tio

n

on

th

e u

se o

f e

-cig

aret

tes,

par

ticu

larl

y w

ith

re

gar

d t

o t

he

imp

lem

enta

tio

n o

f Sm

oke

Fr

ee N

HS.

Th

is is

bo

th in

th

e lig

ht

of

the

advi

ce p

rovi

ded

fro

m P

HE

and

als

o a

s a

resu

lt

of

the

shar

ed le

arn

ing

fro

m a

nu

mb

er o

f Tr

ust

s w

ho

are

su

cces

sfu

lly m

anag

ing

th

e u

se o

f e

-cig

aret

tes.

Ad

dit

ion

ally

, th

e Tr

ust

h

as s

ecu

red

su

pp

ort

fro

m t

hes

e Tr

ust

s in

th

e re

view

ing

of

ou

r p

osi

tio

n. T

his

incl

ud

es

Tru

sts

wh

o h

ave

succ

essf

ully

man

aged

th

is

for

men

tal h

ealt

h in

pat

ien

t fa

cilit

ies.

Th

e ad

vice

an

d in

form

atio

n f

rom

PH

E to

get

her

w

ith

th

e sh

ared

lear

nin

g f

rom

th

ese

exam

ple

s o

f su

cces

sfu

l im

ple

men

tati

on

w

ill c

on

trib

ute

to

th

e Tr

ust

’s r

evie

w o

f it

’s

po

siti

on

wit

h r

egar

d t

o e

-cig

aret

tes.

Th

e co

llati

on

of

this

info

rmat

ion

fo

r B

oar

d le

vel

dis

cuss

ion

s w

ith

reg

ard

to

th

e w

ay f

orw

ard

is

curr

entl

y b

ein

g p

rep

ared

.

The

Tru

st c

on

sid

ered

th

is in

fo

rmu

lati

ng

o

ur

init

ial d

ecis

ion

s, h

ow

ever

at

that

tim

e th

e p

ictu

re w

ith

reg

ard

to

a w

ider

var

iety

o

f as

soci

ated

ris

ks

was

sig

nifi

can

tly

less

cl

ear

than

it n

ow

is. G

enu

ine

con

sid

erat

ion

s su

ch a

s fi

re/c

har

ger

saf

ety

and

un

reg

ula

ted

p

rod

uct

s w

ere

also

co

nsi

der

ed t

og

eth

er w

ith

th

e u

nkn

ow

n lo

ng

er-t

erm

ris

ks

of

e-c

igar

ette

u

se. A

s n

ew a

nd

rel

iab

le in

form

atio

n a

nd

ex

per

ien

ce h

as n

ow

bee

n m

ade

avai

lab

le,

the

Tru

st is

in a

go

od

po

siti

on

to

co

nsi

der

ou

r cu

rren

t ap

pro

ach

. Th

e h

ealt

h h

arm

red

uct

ion

b

enefi

ts o

f e

-cig

aret

tes

for

ind

ivid

ual

s o

ver

tob

acco

cig

aret

tes

are

no

w e

xplic

itly

cle

ar.

The

PHE

advi

ce a

nd

info

rmat

ion

wit

h r

egar

d

to t

his

has

bee

n v

ery

hel

pfu

l. A

dd

itio

nal

ly,

man

y o

f th

e o

ther

po

ten

tial

ris

ks

are

far

bet

ter

un

der

sto

od

no

w. T

he

Tru

st f

eels

th

is

giv

es u

s an

exc

elle

nt

bas

e fr

om

wh

ich

to

co

nsi

der

an

d u

pd

ate

ou

r ap

pro

ach

wh

ere

app

rop

riat

e.

The

Tru

st c

on

sid

ered

an

y an

d a

ll p

ote

nti

al

risk

s w

hen

dev

elo

pin

g it

’s o

rig

inal

p

osi

tio

n w

ith

reg

ard

to

th

e u

se o

f e

-cig

aret

tes.

Th

is in

clu

ded

an

y p

ote

nti

al

seco

nd

-han

d h

arm

an

d t

ang

enti

al

con

seq

uen

ces

(no

t o

nly

hea

lth

rel

ated

).

The

Tru

st w

ill in

clu

de

any

up

dat

ed

kno

wle

dg

e an

d in

form

atio

n r

egar

din

g

thes

e co

nsi

der

atio

ns

as p

art

of

the

revi

ew

of

ou

r p

osi

tio

n.

Ou

r u

nd

erst

and

ing

of

the

curr

ent

info

rmat

ion

an

d k

no

wle

dg

e av

aila

ble

is

th

at t

her

e is

no

t st

ron

g e

vid

ence

of

sig

nifi

can

t h

ealt

h h

arm

s fr

om

sec

on

dar

y ‘s

mo

ke’ a

s it

is v

apo

ur

and

is n

ot

pro

du

ced

fro

m a

to

bac

co p

rod

uct

, no

r is

it

ign

ited

as

such

.

We

are

awar

e h

ow

ever

of

issu

es s

uch

as

larg

e cl

ou

ds

of

stro

ng

sm

ellin

g v

apo

ur

bei

ng

un

ple

asan

t fo

r so

me

peo

ple

an

d

po

ssib

ly d

istr

essi

ng

to

so

me

peo

ple

un

der

so

me

circ

um

stan

ces.

We

are

also

aw

are

of

the

po

ten

tial

em

erg

ence

of

seco

nd

ary

mar

kets

as

soci

ated

wit

h e

-cig

aret

tes

(as

ther

e is

wit

h t

ob

acco

cig

aret

tes)

. Th

e Tr

ust

w

ill r

emai

n v

igila

nt

wit

h r

egar

d t

o t

his

, p

arti

cula

rly

wit

h o

ur

mo

re v

uln

erab

le

po

pu

lati

on

s.

We

also

rem

ain

vig

ilan

t ab

ou

t th

e p

oss

ibili

ty o

f e

-cig

aret

tes

bei

ng

im

plic

ated

in fi

re s

etti

ng

(d

elib

erat

e o

r ac

cid

enta

l) a

nd

th

e ve

ry o

bvi

ou

s se

con

d-h

and

har

m t

hat

co

uld

bri

ng

. We

are

awar

e h

ow

ever

of

the

sig

nifi

can

tly

incr

ease

d s

afet

y p

rofi

le o

f th

ese

dev

ices

n

ow

ove

r ea

rlie

r, u

nre

gu

late

d m

od

els.

Shef

fiel

d H

ealt

h

and

So

cial

Car

e N

HS

Fou

nd

atio

n

Tru

st

No

, we

per

mit

th

ese

wit

hin

ou

r sm

oke

-fre

e p

olic

yN

/AY

es, t

his

is w

hy

we

allo

w t

hem

We

on

ly a

llow

ou

tdo

or

use

; an

y se

con

d

han

d h

arm

is li

kely

to

be

smal

l by

com

par

iso

n w

ith

eit

her

th

e d

irec

t o

r se

con

d h

and

eff

ects

of

actu

al s

mo

ke

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55 E-cigarettes

NH

S Tr

ust

Qu

esti

on

1Q

ues

tio

n 2

Qu

esti

on

3Q

ues

tio

n 4

No

rth

um

ber

lan

d,

Tyn

e an

d W

ear

NH

S Fo

un

dat

ion

Tr

ust

No

, sel

ecte

d e

cig

aret

tes

are

allo

wed

NT

W h

as a

lrea

dy

agre

ed t

o s

up

ply

a li

mit

ed

nu

mb

er o

f e

-cig

aret

tes

on

ad

mis

sio

n a

nd

al

low

pu

rch

ase

in h

osp

ital

sh

op

s th

erea

fter

. W

e ar

e m

od

ifyi

ng

ou

r p

olic

y an

d p

roce

du

res

acco

rdin

gly

.

Yes

We

wis

h t

o a

void

no

n-s

mo

kers

bei

ng

ex

po

sed

to

nic

oti

ne

vap

ou

r so

will

res

tric

t va

pin

g in

co

mm

un

al a

reas

. We

hav

e co

nce

rns

abo

ut

po

ssib

le lo

ng

ter

m e

ffec

ts

of

exp

osu

re t

o n

ico

tin

e an

d/o

r ex

cip

ien

ts.

Oxl

eas

NH

S Fo

un

dat

ion

Tru

stN

oY

es a

s p

er p

olic

yY

esM

on

ito

rin

g p

leas

e se

e p

olic

y ab

ou

t th

is

Du

dle

y an

d

Wal

sall

Men

tal

Hea

lth

Par

tner

ship

N

HS

Tru

st

The

Tru

st c

urr

entl

y h

as n

o b

an in

pla

ce.

The

dra

ft s

mo

ke f

ree

po

licy

wh

ich

is in

d

evel

op

men

t d

oes

no

t ex

clu

de

the

use

of

elec

tro

nic

cig

aret

tes,

th

e p

olic

y st

ipu

late

s th

at t

he

dev

ise

mu

st b

e a

seal

ed u

nit

id

enti

fied

by

the

Tru

st.

Cu

rren

tly

we

do

no

t h

ave

a b

an.

Yes

th

is is

un

der

co

nsi

der

atio

n b

y th

e sm

oke

fr

ee s

teer

ing

gro

up

.Y

es t

his

is u

nd

er c

on

sid

erat

ion

by

the

smo

ke f

ree

stee

rin

g g

rou

p.

Wo

rces

ters

hir

e H

ealt

h a

nd

Car

e N

HS

Tru

st

On

rev

iew

of

the

Tru

st’s

sm

oke

fre

e p

olic

y it

cle

arly

sta

tes

that

we

are

min

dfu

l of

com

mo

n la

w a

nd

sta

tuto

ry d

uti

es t

o p

rote

ct

the

hea

lth

an

d s

afet

y o

f al

l ou

r em

plo

yees

an

d t

her

efo

re w

e d

o n

ot

sup

po

rt t

he

use

of

e-c

igar

ette

s in

th

e w

ork

pla

ce. I

t is

exp

ecte

d

that

sta

ff t

reat

e-c

igar

ette

s in

th

e sa

me

way

as

oth

er t

ypes

of

smo

kin

g. H

ow

ever

, th

ere

are

exp

ecta

tio

ns

to t

his

in r

egar

d t

o

pat

ien

ts a

s to

wh

eth

er s

pec

ial a

rran

gem

ents

n

eed

to

be

mad

e so

th

at t

he

per

son

may

b

e p

erm

itte

d t

o s

mo

ke o

n a

tru

st s

ite.

I am

aw

are

that

fo

r in

pat

ien

ts t

he

war

ds

hav

e n

o b

an in

pla

ce in

reg

ard

to

th

e u

se o

f e

-cig

aret

tes

or

vap

es a

nd

th

is is

en

cou

rag

ed

for

tho

se in

div

idu

als

wh

o w

ish

to

giv

e u

p

smo

kin

g. T

he

war

d e

nvi

ron

men

ts t

reat

e

-cig

aret

tes

the

sam

e as

no

rmal

cig

aret

te

and

req

ues

ts t

hat

pat

ien

ts u

se t

he

ou

tsid

e ar

eas

to u

se t

hes

e. It

is e

xpec

ted

th

at

pat

ien

ts c

om

ply

wit

h t

his

fo

r th

e co

mfo

rt o

f o

ther

pat

ien

ts. H

ow

ever

th

e u

se o

f el

ectr

on

ic

cig

aret

tes

wit

hin

ou

r fa

cilit

ies

is b

ann

ed f

or

staf

f.

At

the

pre

sen

t ti

me

ther

e ar

e n

o p

lan

s to

re

view

th

is p

osi

tio

n a

s o

ur

po

licy

has

bee

n

rece

ntl

y u

pd

ated

, ho

wev

er t

his

will

be

kep

t u

nd

er r

evie

w t

o e

nsu

re a

ny

nat

ion

al

gu

idan

ce is

refl

ecte

d.

Phys

ical

hea

lth

mo

nit

ori

ng

an

d p

rom

oti

on

o

f p

osi

tive

ph

ysic

al h

ealt

h f

orm

s an

im

po

rtan

t as

pec

t o

f th

e w

ork

un

der

take

n

by

ou

r in

pat

ien

t st

aff

in s

up

po

rtin

g a

nd

p

rom

oti

ng

th

e p

hys

ical

hea

lth

an

d w

ellb

ein

g

of

ou

r in

pat

ien

ts. A

s p

art

of

this

th

e u

se o

f e

-cig

aret

tes

or

vap

es is

su

pp

ort

ed f

or

tho

se

men

tal h

ealt

h p

atie

nts

wh

o w

ish

to

giv

e u

p

smo

kin

g, a

lon

gsi

de

the

use

of

oth

er n

ico

tin

e re

pla

cem

ent

pro

du

cts.

Ther

e d

oes

no

t ap

pea

r to

be

evid

ence

th

at s

eco

nd

han

d d

amag

e sh

ou

ld b

e le

ss

of

that

th

an o

ther

typ

es o

f sm

oki

ng

as

the

likel

iho

od

of

ind

ivid

ual

har

m is

red

uce

d.

Ho

wev

er, w

ith

in t

he

clin

ical

en

viro

nm

ent

ther

e m

ay b

e co

nce

rn o

f d

iffe

ren

t ri

sks

un

rela

ted

to

th

e va

po

ur

that

is e

xpel

led

.

No

rth

St

affo

rdsh

ire

Co

mb

ined

H

ealt

hca

re

No

, we

allo

w t

he

use

of

e ci

gar

ette

s in

o

utd

oo

r sp

aces

fo

llow

ing

ou

r jo

urn

ey t

o

“To

bac

co S

mo

ke F

ree”

in A

pri

l 201

8.

N/A

Yes

, in

co

llab

ora

tio

n w

ith

ou

r PH

co

lleag

ues

an

d s

up

po

rtin

g e

vid

ence

.W

e o

nly

allo

w t

he

use

of

e-

cig

aret

tes

in

ou

tdo

or

spac

es.

Sole

nt

NH

S Tr

ust

Sole

nt

NH

S Tr

ust

allo

ws

the

use

of

dis

po

sab

le

e-c

igar

ette

s, b

ut

no

t re

char

gea

ble

vap

es.

We

did

co

nsi

der

th

e h

arm

of

e-c

igar

ette

s,

bu

t co

mp

ared

it t

o t

he

har

m o

f n

orm

al

tob

acco

an

d t

he

imp

licat

ion

s o

n o

ur

pat

ien

ts.

In r

elat

ion

to

sec

on

d h

and

har

m o

f e

-cig

aret

tes,

th

is is

min

imis

ed b

y o

nly

al

low

ing

th

eir

use

in o

ur

op

en g

ard

ens.

Hu

mb

er N

HS

Fou

nd

atio

n T

rust

No

N/A

Yes

No

t p

rese

ntl

y

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E-cigarettes 56

Formal minutesMonday 16 July 2018

Members present:

Norman Lamb in the Chair

Bill GrantLiz Kendall

Stephen MetcalfeCarol Monaghan

Draft Report (E-cigarettes), proposed by the Chair, brought up and read.

Ordered, That the draft Report be read a second time, paragraph by paragraph.

Paragraphs 1 to 83 read and agreed to.

Summary agreed to.

A Paper was appended to the Report as Appendix 1.

Resolved, That the Report be the Seventh Report of the Committee to the House.

Ordered, That the Chair make the Report to the House.

Ordered, That embargoed copies of the Report be made available (Standing Order No. 134).

[Adjourned till Tuesday 17 July 9.00am.

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57 E-cigarettes

WitnessesThe following witnesses gave evidence. Transcripts can be viewed on the inquiry publications page of the Committee’s website.

Tuesday 9 January 2018 Question number

Professor Peter Hajek, Professor of Clinical Psychology, Queen Mary University of London; Professor Mark Conner, Professor of Applied Social Psychology, University of Leeds; and Professor Riccardo Polosa, Professor of Internal Medicine, University of Catania Q1–72

Dr Lion Shahab, Senior Lecturer in Health Psychology, University College London; Dr Jamie Brown, Deputy Director, Tobacco and Alcohol Research Group, University College London; and Professor Paul Aveyard, Co-ordinating Editor, Cochrane Tobacco Addiction Group Q73–132

Tuesday 27 February 2018

Dr Ian Jones, Vice-President, Reduced-Risk Products, Japan Tobacco International; Dr Chris Proctor, Chief Scientific Officer, British American Tobacco; Dr Moira Gilchrist, Vice-President, Scientific and Public Communications, Philip Morris Limited; and Dr Grant O’Connell, Regulatory and Scientific Affairs, Fontem Ventures Q133–183

Professor David Harrison, Chair of the UK Committee on Carcinogenicity of Chemicals in Food, Consumer Products and the Environment (COC); and Dr Lynne Dawkins, Associate Professor, Centre for Addictive Behaviours Research, London South Bank University Q184–216

Tuesday 27 March 2018

Michelle Jarman-Howe, Executive Director, Public Sector Prisons South; and Heather Thomson, Smoke-free Lead, Nottinghamshire Healthcare NHS Foundation Trust Q217–291

Deborah Arnott, Chief Executive, Action on Smoking and Health; and Hazel Cheeseman, Director of Policy, Action on Smoking and Health Q292–354

Tuesday 24 April 2018

Rob Morrison, Senior Regulatory Policy Executive, Advertising Standards Authority; Professor John Newton, Director of Health Improvement, Public Health England; Professor Gillian Leng, Deputy Chief Executive, National Institute for Health and Care Excellence; and Dr Ian Hudson, Chief Executive, Medicines and Healthcare products Regulatory Agency Q355–439

Steve Brine MP, Parliamentary Under-Secretary of State for Public Health and Primary Care; and Dr Tim Baxter, Deputy Director of Healthy Behaviours, Department of Health and Social Care Q440–495

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E-cigarettes 58

Wednesday 9 May 2018

John Dunne, Director, UK Vaping Industry Association; Fraser Cropper, Chair, Independent British Vape Trade Association; and Sarah Jakes, Chair, New Nicotine Alliance Q496–559

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59 E-cigarettes

Published written evidenceThe following written evidence was received and can be viewed on the inquiry publications page of the Committee’s website.

ECG numbers are generated by the evidence processing system and so may not be complete.

1 Action on Smoking and Health (ECG0071) (ECG0107)

2 Advertising Standards Authority (ECG0015)

3 Ariff Patel (ECG0012)

4 ASH Scotland (ECG0011)

5 ASH Wales (ECG0066)

6 Association for Young People’s Health (ECG0093)

7 Association of Convenience Stores (ECG0032)

8 Beckett Associates (ECG0090)

9 Benjamin Smith (ECG0004)

10 Blue Skies China (ECG0086)

11 British American Tobacco UK (ECG0074)

12 British Heart Foundation (ECG0065)

13 British Lung Foundation (ECG0042)

14 British Medical Association (ECG0037)

15 British Psychological Society (ECG0088)

16 BSMW Ltd. (ECG0052)

17 Cancer Research UK (ECG0057)

18 Carole Smith (ECG0001)

19 Centre for Addictive Behaviours Research, LSBU (ECG0018)

20 Charles Hamshaw-Thomas (ECG0083)

21 Chartered Trading Standards Institute (ECG0040)

22 Cheshire and Wirral Partnership NHS Foundation Trust (ECG0072)

23 CiggyJuice Ltd (ECG0043)

24 Clive Bates (ECG0078)

25 CLOSER (ECG0077)

26 David Bareham and Professor Martin McKee (ECG0039) (ECG0094)

27 Department of Health and Social Care (ECG0030) (ECG0095)

28 DISPLAY Study Research Team (ECG0069)

29 Dr Caitlin Notley (ECG0028)

30 Dr Charlotte Smith (ECG0014)

31 Dr Graham Cope (ECG0013)

32 Dr Nicola Gray (ECG0091)

33 Dr Richard Holliday (ECG0036)

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34 Dr Robert Combes and Professor Michael Balls (ECG0080)

35 EL-Science (ECG0038)

36 Imperial Brands (ECG0063)

37 INNCO (ECG0079)

38 Institute of Economic Affairs (ECG0020)

39 JAC Vapour Ltd (ECG0068)

40 Japan Tobacco International (ECG0061)

41 Johnson & Johnson Ltd (ECG0112)

42 Keith Butt (ECG0005)

43 Kind Consumer Limited (ECG0026)

44 Leicester City Council (ECG0022)

45 Lord Brabazon of Tara, Earl Cathcart and Viscount Ridley (ECG0033)

46 Medic Pro Limited (ECG0075)

47 Medicines and Healthcare products Regulatory Agency (ECG0103)

48 Melanie Atwood (ECG0105)

49 Mental Health and Smoking Partnership (ECG0060)

50 Miss Daniele Kerr (ECG0076)

51 Mr Anthony Stuart (ECG0008)

52 Mr Christopher Lukehurst (ECG0021)

53 Mr Clive Bates (ECG0096)

54 Mr Ian Bardrick (ECG0006)

55 Mr Michael Jones (ECG0002)

56 Mr Oliver Kershaw (ECG0059)

57 MRC/CSO Social and Public Health Sciences Unit, University of Glasgow (ECG0055)

58 National Institute for Health and Care Excellence (NICE) (ECG0067)

59 Nerudia (ECG0048)

60 New Nicotine Alliance (UK) (ECG0044)

61 NFRN (ECG0046)

62 NHC NHSFT (ECG0070)

63 NHS England Mental Health Trusts additional replies to Committee (ECG0116)

64 NHS England Mental Health Trusts additional reply to Committee (ECG0117)

65 NHS England Mental Health Trusts replies to Committee question (ECG0102)

66 NHS Providers (ECG0109)

67 NJOY Innovations Ltd (ECG0110)

68 Origin Packaging Ltd (ECG0099)

69 PAGB (Proprietary Association of Great Britain) (ECG0050)

70 Petrol Retailers Association (ECG0104)

71 Pfizer Ltd (ECG0023)

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72 Philip Morris Limited (ECG0073) (ECG0115)

73 Piers Clifford (ECG0009)

74 Professor Mark Conner (ECG0024)

75 Professor Peter Hajek (ECG0017)

76 Professor Riccardo Polosa (ECG0034) (ECG0106)

77 Protec Fire Detection plc (ECG0010)

78 Public Health England (ECG0108)

79 Public Health England and MHRA (ECG0081)

80 Roger Gross (ECG0003)

81 Royal College of Physicians (ECG0035)

82 Royal College of Physicians of Edinburgh (ECG0025)

83 Royal Society for Public Health (ECG0049)

84 Scottish Grocers Federation (ECG0064)

85 Smoking in Pregnancy Challenge Group (ECG0062)

86 Stephen Roberts (ECG0019)

87 Stoke-on-Trent City Council (ECG0029)

88 Swedish Match (ECG0045)

89 Terry Walker (ECG0007)

90 The Cochrane Tobacco Addiction Group (ECG0041)

91 The Freedom Association (ECG0027)

92 The Independent British Vape Trade Association (ECG0058) (ECG0084) (ECG0114)

93 Tobacco Manufacturers’ Association (ECG0053)

94 UK Centre for Tobacco and Alcohol Studies (ECG0031)

95 UK Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (ECG0082)

96 UK Vaping Industry Association (ECG0054) (ECG0101) (ECG0111)

97 University College London Tobacco and Alcohol Research Group (ECG0047)

98 University of Liverpool (ECG0056)

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List of Reports from the Committee during the current ParliamentAll publications from the Committee are available on the publications page of the Committee’s website.

Session 2017–19

First Report Pre-appointment hearing: chair of UK Research & Innovation and executive chair of the Medical Research Council

HC 747

Second Report Brexit, science and innovation HC 705

Third Report Genomics and genome editing in the NHS HC 349

Fourth Report Algorithms in decision-making HC 351

Fifth Report Biometrics strategy and forensic services HC 800

Sixth Report Research integrity HC 350

First Special Report Science communication and engagement: Government Response to the Committee’s Eleventh Report of Session 2016–17

HC 319

Second Special Report Managing intellectual property and technology transfer: Government Response to the Committee’s Tenth Report of Session 2016–17

HC 318

Third Special Report Industrial Strategy: science and STEM skills: Government Response to the Committee’s Thirteenth Report of Session 2016–17

HC 335

Fourth Special Report Science in emergencies: chemical, biological, radiological or nuclear incidents: Government Response to the Committee’s Twelfth Report of Session 2016–17

HC 561

Fifth Special Report Brexit, science and innovation: Government Response to the Committee’s Second Report

HC 1008

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