From nurse education, clinical, or workforce issues through to healthy living, Nursing Review has it covered.

When it comes to smoking cessation tools, it seems there are mixed signals around e-cigarettes. Some argue they could be lifesavers for tobacco smokers struggling to quit; others argue they are a smokescreen for a new generation of problems. So what knowledge should nurses have on the subject? Nursing Review attempts to clear the air. 

Selling nicotine for e-cigarettes is illegal in New Zealand. Any callers to Quitline who ask are told the Ministry of Health advises there’s not enough evidence to recommend e-cigarettes as an aid to quit smoking.

But just google ‘e-cigarettes’ and at least 20 New Zealand websites pop up selling various e-cigarette or vaping devices and vaping e-liquids in flavours from tobacco to caramel. (For the uninitiated, vaping is inhaling and exhaling the vapour produced by an electronic cigarette or similar device.)

And with just a few more clicks, people can go offshore to China or the USA and legally import nicotine liquid or cartridges for personal use in their e-cigarette or electronic nicotine delivery system (ENDS).

Quitline clients are definitely ‘very aware’ of e-cigarettes, Quitline’s director of strategy and communication Bruce Bassett told a national symposium on e-cigarettes in March.

Last year’s satisfaction survey of 611 Quitline clients found 15 per cent had used e-cigarettes but Bassett says a smaller, more recent survey of 34 clients found 75 per cent had used them – though mostly without nicotine.

Bassett says a further survey of 16 Quitline advisors found most had several callers a day mentioning e-cigarettes and those enquiries were increasing.

Most of the callers were keen to know whether e-cigarettes or ENDS were safe, where to get them and whether they would work. Bassett asked the advisors whether they thought they could offer a better service if they could talk freely about e-cigarettes and 10 said ‘yes’, five said ‘possibly’ and just one said ‘no’.

If a smoker heads to Britain’s National Health Service website to ask whether or not e-cigarettes are safe, they are also told nobody can say for sure without more research. But the website also adds: “However, compared with regular cigarettes, they are certainly the lesser of two evils”.

A quick tour of the internet also shows local smokers that ENDS are freely available and widely advertised in the USA, UK and Europe, with an estimated 2.1 million users in the UK and about 20 million in the USA. Though with ads promoting flavours from bubble gum to cola and, in American ads in particular, showing sleek young things in bikini thongs and glamorous women blowing ‘smoke’ clouds, Kiwi smokers may well wonder who the target market for e-cigarettes actually is.

Murray Laugesen	Janet Hoek	Chris Bullen

Helping or hindering tobacco control?

While it is not surprising that many New Zealander smokers are curious about giving e-cigarettes a go, what advice should a Kiwi nurse give a smoking client who’s switched to e-cigarettes and wants to know whether they are safe? Or to a heavy smoker struggling to quit who wonders whether ENDS could be the answer for them?

The quick, unhelpful answer is that there’s no easy answer, partly because the arrival of e-cigarettes has generally divided the tobacco control community, both here and overseas, into two loose camps.

In the ‘precautionary’ camp are those – including our Ministry of Health, the Cancer Society and the World Health Organisation (WHO) – who argue that longitudinal, robust research is not there to prove that ENDs are either safe or effective as a quit smoking aid and quitters should stick to proven nicotine replacement treatments (NRT) like patches, lozenges and gum. There is also concern that e-cigarettes may see smokers continue to smoke tobacco and that aggressive marketing at youth could see ‘vaping’ become the gateway for a new generation of nicotine addicts and potential tobacco smokers.

In the ‘lesser of two evils’ or ‘harm reduction’ camp are those who argue that other NRT treatments don’t offer the same ‘hand-mouth’ experience that makes ENDS appeal to many smokers. And while we wait for longitudinal and definitive research on whether the constantly evolving ENDS technology is safe and effective, around 5,000 Kiwis a year are dying from smoking-related diseases.

Nursing Review talks to people from both camps – and those trying to find a middle-ground – about the pros and cons of e-cigarettes.

Early advocate remains strong

Murray Laugesen is a public health physician with a passion to make New Zealand smokefree, who has definitely pitched his tent in the ‘lesser of two evils’ camp.

The chair of charitable trust End Smoking NZ wants people to quit smoking and cigarettes sales banned, but in the meantime he wants to reduce the deadly harm caused by smoking tobacco. He has long been known for sticking his neck out in seeking safer alternatives to smoking tobacco for the addicted – including snuff and chewing tobacco – to stop the high death rate from lung cancer and other smoking-related diseases. “But I came to the reluctant conclusion that (recalcitrant) smokers were not interested in anything except smoking.”

So when the pioneering Chinese manufacturer of e-cigarettes approached him in 2007 wanting to know whether their product was safe, he was definitely interested. He saw it potentially meeting the need of many smokers struggling, or unwilling, to quit.

“I found that as far as I could tell the Ruyan [e-cigarette product] was safe in all respects so I gave them my report and that was it.”

He says he hasn’t been involved with Ruyan for a number of years but has retained an active interest in the ongoing evolution of e-cigarettes, particularly the latest versions that use a refillable tank. These, he says, are the most efficient yet in delivering nicotine to nicotine-addicted smokers and he is keen to see a randomised control trial on the efficacy of the tank devices as a quitting aid.

Laugesen’s own small study into the toxins produced by e-cigarettes was published this year in the New Zealand Medical Journal (see sidebar ‘E-cigarettes: recent findings’) and he says there is nothing much in the way of toxicants found in e-cigarettes that aren’t also found in nicotine patches or gum.

He also says New Zealand could wait to find out whether there are long-term risks from vaping nicotine, but with people dying every year from smoking combustible cigarettes he thinks that’s a costly option in both money and human suffering.

For Laugesen, it is quite simple – tobacco smoke kills people and e-cigarettes don’t.

So what does he think nurses should be advising persistent smokers?

“If a smoker can’t quit with nicotine patch or gum, they should definitely consider e-cigarettes, particularly the tank-style, as a possibility and nurses should encourage people to go ahead and give it a try.

“But it would be a lot easier for everybody if the Ministry of Health would move and make e-cigarettes available for sale in New Zealand,” says Laugesen. “There’s no reason why cigarettes, that kill 5,000 New Zealanders a year, should be permitted while e-cigarettes are only available by ordering from overseas.”

Time to take a deep breath

Few products are as dangerous as smoking tobacco, agrees Professor Janet Hoek, who falls into the precautionary camp.

“There is general agreement that using ENDS is not as harmful as smoking,” says Hoek, a University of Otago academic with a research interest in the marketing of e-cigarettes, particularly to children and young people. But she adds that agreeing ENDS are less harmful than tobacco is not the same as saying that ENDS are harmless.

Until there is long term data on the many types of ENDS available and the many types of inhaling (now including competitive ‘cloud chasing’) it will not be known whether ENDS and vaping are safe.

Hoek also points out that the question remains: do e-cigarettes help people quit? While there are anecdotal testimonials from former smokers that ENDS helped them quit, Hoek points to the meta-analysis by Professor Stanford Glantz (see sidebar ‘E-cigarettes: recent findings’) that indicates smokers using ENDS are less likely to quit smoking and that smokers continuing both vaping and smoking (dual use) is common. Once again, she says, there is a shortage of good data and more studies are needed.

So what does she think nurses should tell smokers about ENDS as a quitting aid? The short answer is that ENDS have helped some smokers quit, answers Hoek, but, she adds, the big picture analysis suggests that ENDS users are less rather than more likely to quit smoking.

Paul Badoc, the national manager of the Ministry of Health’s Tobacco Control Programme, agrees, saying that the behavioural research suggests many smokers use tobacco and e-cigarettes depending on what is socially acceptable at any given time and location. He points to the 2014 Cochrane review (see sidebar and page 37) showing that the evidence for e-cigarettes as a quit smoking aid is low and more studies are required. The WHO review of the 2014 Framework Convention on Tobacco Control conference also recommended a precautionary approach to e-cigarettes and advised people to use approved NRT products instead.

Homegrown research findings

New Zealand is one of the few countries to have carried out a random control trial comparing nicotine e-cigarettes, nicotine patches and placebo e-cigarettes as aids to quitting smoking.

The Health Research Council project was led by Professor Chris Bullen, a public health physician who is director of The University of Auckland’s National Institute for Health Innovation and co-director of the government-funded Tobacco Control Research Tūranga. Published in late 2013, the trial, involving 657 Kiwi smokers, found that e-cigarettes, with or without nicotine, were ‘modestly effective’ in helping smokers quit; it was one of two studies found in a Cochrane Review (also involving Bullen) to show some low level evidence that e-cigarettes may be effective as a quitting aid.

So what would Bullen say to a long-standing smoker who asks him whether e-cigarettes are better for their lungs than smoking tobacco? “Those who vape for a few months as a means to quit tobacco smoking will almost certainly experience significant and rapid health benefits,” says Bullen. “But if a vaper also continues to smoke they won’t experience the same benefits, as even a single cigarette carries health risks.”

And, of course, the long-term health risks of vaping regularly are not known yet but, knowing what he does of the chemicals in e-cigarette vapour, he believes it is “very unlikely” there are major risks and they are unlikely to be “anywhere near as harmful or great as smoking”.

How effective does he believe e-cigarettes are for helping people quit? If e-cigarettes with nicotine are used daily, they are at least as effective a quitting aid as nicotine patches, says Bullen of the research to date.

“Ideally though, people should try the optimal ways of using existing evidence-based approaches first: patches plus a faster acting product (such as gum), plus counselling or other behavioural support (such as a text message quit support programme or a theory-based app such as SF28); or varenicline [trade name Champix] alone or in combination with NRT.”

If these methods are unsuccessful, despite the quitter’s best efforts, then e-cigarettes are an option to be considered, he believes.

Bullen emphasises that e-cigarettes are no ‘magic bullet’ and should always be viewed as just one strategy in the total tobacco control package that includes price, plain packaging, sales restrictions etc. But meanwhile, he says some regulation of e-cigarettes is essential – at a minimum to ensure product quality, childproof lids on nicotine bottles and to restrict marketing and sales to minors.

Marketing, big tobacco and e-cigarettes

The Ministry of Health is in an ‘ongoing’ process of considering regulatory options for e-cigarettes and associated products in New Zealand.

It is the current unregulated market and future marketing of e-cigarettes that worries many as much, or more, than their safety and efficacy. They look across to the USA where the unregulated e-cigarette market is expected to top $3 billion this year and the biggest selling brand is marketed by a multinational tobacco company.

It leaves many with a foot in both camps, including the New Zealand Nurses Organisation, which regards promoting e-cigarettes as a “harm reduction tool for recalcitrant smokers” as a valid use if properly supervised.

But, and it is a big BUT, NZNO also has major concerns about the safety and marketing of e-cigarettes, particularly now that the major multinational tobacco companies have entered the e-cigarette market.

NZNO researcher Dr Leonie Walker acknowledges e-cigarettes are a polarising issue.

“If the machines and flavours weren’t geared far more to getting new smokers than helping quitters, and if recent research hadn’t confirmed youth experimentation, we’d be less concerned,” says Walker (see sidebar ‘More New Zealand teenagers vaping’).

NZNO recently briefed the Associate Health Minister on its fears that public health gains will be undermined if tobacco companies succeed in gaining access to the New Zealand market for their new e-cigarette products, particularly with overseas experience showing aggressive marketing, recruitment of young people and the promotion of dual tobacco and e-cigarette use.

In addition, if vaping becomes visible and acceptable in public places, some fear it could undermine the smokefree message and quitters may be tempted to reach for a fag if they see others blowing vapour ‘smoke ring’ clouds.

Meanwhile NZNO says New Zealand’s current position – where nicotine for e-cigarettes must be bought online and there are no controls in place – is ‘untenable’.

The organisation’s preference is for e-cigarettes to be regulated as medicines and their sale and promotion handled like any other nicotine replacement therapy, including being accompanied by quit education and support.

Failing that, Walker says, it hopes at the very least that e-cigarette and refills are subjected to the same point of sale display and advertising restrictions as tobacco cigarettes.

But she adds that the sophisticated marketing used overseas to drive the potentially multi-billion dollar e-cigarette industry must still ring warning bells and New Zealand needs to heed that warning and go cautiously.

One smokefree nurse’s perspective

E-cigarettes are already steadily seeping into New Zealand’s ‘smoking’ culture. This is opening up new etiquette and ethical dilemmas as our smokefree legislation bans smoking, but not vaping, in public places.

“Go to any restaurant here in Auckland and you are bound to find someone using an e-cigarette in the evening somewhere,” says Karen Stevens, a Smokefree Nurses Aotearoa member. The respiratory clinical nurse specialist points out it’s a tough call for the waitress to decide ‘is this a real cigarette or not?’; particularly as the end of the early generation ‘cigalike’ e-cigarettes used to glow red, as if they were burning. There is also still a lack of research into whether exhaled vapour may be harmful to others.

Stevens, who manages Auckland District Health Board’s smokefree service, says that is one of the reasons why the board’s own smokefree policy treats e-cigarettes just like an ordinary cigarette and asks people to go outside.

While e-cigarette users are only a minority of its patients, visitors or staff, she says vaping is becoming increasingly common. Not as common as tobacco smoking though, with the 2013 census showing 463,000 adults (15.2 per cent of our adult population) still smoke.

From a personal perspective and as a respiratory nurse specialist, Stevens wants those smoking statistics to fall and sits firmly in the ‘harm reduction’ camp.

“The crucial thing is we don’t want people to deliberately inhale smoke from combustion into their lungs on a daily basis,” says Stevens.

“So whenever we talk to any group of people about helping them stop smoking, we need to very clearly delineate that we want them to be smokefree, not necessarily nicotine free.

“I’ve got staff members – some of them nurses – and they’ve stopped smoking but are still on nicotine lozenges or gum four or five years down the track. They are not smoking but they find if they don’t get the regular nicotine they get cravings and find it hard to concentrate.”

So what about nicotine via an e-cigarette? How would she respond to a smoker who has struggled to quit with approved NRT who asks about using ENDS?

For a start, she points to a recent UK study (see sidebar ‘E-cigarettes: recent findings’) where 20 per cent of surveyed smokers who attempted to quit on their own using just e-cigarettes reported successfully quitting, which was double the rate of those using solely over-the-counter NRT.

“I would say [to any smoker who asks] that the risks of ill-health from e-cigarettes are far less than from smoking tobacco, so in terms of harm reduction the e-cigarette may be a good option for them.”

Should nurses be telling patients this? Yes, says Stevens, as she believes information about any quitting aid that prevents smoke inhalation, and doesn’t have significant poisonous affects itself, should be provided.

“A current smoker who wants to stop smoking and to reduce the risk to their health and wellbeing would jump at a chance to do it with a device where you still have the ‘hand-to-mouth’ going on and you still have all the habits associated [with smoking] but you have very much reduced harm.”

She agrees more research and regulation is needed, but also believes e-cigarettes can be considered another option in the NRT arsenal helping people to stop inhaling toxic smoke that is proven to kill. And for those who argue against e-cigarettes because some vapers also smoke as well, she points out that dual usage is not new, with some smokers continuing to smoke while using evidence-based NRT like gums and lozenges, and even prescription drugs such as Champix.

“The ideal is not to use nicotine at all, but then how many people are addicted to caffeine, and now sugar, which is also getting a bad press?”

Her overall advice on e-cigarettes is to proceed with caution and remain focused on the main objective. “Basically, every breath should be a breath of fresh air – it should not have smoke in it – that’s the bottom line for whatever we talk about.”

Smokefree Nurses Aotearoa: a foot in both camps

Dr Grace Wong, the director of Smokefree Nurses Aotearoa, says currently the advocacy group – dedicated to supporting nurses help people quit smoking – doesn’t have a formal position on e-cigarettes.

Smokefree Nurses’ brief website advice on e-cigarettes recommends, like the Ministry of Health, that regulated NRT should be nurses’ first-line smoking cessation aid.

But the website also neatly sums up the current ‘foot in both camps’ dilemma by adding: “There is not enough evidence to recommend e-cigarettes to patients OR discourage the use of them as a substitute for smoking”.

Are they less harmful than tobacco? “Well, almost certainly they are,” replies Wong, “but they are not less harmful than not vaping or smoking.” (An interesting aside is that Wong says nurses and GPs were recently informed that ex-smokers who use e-cigarettes now officially count as non-smokers for health statistic purposes.)

Like NZNO, Wong is keen to reduce harm to current smokers and also to curtail the risk of a new generation of smokers being created. “A lot of the concern is about young people trying e-cigarettes – not as a substitute for tobacco or smoking – but to see what they are like,” says Wong.

She points to the latest Health Promotion Agency survey showing a rapid rise in New Zealand teenagers trying out e-cigarettes in the past two years (see sidebar ‘More New Zealand teenagers vaping’). The worry, unproven to date, is whether the next step is smoking, particularly when looking at the United States where tobacco companies’ current marketing of e-cigarettes is very reminiscent of the halcyon days of tobacco cigarette marketing.

Regulation is the logical next step for New Zealand, believes Wong, with e-cigarettes already here and nicotine liquids only a few clicks on the internet away. “I think the stable door is open and the horse has bolted – it’s gone and we can’t turn back time,” she says. “But we can regulate it and put some reins on the horse.”

Smokefree by 2025?

Everybody agrees more research is needed and most agree more regulation is required for the controversial product that is now a multi-billion dollar industry.

“They (e-cigarettes) are here to stay and we have to decide what to do with them,” sums up Bullen. “Can they be seen as an opportunity or relegated to a threat?”

He believes it is possible for New Zealand to regulate a quality-assured e-cigarette for smokers wishing to try them “without increasing the likelihood of reversing our successes with (reducing) youth-smoking and gradually declining smoking rates”.

The Health Research Council recently granted $1.2 million to The University of Auckland for a further randomised trial of e-cigarettes (with and without nicotine) for smoking cessation – this time combined with nicotine patches.

Whether such research and regulation can come together in time for e-cigarettes to be proven a friend (or foe) of the Government’s Smokefree New Zealand 2025 goal is as yet unknown.

But here’s hoping the air is clearer for all of us very soon.

E-cigarettes recent findings

Toxicity (2015)

Murray Laugesen’s research into the concentration of nicotine and toxins in vapour from 14 electronic cigarette brands available in New Zealand concluded that e-cigarettes yielded a level of toxic aldehydes 200 times lower per puff than a Marlboro cigarette. He also found that the later-generation (2013 onwards) brands of e-cigarettes yield more nicotine than earlier brands but far lower toxin levels than both cigarettes and earlier brands of e-cigarettes, indicating “potential as safer substitutes for tobacco”.

New Zealand Medical Journal, March 27 2015, Vol 28 No 1411.

E-cigarettes: A scientific review (2014)

A meta-analysis of research on e-cigarettes, including studies available at the time into smokers quitting while using e-cigarettes. Led by Professor Stanton Glantz (Centre for Tobacco Control Research and Education, University of California, San Francisco), the analysis found that smokers (including those not trying to quit) who use e-cigarettes are 30 per cent less likely to quit smoking than smokers who don’t use e-cigarettes. The study also found that dual use of both e-cigarettes and tobacco cigarettes was of concern.

Circulation 2014; 129: 1972-1986. Available at www.circ.ahajournals.org/content/129/19/1972.long.

Electronic cigarettes for smoking cessation and reduction (Cochrane Review 2014)

The review looked at 13 trials published up until July 2014 and found low grade evidence from two random control trials (including a New Zealand trial led by Chris Bullen, also one of the co-authors of the Cochrane Review) that e-cigarettes can help smokers to stop smoking long-term compared with placebo e-cigarettes. (See CAT analysis of review in evidence-based practice article on page 31.) Full review available at www.cochrane.org

‘Real-world’ effectiveness of e-cigarettes

This study led by Jamie Brown with Professor Robert West (director of Tobacco Studies at the Cancer Research UK Health Behaviour Unit, University College London) surveyed 5,863 adult smokers who had attempted to quit at least once in the previous 12 months. Of those who hadn’t sought professional support, the eight per cent (464) who had tried to quit using an e-cigarette only were more likely to report continued quitting of smoking than the 32 per cent who used licensed NRT bought over the counter and the 60 per cent who had attempted without any aid or professional support.

Addiction Vol 109, Issue 9, September 2014. Available online at http://onlinelibrary.wiley.com/doi/10.1111/add.12623/abstract

More New Zealand teenagers vaping 

The latest survey of year 10 students (14 to 15-year-olds) found that the number of teenagers trying out electronic cigarettes has nearly tripled in two years.

The Health Promotion Agency first asked about electronic cigarette use in its 2012 Youth Insights survey and found that seven per cent had tried them, but when they surveyed the 2014 year 10 cohort they found the rate who had "ever tried electronic cigarettes" had rapidly increased to 20 per cent. The most common reason cited for trying e-cigarettes was curiosity (65%), followed by somebody recommending them (24%) and that they were considered 'safer than cigarettes' (20%). Trying e-cigarettes was most common amongst current, infrequent and ex-smokers. (Students were not asked whether they had tried nicotine or non-nicotine e-cigarettes).

The same 2014 survey found that six per cent of year 10 students were regular tobacco smokers and that 11.4 per cent had smoked tobacco in the previous month.

The yearly ASH Year 10 Snapshot Survey in 2014 also found that the number of students regularly smoking (at least once a month) was six per cent, but the number of year 10 students smoking daily had fallen below three per cent for the first time since the survey began in 2000. In addition, the number who had never smoked was the highest ever at 77 percent.