Thanks Neil. You asked me, Eduardo and Chris to comment on take home messages about vaping. I thought I'd do one list of all take-home messages about tobacco and nicotine as it's hard to separate.
Take-home messages from me (developed over time and influenced by expert colleagues from the NHS in London and also IPCRG):
- Nicotine dependence is a long-term relapsing treatable condition that often starts in childhood.
- It includes cigarette smoking, use of chewed tobacco, hookah and now e-cigarettes
- It is the nicotine that is addictive but the other substances that cause most harm eg tobacco smoke.
- It is therefore best to never start. Policy measures are most effective and are the WHO "best buys" (in the WHO MPOWER framework these are P = protect; W = warn; E = enforce bans on tobacco advertising, promotion and sponsorship; and R: raise taxes on tobacco).
- However, the O is also important for those already dependent. O= offer help to quit. and the M - monitor.
- Without treatment, up to 2/3 of those who are tobacco dependent will die of this dependence from a huge range of conditions including cancer, chronic respiratory diseases and heart disease (see earlier posts). Typically the more "pack years" the worse the outcome (20 cigarettes = 1 pack; 52 packs = 1 pack year)
- People with severe mental illness have often had the highest pack years and die up to 20 years prematurely compared to the general population (see earlier posts)
- All those who are dependent will also have worse quality of life. Breathlessness, cough, fatigue are common problems. The different products affect different parts of the body more - eg chewed tobacco causes oral cancer, smoking causes lung cancer and chronic obstructive pulmonary disease (COPD).
- The good news is it is treatable: the best evidence suggests pharmacotherapy + counselling.
- In terms of pharmacotherapy, the WHO Essential Medicines List includes Nicotine Replacement Therapy (long-acting patch that deals with nicotine withdrawal and short-acting gum that deals with cravings; there are other types of NRT that may be preferred but these aren't on the WHO List); varenicline (safe and effective but currently has supply issues - look out for generic varenicline) and buproprion (tends to need more monitoring)
- Clinicians (all disciplines) therefore have a duty to diagnose and treat it.
- Consider the Number Needed to Treat to have an impact - avoid premature death - (NNT) for treating tobacco dependence using varenicline + behavioural support is about 20. And typically treatment is needed for up to 6 months. Compare this to antihypertensive treatment for mild hypertension to avoid one stroke or MI death over 1 year is 700. https://www.nature.com/articles/s41533-017-0039-5/tables/2
- With limited time, use Very Brief Advice - models such as Every Contact Counts means that there should be the same message given whichever healthcare professional the dependent person encounters.
- Very Brief Advice: Ask about tobacco smoking and record in notes; Advise on how best to stop; ACT: direct to best available support and treatment to help them quit.
- Find out more here: https://www.ipcrg.org/themes/tobacco-dependence and https://www.pcrs-uk.org/sites/default/files/tobacco_dependency_pragmatic...
- The good news about the VBA framework is you can use for other behaviours too see https://www.who.int/europe/publications/i/item/9789289058551
- Studies are underway to see if it also works for chewed tobacco - a major issue in South Asia where colourful packs are sold to young children
- Most e-cigarettes contain nicotine but not tobacco
- Some people do not want to quit nicotine or the habit of "smoking" and therefore find e-cigarettes a safer alternative
- Some find they can gradually quit using e-cigarettes
- The latest Cochrane "living" (ie updated whenever there is significant new evidence) report 2022 suggests e-cigarettes are therefore a useful quitting tool (see earlier posts)
- This is completely different from people who have not previously smoked or chewed tobacco in any form taking up e-cigarettes. Clearly they are now introducing something addictive into their lives which wasn't there before. So it's a question of weighing up the benefit and harm.
I welcome comment/correction!
Thanks
Siân
HIFA profile: Sian Williams is Chief Executive Officer at the International Primary Care Respiratory Group in the UK. Professional interests: Implementation science, NCDs, primary care, respiratory health, education, evaluation, value, breaking down silos. sian.health AT gmail.com
