Policy on E-Cigarettes

From 1st May 2014 the use of e-cigarettes will not be permitted in any HSE building or on any HSE Tobacco-Free Campus. In addition, their use by patients, staff and visitors is prohibited in all healthcare settings and campuses until further notice

Read the HSE Press Release on this topic here.

As the national body responsible for the health promotion and improvement, health protection and prevention of illnesses and disease, the HSE has adopted a Tobacco Control Framework and given a commitment that all HSE campuses will be tobacco free.  Our Tobacco Free Campus Policy helps change social norms around tobacco

Our ability to implement the Tobacco Free Campus Policy, which is already in place in many hospitals and healthcare facilities, is increasingly facing difficulties arising from the use of electronic cigarettes (e-cigarettes) by staff and service users.

The HSE has a legitimate concern that because e-cigarettes resemble ordinary tobacco, their use may promote or re-normalise smoking and make it harder to implement our tobacco free campus policy.  Furthermore, scientific testing indicates that the products vary widely in the amount of nicotine and other chemicals they deliver. At present we cannot say that e-cigarettes are safe; WHO is of the view that the safety of e-cigarettes has not been scientifically demonstrated and the potential risks they pose for the health of users remains undetermined.  Manufacturers of oxygen supplies for hospitals have advised the health system that e-cigarettes pose a potential fire hazard in proximity to oxygen sources.

The HSE has now updated the National Tobacco Free Campus policy to the effect that the sale, advertising and use of e-cigarettes is not permitted within HSE facilities or on HSE campuses.

E-Cigarettes in Smoking Cessation

"The HSE is at the forefront of tackling the harm caused by tobacco in Ireland and is the largest provider of QUIT support services to smokers. We welcome any measures that will help reduce the tens of thousands of people disabled, killed or bereaved by cigarettes each year, and want to help every smoker to QUIT. While E-Cigarettes are a new and potentially helpful addition to the many proven QUIT supports and products available - the Health Service can only endorse products that are proven to be safe, and proven to be effective; e-cigarettes have not yet achieved either test."

Context

Ireland is recognised as a world leader in tobacco control but despite considerable success in reducing smoking prevalence over the last ten years (28% ->23%) smoking remains that leading preventable cause of chronic disease and mortality in Ireland; responsible for a range of respiratory diseases, cardiovascular diseases and cancers, and with over 5,800 people (~16/day) still dying each year from tobacco related disease. There are still over 850,000 smokers in Ireland and 1 in 2 smokers continue to die from tobacco related disease, losing an average of 10 years of life.

The best thing a smoker can do for their health is to quit smoking completely and quit for good.

Smoking is a major cause of inequalities with smoking prevalence and the associated disease burden having a strong social gradient whereby the poorest, most disadvantaged sections of society are more likely to smoke and die younger. Yet, studies show that people who never smoke from the poorest backgrounds have much better survival than people who smoke from well off backgrounds.

National Tobacco Control Policy " Tobacco Free Ireland" sets out a target of a Tobacco Free Ireland by 2025 i.e. smoking prevalence of <5%. The policy details a comprehensive range of measures to achieve this goal. Treating tobacco dependence as a care issue by providing treatment and supporting smokers to quit are essential elements in meeting this goal and in addressing Ireland's chronic disease burden.

Tobacco Dependence

Tobacco dependence is caused by an addiction to the nicotine in tobacco products. Quitting tobacco is not easy. some smokers need to make several quit attempts before they are able to quit for good. Tobacco dependence is classified internationally as a chronic relapsing disease, has extremely serious health consequences and needs to be treated as such. In treating tobacco dependence health professionals use a range of safe evidenced based services, supports and medications to help smokers quit.

Smoking Cessation Medication /Supports

A range of medicines have been developed for use in a controlled manner to help treat tobacco/nicotine dependance. The safety and efficacy of these products has been rigorously tested and they have been approved both nationally and internationally for use in treating tobacco dependence. Products for which medicinal claims are made or which contain substances likely to have effects on the body are considered as medicines and in Ireland need a marketing authorisation from the Health Protection Regulatory Authority (HPRA). This includes Nicotine Replacement Therapies e.g. gums, patches, sprays and inhalers (NRT Products). These products have been shown in repeated clinical trials to double a smokers chances of quitting. When used in combination with behavioural tobacco cessation counselling, a smokers chances of quitting can be 4-6 times higher.

What are E-Cigarettes?

Electronic Cigarettes otherwise known as electronic nicotine delivery systems (ENDS) use battery power to heat an element to disperse a solution of propylene glycol or glycerine, water, flavouring and nicotine, resulting in an aerosol that can be inhaled by the user (commonly termed vapour). Electroinic Cigarettes do not contain tobacco, do not rely on combustion and do not create carbon monoxide (one of a range of poisonous gases contained in tobacco smoke which is readily absorbed into the blood stream and displaces oxygen).

Regulation of E-Cigarettes

Tobacco products are regulated under the Tobacco Products Directive. E-cigarettes have recently been regulated as a result of the enactment of the Tobacco Products Directive legislation. For further information on the Tobacco Products Directive please click here.

Are E-Cigarettes Safe?

We don't really know until they have been thoroughly assessed and monitored in a large population over time. E-Cigarettes contain nicotine which is addictive. E-cigarette vapour also contains propylene glycol, which has not been adequately studied with regard to its safety when heated and inhaled deeply and repeatedly. also present are a variety of additives and contaminants.

The HSE would not recommend anyone who is not already a smoker (i.e. using a regular tobacco product) to use an E-Cigarette, however compared with regular cigarettes, e-cigarettes are generally regarded as being less harmful than regular tobacco.

Because the vapour from e-cigarettes does not contain tobacco combustion products, which are known to be responsible for most of the adverse health effects of smoking, using e-cigarettes (known as "vaping") is generally regarded as a safer alternative to smoking tobacco for those unable or unwilling to stop using nicotine.

Will e-cigarettes help smokers quit?

It is now widely accepted that the compulsive use of tobacco is a result of the development of dependence upon the nicotine present in tobacco and many of the approved pharmacological interventions such as Nicotine Replacement Therapy(NRT) that are employed to aid smoking cessation, target this dependence in a controlled manner. E-Cigarettes can reduce urges to smoke and may help smokers to quit although data in this area is not as robust as those for licensed stop smoking medicines. However, no e-cigarettes have been approved as a medicine for smoking cessation by the HPRA in Ireland; consequently the HSE cannot recommend E-Cigarettes as a smoking cessation aid.

In considering Electronic Nicotine Delivery Systems (ENDS), such as Electronic Cigarettes as a potential cessation aid, a 2014 WHO report notes that the evidence for the effectiveness of ENDS as a method for quitting tobacco smoking is limited and does not allow conclusions to be reached; and recommends that smokers should first be encouraged to quit smoking and nicotine addiction using a combination of already approved treatments.

The HSE in consultation with other agencies to develop the evidence base in this area and is keeping emerging evidence under review. The Health Information and Quality Authority(HIQA) is undertaking a health technology assessment (HTA) of smoking cessation interventions (June - December 2016). The aim of this assessment is to compare the clinical and cost-effectiveness of a range of available interventions to help people quit smoking, to aid decision making in relation to the provision of smoking cessation therapies in Ireland.

HSE Cessation Services

The HSE encourages all smokers to QUIT smoking and to consider and inform themselves of all options available to help them in order to succeed. The HSE provides and promotes a range of safe and evidence-based services, supports and aids that help people to quit and stay quit.

NRT has been designed and approved by the HPRA for use in a controlled manner to assist in smoking cessation.

The HSE cannot recommend E-Cigarettes as a smoking cessation aid as they are currently not regulated or approved for that purpose.

The HSE recommends that smokers trying to quit, use a combination of already approved treatments.

Smokers who have tried approved treatments without success and intend to use E-cigarettes in an effort to quit should consider using them in combination with HSE behavioural support/counselling services and seek advice from a HSE smoking cessation specialist.

HSE's QUIT Services at:

Quit.ie

Freephone 1800 201 203

Freetext QUIT to 50100

Email: Support@quit.ie

Facebook: www.facebook.com/HSEQUIT

Tweet: @HSEQuitTeam

The Tobacco Control Framework Implementation Group have developed the following guidance to support staff in the management of any issues that may arise in the implementation of this policy.

Sample Posters for Local Adaptation, prohibiting e-cigarettes: