NICE comes out in support of e-cigarettes

Late last week, another independent public health organisation came out in favour of e-cigarettes and vaping. This time, it was the National Institute for Health and Care Excellence. It represents the latest victory in a series of wins for vape users and the vaping industry in general since the beginning of the year.

Let's unpack the latest good news.

The National Institute for Health and Care Excellence

The National Institute for Health and Care Excellence was originally set up to prevent variation in treatment being offered by the NHS. In the mid-2000s, they also took on responsibility for developing public health guidance after merging with the Health Development Agency. Now, this isn't standard guidance for you or me. Instead, NICE writes for 'healthcare practitioners': doctors, GPs, surgeons, nurses, NHS secretaries, social workers, and anyone else working in the health industry.

Since NICE is has the ear of healthcare practitioners the country over, they make use of it by producing standardised guidelines for how the NHS ought to treat patients.

This includes patients visiting their GP seeking to quit smoking.

NICE understands that e-cigarettes can't be marketed as medicinal products, nor prescribed by doctors. That doesn't mean, however, that doctors can't talk to their patients about e-cigarettes themselves, and the role that they can play in quitting smoking. And that's exactly what the NICE guidelines address (among other things).

The NICE guidelines

The guidelines published at the end of March are actually an update on two separate guidelines published over the course of the past decade, and feature updates to recommendations made as far back as 2006. They cover a broad variety of issues but we're interested in what they have to say about vaping.

Now, we'll be upfront: NICE does have certain reservations about vaping. For one, no vaping products are currently licensed as medications, due to a lengthy and complicated licensing process. NICE also insists that e-cigarettes are not totally risk-free, which lines up with most modern evidence.

That's just about where the bad news ends. Their reservation about licensing is moderated by the reminder that the e-cigarette industry is heavily regulated under the Tobacco and Related Products Regulations 2016 (our version of the EU TPD). And in the same breath as claiming that e-cigarettes are not risk-free, NICE urges that "the evidence suggests that e-cigarettes are substantially less harmful to health than smoking."

How the committee made the recommendation

Along with the guidelines themselves, NICE publishes short explanations of how they developed their guidelines. They also publish rationales for including certain guidelines within their advice. This gives us a detailed view of the thinking behind their e-cigarette guidelines.

Surveys run by NICE indicate that healthcare practitioners *are* being asked about e-cigarettes by their patients. And right they are to ask, since recent evidence has proven that the general public is still extremely misinformed about the relative harms of nicotine, tobacco, and e-cigarettes. Healthcare practitioners, however, don't necessarily know much more than the general public, since e-cigarettes haven't ever been part of their training and background—after all, they're not licensed medicinal products.

The guidelines that NICE has produced, then, are based in large part off of recent large-scale independent research studies. Public Health England's evidence review from back in February was a big source of information; the Royal College of Physicians of London's *Nicotine without smoke* report from April of 2016 was another.

NICE also makes special note of the lack of good long-term evidence. This is a real problem in the e-cigarette industry: the technology is so young that we haven't had time to study its long-term effects. And even less study has been performed on e-cigarettes as medicinal products. Maybe that's why PHE wants to shorten the MHRA medicinal product licensing process (if only temporarily).

Still, NICE has decided to err on the side of caution, since people who smoke shouldn't be discouraged from switching to e-cigarettes by a lack of evidence alone, especially since what evidence there is points to e-cigarettes' significant benefit over tobacco.

Looking forward

All of this should shape policy written and informed by healthcare practitioners in the next few years, so keep an eye on the vaping legislation coming out over the course of 2018.

In the meantime NICE notes that the costs of adopting these guidelines shouldn't be particularly expensive, either in time or in resources. "Managers of services providing stop smoking support may need to ensure staff are aware of the latest information, but costs should be minimal," NICE writes.

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