“Should adult patients and guests be allowed to smoke e-cigarettes inside the hospital”

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20 Nursing Times 12.02.14 / Vol 110 No 7 / www.nursingtimes.net Nursing Practice Research review Smoking cessation Keywords: E-cigarettes/Smoking cessation/Vaping ●This article has been double-blind peer reviewed E-cigarettes have a glowing light and emit Alamy vapour so they resemble real cigarettes Authors Wendy Preston is nurse consultant, George Eliot Hospital, Nuneaton, Warwickshire, and senior lecturer, Coventry University; Stephen Ayre is library services manager, George Eliot Hospital. Abstract Preston W, Ayre S (2014) Are e-cigarettes a safer alternative to smoking? Nursing Times; 110: 7, 20-21. Smokers appear to be using electronic cigarettes in attempts to quit but the products are currently unregulated. This article explores evidence regarding electronic nicotine delivery devices – usually known as e-cigarettes – and how this relates to clinical practice. It also discusses secondary care smoking cessation services in the light of NICE guidance. The safety of electronic cigarettes has received considerable attention (Hogenboom, 2013; Traynor, 2013), as people appear to be increasingly using them as an alternative to tobacco (Action on Smoking and Health, 2014). Electronic nicotine delivery devices (ENDDs) – commonly called e-cigarettes – are electronic devices that mimic real cigarettes. Operated using chargeable batteries, they deliver nicotine through vapour rather than smoke. They usually look like cigarettes, and reproduce the glowing light at the end of a cigarette when it is inhaled, and steam that mimics smoke when it is exhaled. The nicotine content varies and they are made in several strengths. There are also devices that deliver vapour with nicotine, in a process known as “vaping”. These also come in a variety of strengths and flavours, and can contain shisha, which is predominately a fruitbased tobacco mix. 5 key points 1 E-cigarettes are electronic devices that mimic real cigarettes 2The nicotine content of e-cigarettes is variable and they can be purchased in several strengths 3Regulation of e-cigarettes and related devices may help to develop this potential treatment 4Patients should be encouraged to attend smoking cessation services 5More research on e-cigarettes is required E-cigarettes: product variety Tobacco is smoked to obtain nicotine, mainly to relieve nicotine withdrawal symptoms. Although nicotine has few serious adverse effects, smokers expose themselves to serious harm from tar and gases, including oxidant gases and carbon monoxide, from cigarettes (National Institute for Health and Care Excellence, 2012). Replacing conventional cigarettes with e-cigarettes and similar devices could appear to be reducing harm from cigarettes, and a body of evidence is developing to support this (ASH, 2014). However, currently, the evidence for smoking cessation is stronger, and NICE recommends a programme of behavioural support and a licensed nicotine replacement product or medication (NICE, 2012). E-cigarettes are not regulated medicines so the ingredients and amount of nicotine contained in each e-cigarette may vary. In response to this, the Medicines and Healthcare Products Regulatory Agency is planning to introduce regulation from 2016. The difficulty when looking at the effectiveness of e-cigarettes in helping smokers quit is that the range of devices is vast and they work in different ways. There are many formulas and flavours; these are tested as food products for oral consumption – their effects on airways when inhaled have not been studied. These issues were discussed at the E-Cigarette Summit held in November 2013 in London (http://e-cigarette-summit. com), which was attended by health professionals and policy makers. Discussions highlighted the range of flavours, that the long-term effect on airways is unknown and that the products have the potential to be an irritant. In this article… Definition of e-cigarettes Research on the effectiveness of these devices Advice to give patients about their use E-cigarettes are becoming an increasingly popular alternative to smoking. However, it is still not clear whether they are a safe and effective way of quitting Are e-cigarettes a safer alternative to smoking? www.nursingtimes.net / Vol 110 No 7 / Nursing Times 12.02.14 21 Recent research on e-cigarettes Last year, two studies were published looking at the effectiveness of e-cigarettes in cessation. The first was a randomised control trial studying 697 adults who wanted to stop smoking (Bullen et al, 2013). The study investigated whether e-cigarettes were more effective than nicotine patches at helping smokers to quit. Participants were given electronic cigarettes with 16mg of nicotine, a daily 21mg nicotine patch or placebo electronic cigarettes. They were studied from the week before they intended to stop smoking until 12 weeks after their designated quit day. The study found that e-cigarettes, with or without nicotine, were moderately effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches. However, the researchers said more studies were urgently needed to establish the benefits and harms of e-cigarettes as they were unable to follow up the results of 22% of participants. The second 12-month randomised control trial looked at the efficiency and safety of e-cigarettes (Caponetto et al, 2013). Three hundred smokers, aged 18-60 years, who did not intend to quit were divided into three groups. One group was given up to four 7.2mg nicotine cartridges per day, the second 7.2mg nicotine cartridges for six weeks followed by up to four 5.4mg nicotine cartridges per day for six weeks, and the third group up to four placebo cartridges per day. While all three groups smoked fewer cigarettes at the end than at the start of the study, after 52 weeks there were no significant differences between them in terms of the number of cigarettes smoked or quit rates. The study also found that, for smokers not intending to quit, the use of e-cigarettes, with or without nicotine, decreased cigarette consumption and resulted in their being able to stop smoking without significant side-effects. Again, because of the high drop-out rate (39%), researchers recommended that more studies were needed to establish the safety and effectiveness of e-cigarettes. Using e-cigarettes in practice In clinical practice, the lack of robust evidence makes it difficult for health professionals to recommend e-cigarettes or related devices. However, patients are using e-cigarettes to help them quit and practitioners need to respond to this development. People using e-cigarettes should still be offered smoking cessation referrals because quitting is thought to have better outcomes than harm reduction. Patients should be informed of the lack of robust evidence supporting the use of e-cigarettes to stop smoking, but it is important to be non-judgemental if they are using them. If patients are not ready to try quitting, this may be a harm reduction opportunity and, in time, may lead to cessation. Advice on cessation services is outlined in Box 1 and use of e-cigarettes in Box 2. E-cigarettes: the future Once regulated, e-cigarettes and related devices may become useful in smoking cessation as part of a treatment plan that includes behavioural support. However, more research is required to provide evidence on how effective this approach would be in helping people to quit, and this research needs to compare like with like. For example, it could compare: behavioural support; nicotine patch and e-cigarettes with behavioural support; nicotine patches; and a short-acting nicotine replacement product. Smokers have the best chance at quitting if they have medication combined with behavioural support for at least 12 weeks, and a combination approach to nicotine replacement therapy is more effective than a single therapy (NICE, 2008). This means future research needs to compare e-cigarettes or similar devices with a combination approach (NICE, 2013a; 2013b). More research is also needed to establish how e-cigarettes work and their effect on the body. NT References Action on Smoking and Health (2014) E-Cigar
ettes Briefing. London: ASH. tinyurl.com/ ash-e-cig British Thoracic Society (2013) Stop Smoking Champions. The Case for Change. London: BTS. tinyurl.com/BTS-smoking Bullen C et al (2013) Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet; 382: 9905, 1629-1637. Caponnetto P et al (2013) Efficiency and safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One;  8: 6, e66317. Hogenboom M (2013) Electronic cigarettes could save millions of lives. BBC News; 12 November. tinyurl.com/bbc-e-cig National Institute for Health and Care Excellence (2013a) Smoking Cessation in Secondary Care: Acute, Maternity and Mental Health Services. London: NICE. nice.org.uk/PH48 National Institute for Health and Care Excellence (2013b) Tobacco: Harm Reduction Approaches to Smoking. London: NICE. nice.org.uk/PH45 National Institute for Health and Care Excellence (2012) Smoking Cessation Care. London: NICE. cks. nice.org.uk/smoking-cessation National Institute for Health and Care Excellence (2008) Smoking Cessation Guidance. London: NICE. nice.org.uk/PH10 Traynor I (2013) Refillable electronic cigarettes face EU ban. The Guardian; 17 December. tinyurl. com/ban-e-cig-eu ● E-cigarettes are not licensed so health professionals should not recommend them ● Devices vary significantly and offer a wide range of nicotine doses ● Abrupt cessation is the most effective method of smoking cessation. Support is available from NHS stop smoking services in a range of locations ● Health professionals should suggest to patients that advice can be sought from smoking cessation services for support to cut down to quit ● Health professionals should consult hospital smoke-free policies to check whether e-cigarettes are allowed Smoking cessation services should be available in a range of locations that are accessible to the public, including hospitals. National Institute for Health and Care Excellence (2013a) guidelines describe how stopping smoking at any time has considerable health benefits for people who smoke and for those around them. In hospitals, there are additional advantages, including shorter hospital stays, lower drug doses, fewer complications, higher survival rates, better wound healing, fewer infections and fewer readmissions after surgery. NICE (2013a) recommends that smoking should be banned on hospital premises. Secondary care providers have a duty of care to protect the health of and promote healthy behaviour among people who use or work in their services. The British Thoracic Society has published a recommendation paper for services. It also has a range of resources to help clinicians develop services, such as the Case for Change paper and the Return on Investment calculator (BTS, 2013). ● Details of local smoking cessation services are available at www.nhs.uk/ smokefree or by calling 0300 123 1014. Box 1. Stop-smoking services Box 2. e-cigarettes and clinical practice Nursing Times.net For articles on smoking cessation, go to nursingtimes.net/smoking

1 Will you permit or prohibit e-cigarette use? Five questions to ask Five questions to ask before you decide This briefing has been produced following approaches by organisations considering permitting or prohibiting the use of electronic cigarettes by their staff, clients or customers, or generally on their premises. The public health community is still debating the pros and cons of these new products and the advice of policy makers is limited by the available evidence. This briefing has been written to assist you in reaching your own decision. The information we are providing is consistent with that published by the Medicines and Healthcare products Regulatory Agency (MHRA) in respect of nicotine containing products (NCPs), public health guidance on smoking cessation and tobacco harm reduction issued by the National Institute for Health and Care Excellence (NICE), advice from the Chartered Institute of Personnel and Development (CIPD) and the requirements of the smokefree legislation as advised by the Chartered Institute of Environmental Health (CIEH).1,2,3,4 The term “electronic cigarette” is a generic term and not very helpful since, despite their name, “electronic cigarettes” are totally different from cigarettes. Many, but not all, are in the form of thin white tubes that look like cigarettes. Some electronic cigarettes contain nicotine, some do not. Some produce a white odourless vapour, others produce no vapour at all. They do not burn tobacco and do not create smoke (products of combustion). In this briefing we will refer to them as Nicotine Containing Products (NCPs).5 Recommended approach In order to establish a sensible and justifiable policy, we are advising that you first consider the following five questions: 1. What are the issues you trying to deal with? 2. What do you think you need to control? 3. Do you have concerns about the possibility of harm from NCPs? 4. Will restricting or prohibiting use of Nicotine Containing Products support compliance with smokefree policies? 5. Do you want your policy to help to improve people’s health? 1. What are the issues you are trying to deal with? Three main issues of concern have been raised by public health professionals. • Maintaining compliance with smokefree legislation Throughout the UK smoking is prohibited by law in virtually all enclosed workplaces and public places, on public transport and in vehicles used for work. This is because of the conclusive scientific evidence of the harm that can be caused not only to the smokers themselves, but also to people other than the smoker through the inhalation of so-called ‘secondhand smoke’. However, the smokefree legislation is only concerned with smoking tobacco and other ‘lit’ materials, that Will you permit or prohibit e-cigarette use on your premises? January 2014 2 Will you permit or prohibit e-cigarette use? Five questions to ask is to say, when combustion or burning is taking place. For this reason, it is not an offence to have an unlit cigarette in your hand or your mouth, and neither is it an offence to use an NCP. These issues are explored more fully below.6 • Promoting good role models to children The smokefree laws described above are frequently being extended by local policies for the protection of children. The main reason for restricting or prohibiting smoking in outdoor areas used by children – for example in play parks, school grounds and beaches – is that the less smoking appears as “normal behaviour” to a child, the less likely they are to start to smoke. The evidence of the effect of role models in smoking is strong and children who live in households where more than three people smoke are 8 times more likely to smoke themselves. There is no comparable evidence on NCPs. These issues are dealt with in more detail below.7,8,9 • Projecting a clean and ‘healthy’ image for your premises A further and important use of the voluntary adoption of smokefree policies in areas not covered by the legislation is to establish and maintain the clean and ‘healthy’ image of premises, especially our hospitals, clinics and other treatment and care centres where it can be expected that there will be serious intentions to discourage smoking and maintain a clean and healthy environment. Any employer might deal with the use of NCPs by staff in the same way as they might permit or prohibit eating or drinking on duty. Many business premises have problems with smokers congregating around entrances so that visitors have to pass through smoky areas when arriving and departing.10,11 2. What do you think you need to control? The products you might want to permit or prohibit should depend on the issues you are trying to deal with. • Lookalikes? Should your policy cover only products that resemble cigarettes and therefore could be confused with them? There is no doubt that many NCPs are intended to resemble cigarettes – some even have a torch-light in the end intended to simulate the glowing tip of a lit cigarette. • Nicotine? Should your policy cover the use of all forms of nicotine? There are many forms of medicinal nicotine available on prescription and over-the-counter including lozenges, mouth sprays and gums. In particular, there is a licensed medicine called the Nicorette® Inhalator, which is a thin white tube from which you draw nicotine into your mouth in the same way as you smoke a cigarette. Unlike most NCPs of the electronic cigarette type, it does not produce a vapour, nor does it light up at the end. Would you want your policy to permit or prohibit the use of this medicine which many people find an effective aid to stopping smoking? • Vapour? Should your policy cover only products that create a vapour? From a distance there is no doubt that some people will mistakenly perceive that people are smoking and may make complaints as a result. The inhalator described above, may look very much like a cigarette but does not produce any vapour and it does not have a glowing tip. • Medicines? At the time of writing (October 2013) the MHRA has not licensed any socalled “electronic cigarettes” as medicines but we understand that some are being considered. Again, would your policy include stopping someone from using a licensed medicine which they are using because they have been advised is safe to use and an effective alternative to smoking? 3 Will you permit or prohibit e-cigarette use? Five questions to ask 3. Do you have concerns about the possibility of harm from NCPs? Smoking tobacco in public is harmful in at least three major ways: • Direct harm – smoking tobacco is directly harmful to the smoker, • Indirect harm – both the smoke from lit tobacco and the exhaled air of the smoker are harmful to bystanders, especially indoors or when the smoker and bystander are in close proximity, • Role models – young people who see smoking can mistakenly believe this to be a normal adult activity and this may influence them to smoke themselves. NCPs are not the same as cigarettes, which burn tobacco. It is important to remember that, despite their resemblance to cigarettes, they are in no way cigarettes in anything but name: they do not produce smoke (products of combustion). They may use flavourings which have been derived from tobacco and they may produce a vapour which will be largely propylene glycol (PG), nicotine and flavourings. Studies on animals exposed to high intensities of PG found no evidence of harm and PG is classified as “Generally Recognised as Safe” by the US Food and Drugs Administration: indeed, so safe that it could be ingested as 5% of the daily diet over long periods of time without sign of frank toxicity. While some commentators have raised possible health risks to the user, there is no situation where it would be safer to smoke a cigarette, either for the user or those around them. Importantly, there is no evidence of harm from “secondhand” inhalation of NCP vapour.12,13,14,15,16 The ‘harms’ in relation to the use of NCPs are very different: • Direct harm: The MHRA reviewed 4 brands of NCP and found some evidence of potentially harmful chemicals in some produ
cts. Reviewing the literature the MHRA found high variability and evidence of the presence of several potentially harmful constituents. These two sets of findings informed the decision to regulate NCPs for safety. However, they concluded that reported safety issues “do not of themselves suggest a major public health concern” and found no evidence that NCP use was more harmful than smoking. An analysis of refill liquids found that “impurities are detectable in several brands… but below the level where they would be likely to cause harm”. In the UK, 99% of NCP users are smokers or ex-smokers. In so far as they completely replace tobacco smoking with NCPs, users reduce the harm they cause themselves and others.17,18,19,20 • Indirect harm: We have been unable to find any published scientific evidence of harm from indirect exposure to NCPs. The MHRA review considered four studies looking at passive harm, or what we would call ‘secondhand exposure’. All these studies found levels of potentially harmful constituents in vapour at levels which are, by many times, lower than tobacco smoke, with one concluding “no apparent risk to human health”. Concerns have also been expressed about product safety and there is evidence of fire risk, particularly while some products are being recharged. If that is your concern then a general prohibition of unapproved electrical chargers for all personal devices and the specific prohibition on charging NCPs may be most appropriate. 18, 21 • Role models: Many public health advocates are concerned that the availability and use of NCPs that resemble cigarettes, as some NCPs do, could “re-normalise” smoking, so encouraging their use among children and acting as a gateway to smoking. Others have suggested use of NCPs does not model smoking, but the replacement of smoking, with users conspicuously avoiding the harms smoking causes. As yet, there is little evidence on either side although it seems likely that both effects will occur. The available evidence does suggest that, so far, sustained use of NCPs among children in Britain is limited to those who have already tried smoking. This will remain an important area of research. 17 4 Will you permit or prohibit e-cigarette use? Five questions to ask 4. Will restricting or prohibiting use of Nicotine Containing Products support compliance with smokefree policies? One common rationale for restricting or prohibiting the use of NCPs is to support compliance with smokefree legal requirements and voluntary policies. This is because there are reasonable concerns that if people are allowed to use NCPs in places where the law prohibits smoking, or where no-smoking policies are in place, then they may be mistaken for actually smoking. This may encourage others to smoke believing either that it is permitted to do so or that no action will be taken against them for doing so. Of course, it is entirely a matter for the owner, manager or person in control to decide what is to be permitted on their premises or in their vehicles. The CIPD cautions that employers should consider electronic cigarettes explicitly in their employment policies and that “[employees] could challenge any disciplinary action arising from using e-cigarettes outside of a designated smoking area. To avoid this risk, employers could assign a separate area for e-cigarette users, well away from the designated smoking area”. 3 Other factors employers may wish to take into account include: • In pubs, clubs and restaurants it may be impractical for staff who are busy serving customers to be repeatedly checking to determine whether people are smoking or only using an NCP. In these circumstances a blanket prohibition may well be justified and people wishing to use NCPs that resemble cigarettes could be required to do so outside the premises to avoid confusion with smokers. • In some circumstances, the permission to use NCPs may be used in order to discourage people from leaving the premises, for example where customers are engaged in activities from which the owner derives their income e.g. casinos and bingo halls, and where security cordons are in place e.g. where money or high value items are being stored or sold. • Wherever NCP use is permitted and smoking needs to be discouraged, deterred and detected then the use of smoke alarms and ignition detectors can be useful in distinguishing between smoke and vapour, and signs to advise people these warning devices are being employed can act as a deterrent. Some of these can be set to operate a silent alarm, such as a flashing light, at a reception desk or other location where members of staff can be alerted to investigate. • Where NCPs are being sold, for example at some airports and flights, it might well be considered to be unreasonable not to allow people to actually use the product they have been encouraged to purchase. • There is no doubt that some people will try to avoid enforcement action by claiming an NCP was being used when in fact smoking has taken place. Drivers of taxis and other commercial vehicles have attempted to do so. Local Authority regulatory officers are perfectly able to determine when smoking has taken place through both the smell associated with tobacco smoking and the presence of ash and other smoking materials. • Finally, it should be remembered that offering a safe and effective alternative to smoking tobacco to people who are addicted to nicotine may turn out to support compliance with smokefree legal requirements and make smokefree policies easier to implement. 5 Will you permit or prohibit e-cigarette use? Five questions to ask 5. Do you want your policy to help to improve people’s health? It is likely that the MHRA will license some Nicotine Containing Products as medicines and that these will include some which resemble cigarettes. Under MHRA proposals all similar products which are not licensed would have to be withdrawn from sale, although their actual use would not be illegal. It would probably be impractical for your policy to restrict use of NCPs to only licensed products. However, prohibiting the use of all NCPs, including the licensed products, could mean that you are denying people the use of prescribed medicines, which could assist them in giving up smoking, staying tobacco free or dealing better with periods when they are not allowed to smoke.22 So far, only a few, relatively small randomised control trials have been completed on the use of NCPs in supporting quit attempts and no NCPs have yet been licensed for this purpose. However, emerging evidence suggests that they may be as effective as nicotine products currently and there is evidence that smokers, even those who do not intend to quit, are able to reduce or completely replace their smoking when provided with NCPs.23,24,25 Many NCP users are using them as part of a quit attempt (a supported attempt to stop smoking completely) or to reduce the harm to themselves and others from smoking. Requiring staff who are trying to quit to use their quitting aids only in smoking breaks in areas where others are smoking tobacco is unlikely to help them quit successfully.23,26 Tips on formulating your policy on NCPs • Be clear about what you are trying to achieve, especially on how you are intending to make the situation better. • Be clear about precisely what you are prohibiting – nicotine containing products, things that could be confused with cigarettes, or both. • Make sure your policy is good for health, by helping and not hindering smokers to reduce the harm caused by smoking. • Consider the part that your policy can play in ‘renormalising’ or ‘denormalising’ the smokefree environment and promoting the right role models to children. Further reading • ASH Briefing: Electronic Cigarettes • ASH Factsheet: Smokefree Legislation • ASH Briefing: Use of e-cigarettes in Great Britain among adults and young people • ASH Briefing: The regulation of e-cigarettes and other nicotine products in the UK – Q&A Examples of products Some NCPs look like cigarettes, contain nicotine, have a glowing red tip and emit vapour. Some NCPs do
not emit vapour and have no glowing tip, such as “smokeless cigarettes” Some NCPs have tips that glow other than red Some NCPs are available with nicotine and nicotine-free re-fills. Not all are designed to look like cigarettes. 6 Will you permit or prohibit e-cigarette use? Five questions to ask References 1. MHRA Nicotine Containing Products 2. NICE Public Health Guidance on Tobacco Harm Reduction PH 45 3. Dealing with e-cigarettes at work, CIPD November 2013 4. CIEH Smokefree workplaces and public places 5. ASH Briefing: Electronic Cigarettes 6. ASH Fact Sheet: Smokefree Legislation 7. Thomson G. Should smoking in outside public spaces be banned? Yes BMJ 2008;337:a2806 8. Chapman S. Should smoking in outside public spaces be banned? No BMJ 2008;337:a2804 9. Health and Social Care Information Centre. Smoking, drinking and drug use among young people in England in 2012. 10. NICE Guidance for Smokefree Hospital Trusts 11. NICE Draft Public Health Guidance Smoking cessation in secondary care: acute, maternity and mental health services NICE, 2013 12. Borland, R. Electronic cigarettes as a method of tobacco control. British Medical Journal 2011; 343: d6269. doi:10.1136/bmj.d6269 13. Wagener T, Siegel, M, & Borrelli, B. Electronic cigarettes: Achieving a balanced perspective. Addiction 2012; 107: 1245–1548. doi:10.1111/j.1360-0443.2012.03826.x 14. Cobb NK, & Abrams DB. E-cigarette or drug delivery device? Regulating novel nicotine products. New England Journal of Medicine 2011; 365:193–195. doi:10.1056/NEJMp1105249 15. Robertson OH, Loosli CG, Puck TT et al. Tests for the chronic toxicity of propylene glycol and triethylene glycol on monkeys and rats by vapour inhalation and oral administration. J Pharmacol Exp Ther 1947; 91: 52–76. 16. Database of Select Committee on GRAS Substances (SCOGS) – Propylene Glycol US FDA, 1973 17. Assessment of the constituents of four e-cigarette products CHM Working Group on Nicotine Containing Products 18. Quality, efficacy and safety of unlicensed NCPs CHM Working Group on Nicotine Containing Products 19. ASH Briefing: Use of e-cigarettes in Great Britain among adults and young people (2013) 20. Etter JF, Zather V, Svensson S. Analysis of refill liquids for electronic cigarettes Addiction 2013; 108:9;1671–1679 21. Electronic Cigarettes Information and Fire Prevention Guidance. Greater Manchester Fire and Rescue Service (2013) 22. ASH Briefing: The regulation of e-cigarettes and other nicotine products in the UK – Q&A (2013) 23. Pokhrel P, Fagan P, Little MA, et al. Smokers who try E-Cigarettes to quit smoking: Findings from a multi-ethnic study in Hawaii. Am J Public Health. Published online ahead of print July 18, 2013: e1–e6. doi:10.2105/AJPH.2013.301453 24. Caponnetto P. EffiCiency and safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: A prospective 12-Month randomized control design study. PLoS One 2013; 8(6): e66317. doi:10.1371/ journal.pone.0066317 25. Bullen C, Howe C, Laugesen M, et al Electronic cigarettes for smoking cessation: a randomised controlled trial Published online September 7, 2013 http://dx.doi.org/10.1016/S0140-6736(13)61842-5 26. Dockrell M., Morrison R., Bauld L., McNeill A., E-Cigarettes: Prevalence and attitudes in Great Britain. Nicotine Tob Res (2013) doi: 10.1093/ntr/ntt057 First published online: May 23, 2013