As she retires a hero to many in the field of tobacco harm reduction and public health, Louise Ross has penned this blog, which starts below…
Looking back, but forwards too
In December 2017, I realised there were so many things I wanted to do apart from working for Leicester City Council, especially as my employer was being forced to severely cut our very successful service and blend it with other lifestyle services.
I announced my retirement, planned for the end of March 2018, explaining my rationale to each team member individually (an emotionally taxing episode; we’re a very close team) with the words ‘I want to enjoy some free time because you just don’t know what’s around the corner.’
Turns out, this was truer than I could have known. Within a few weeks, I had been diagnosed with a brain tumour, and never went back to work again.
This doesn’t mean to say I haven’t still been active: my appetite for steering the activities of the team, and influencing wider tobacco control work remains undiminished, and I hope to continue with freelance and voluntary work in the field, particularly making noise on social media.
It seems timely though to look back on my years as a stop smoking service manager (started in 2004, had only just stopped smoking myself, knew very little about my chosen subject) particularly the last four years since we grasped the opportunity presented by vaping.
I think it’s fair to say that if e-cigarettes hadn’t come along, I would have finished sooner. Repeating the mantra of ‘you’re four times more likely to quit with a specialist service’, the annual No Smoking Day efforts, the challenge of coming up with something different for articles (Ten Tips to get you to stick with your New Year’s Resolution) can really only hold your interest for a few years.
Looking back, the biggest breakthrough, prior to vaping, was being able to convince mums-to-be, midwives and other clinicians that it was safe to use nicotine replacement therapy during pregnancy. Prior to around 2006, this was seen as hugely risky, and women who couldn’t stop smoking on their own using sheer willpower just had to carry on smoking. Using a compelling metaphor of a glass of dirty water and a glass of clean water offered to a desperately thirsty person crossing the desert, we finally convinced most parties that clean nicotine was a safer alternative to continuing to smoke. Not all clinicians were convinced straight away, and we still get the occasional healthcare worker telling their patients that the stress of stopping smoking is far worse than continuing to smoke.
Champix was another highlight: frequently criticised for its potential side-effects, it was responsible for many service users who had tried everything else being able to stop smoking, with no adverse events. Word of mouth drove this mini-revolution; successful service users told their families, friends and neighbours, who came to us asking for ‘that tablet’. Of course, GPs were keen to promote the use of Champix too. A prescription drug that may have cost a little bit more than treatment with patches was worthwhile if it prevented worsening respiratory disease, cancer, stroke, cardiovascular disease.
It’s in this context that I scratch my head in frustration and bewilderment when I see how hard some clinicians, policymakers, researchers, so-called experts in tobacco control, fight to stop smokers opting for a harm-reduced source of nicotine – the glass of clean water instead of the dirty water.
The Leicester City Stop Smoking Service introduced the notion of switching to e-cigarettes in 2014, and my own awakening from sceptic to advocate is well-known. Every reporting Quarter since then has shown a consistently better quit rate among those who have used e-cigarettes, for both those who have also used nicotine replacement treatments as well and those who vaped exclusively. Some have done well with vaping alongside Champix too. Ironically, success rates were much higher initially, around 20% greater than the average, falling in the last couple of years to 12-15% greater than average, as people got scared to start or continue to use e-cigarettes, because of media stories.
The team have themselves become enthusiastic advocates; one of their biggest challenges though is dealing with the misinformation that media articles bombard the public with, and we work together on how to confront doubts and fears among clients. Every time a study comes out that scares smokers off vaping, we try to supply the answers.
Popcorn lung is the most common; it probably gets asked about at least once a week. Is this because it paints a picture far more appalling than that of lung cancer? As my partner asks, bemused, ‘They know the awful consequences of smoking, why do they get deterred by spurious risks of vaping?’
The other commonly-voiced objection is that no one knows the risks because no research has been done. We point out that e-cigarettes are probably more researched than any other innovation in history, and besides, it’s smokers and ex-smokers who use them, so there’s little point waiting fifty years for the long-term results, as smoking will have already caused damage and set the scene for poor health years down the line.
The most alarming aspect to e-cigarettes though, whoever you talk to, (apart from vapers and non-vaping advocates) is that e-cigarettes contain that demon substance nicotine. Unlike other preferred legal mood-altering substances – alcohol, chocolate, coffee – nicotine strikes horror into the hearts of much of the population. Not only misunderstood and believed to cause cancer, it is thought to be highly addictive, fatal if touched or swallowed even in tiny quantities, and is the subject of the most bollocksy personal views that get repeated over and over by people who don’t feel the need to check out the facts. And yet it is the continuing use of clean nicotine that may well stop ex-smokers relapsing to smoking once again. After all, NICE said so in their harm-reduction guidance PH45.
After fourteen years managing a stop smoking service, I truly believe that one of the reasons ex-smokers find it so hard to stick with not smoking is that they miss the pleasure of smoking: the fiddling with a packet, the feel of the cigarette, the first draw, the hit of nicotine. This wins in the battle between intention (to not smoke because it’s bad) and desire (I really want that feeling again). All those sensations are comfortably replicated using a good quality, even if basic, vaporiser.
I will always challenge those who take the moral stance over this. ‘It’s OK to use one to stop smoking, as long as they come off that too as soon as possible.’ No, it’s none of your business how long someone chooses to use nicotine for, just like no one wags a finger at your caffeine use. (‘Oh, I have to have four strong espressos before I can start work’ – so your addiction is cool, theirs needs remedial treatment.)
I want to make a brief mention of the amazing work done by the National Centre for Smoking Cessation and Training (NCSCT). (There are many others who deserve accolades, but I’d be scared to miss some out, so I won’t even go there.) Dr Andy McEwen has worked tirelessly to inform and influence stop smoking services and other stakeholders of the value of e-cigarettes. Do look at the website www.ncsct.co.uk for all the resources, including some great short films. Yet some services still keep their heads firmly buried in the sand; it’s often assumed that NCSCT and PHE have some mandate over what stop smoking services do, but the truth is very different. Services are bound by what their local authority says they can do. One manager recently said to me ‘Oh no dear (sic), we can’t talk about those things, no one knows what’s in them, and they’re not regulated in any way’. Ahem, TRPR, anyone?
We were fortunate indeed that our council let us take the lead on vaping, taking some risks along the way, but ultimately proving that excellent results come from listening to service users on how this made a difference like nothing they’d tried before and that that’s what they wanted to use.
The most intriguing part of retiring is that I can still be active in this field, but not have to be answerable to an organisation for what I say. So maybe this isn’t my last word on the subject. I hope I continue to have something to say on the frustrations, the triumphs, the misinformation and the breakthroughs of creating a world where vaping can edge out smoking, and people, in the UK at least, can be encouraged to do something radical for the sake of the health, their wealth, and at the same time enjoy the pleasure that it brings.
Stop Smoking Service Manager, Leicester City Council (retired)
(see the Louise Ross collection for more insights from Louise)