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Hospitals are wrong to ban e-cigarette use

BMJ 2015; 351 doi: (Published 30 September 2015) Cite this as: BMJ 2015;351:h5063
  1. David Shaw, senior research fellow, Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland

Hospitals should encourage innovative use of electronic cigarettes to reduce harm from tobacco, writes David Shaw

All health boards in Scotland with the exception of NHS Lothian have banned the use of electronic cigarettes on their grounds.1 The rationale is that more evidence is needed before we can conclude that e-cigarettes are safe. Even if this were true, it would not be sufficient justification for this policy.

By banning e-cigarettes, hospitals are failing patients who smoke, as well as those who do not. It is true that the safety profile of e-cigarettes is not yet entirely clear, but substantial evidence shows that they are safe, and overwhelming evidence shows that they are much safer for users than conventional cigarettes.2 3 E-cigarettes are also seen as an important tool to help people stop smoking, and the Medicines and Healthcare Products Regulatory Agency will license e-cigarettes as drugs from 2016.4

Smoking cessation

The ban in Scotland means not only that patients who smoke will continue to damage their own health but also that they will be denied the opportunity to access a smoking cessation aid on hospital grounds. Public Health England recently published an evidence review which concluded that e-cigarettes can help people quit smoking (and that they are 95% safer than conventional cigarettes).5 Julie White, chief operating officer at NHS Dumfries and Galloway, one of the NHS boards that has banned e-cigarettes, was quoted by the BBC as saying that “until we have more evidence available to us around their use and their impact, they should be treated like any other nicotine product and they should not be used in the grounds.”1

It will come as a surprise to users of nicotine patches and gum that they are apparently not permitted to use these smoking cessation products while in a hospital. It is inconsistent to ban e-cigarettes while allowing continued use of other nicotine based smoking cessation products. Despite their visual resemblance to cigarettes e-cigarettes contain no tobacco, do not involve combustion, and have much more in common with other non-carcinogenic nicotine delivery systems.

Another problem with the ban is that it will increase the risk of passive smoking by prohibiting a smoke-free alternative. Despite the purported “smoke-free grounds” policy of many hospitals many people still smoke conventional cigarettes on or just outside NHS premises every day. Members of the public often have to hold their breath when entering hospitals to avoid breathing in toxic fumes from several (often very ill) patients smoking just outside the hospital door; permitting e-cigarettes would alleviate this problem. However, NHS Lothian is the only board that will allow the use of e-cigarettes in designated outdoor areas, meaning that the policy of the other boards will perpetuate the risk of passive smoking for patients and visitors.

Even if e-cigarette “vapers” stand outside entrances, wisps of nicotine vapour are likely to be less disgusting and harmful to walk through than clouds of carcinogenic smoke. Furthermore, e-cigarette use is permitted in some hospital wards in England, and it is questionable whether patients should have to go outside to use vaping shelters instead of using a designated room inside the hospital.6

Part of the logic behind the ban is that e-cigarettes “normalise smoking,” and the BBC quoted White as saying that “e-cigarettes mimic the habit and look of smoking and therefore provide negative role modelling for young people.”1 This is a valid point to some extent, but the ban instead sends the message that NHS Scotland cares more about image than about improving the health of its patients and visitors to its hospitals. Permitting e-cigarette use on hospital grounds would provide much more positive role modelling for children than seeing pregnant women and patients with cancer smoking conventional cigarettes in subzero temperatures at the main entrance to hospitals. Furthermore, countries where e-cigarettes are available have seen decreases in the number of children smoking conventional cigarettes,7 8 which suggests that exposure to e-cigarettes can also improve child health.

A great public health opportunity

Banning e-cigarettes also means missing a great public health opportunity. If patients who smoke were given free e-cigarettes and the ban on normal cigarettes on hospital grounds were strictly enforced, it might improve health and reduce passive smoking around the hospital. Furthermore, any patients who switched to e-cigarettes during a hospital stay might continue vaping rather than return to tobacco cigarettes, further benefiting public health. Hospitals should be using e-cigarettes in creative ways to improve patients’ health rather than banning them while continuing to tolerate conventional smoking around their premises.

The ideological opposition to e-cigarette use in hospitals is understandable to an extent, because smoking is a highly polarised public health problem.9 E-cigarettes are not completely harmless, and their connections with the deadly tobacco industry make many people uncomfortable.10 But their potentially beneficial effect on individual and public health is undeniable. By refusing to allow the use of e-cigarettes on hospital grounds, the NHS is harming the health of patients and the wider public.


Cite this as: BMJ 2015;351:h5063


  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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