Smoke Free Hospital Policy v8

Policy Title

Smoke Free Policy

Policy Number

RM37

Version Number

8.0

Ratified By

Health and Safety Committee

Date Ratified

21/11/2019

Effective From

01/01/2020

Author(s) (name and designation)

Joanne Coleman, Quality Improvement Lead

Sponsor

Andy Beeby, Medical Director

Expiry Date

01/01/2022

Withdrawn Date

Unless this copy has been taken directly from Pandora (the Trust’s Sharepoint document management system) there is no assurance that this is the most up to date version This policy supersedes all previous issues

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Version Control

Version Release Author/Reviewer Ratified by/Authorised by

Date Changes (Please identify page no.)

1.0

01/10/2004 Joint Consultative Committee

July 2004

2.0

01/10/2005 Trust Policy Forum

Sept 2005

3.0

01/10/2007 RA Smith JCC July 2007

4.0

01/10/2009 RA Smith JCC March 2009

5.0

10/07/2012 Julie Orr (Acting Occupational Health Manager)

PQRS May 2012

6.0

19/08/2015 Claire Hobson Specialist Nurse Practitioner (Occupational Health

Human Resources Committee

17/08/2015 Pg 4 – updated statistics Pg 6 – patients now given a helpline number rather than an appointment with a smoking cessation advisor Pg 9 – updated references

7.0 18/01/2018 Claire Hobson (Specialist Nurse Practitioner (Occupational Health)

Director of Strategy and Transformation

02/01/2018 Page 4 statistics updated Page 9 references updated

8.0 21/11/2019 Joanne Coleman (Quality Improvement lead)

Health and Safety Committee

01/01/2020 Significant and substantial re-write to reflect advances in smokefree NHS policy, impetus on treating tobacco dependency and development of the evidence base with respect to e-cigarette use.

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Contents Section Page 1 Introduction ............................................................................................................................. 4 2 Purpose .................................................................................................................................... 5 3 Aim of policy............................................................................................................................. 5 4 Duties (roles and responsibilities) ............................................................................................ 6

5 Scope ........................................................................................................................................ 6 6 Definitions ................................................................................................................................ 6 7 Smoke Free Hospital policy ...................................................................................................... 7

7.1 Staff .............................................................................................................................. 7 7.2 Visitors and contractors ............................................................................................... 8 7.3 Patients ......................................................................................................................... 9 7.4 E cigarettes ................................................................................................................... 10

8 Monitoring ............................................................................................................................... 12 9 Diversity and Inclusion ............................................................................................................. 12 10 Consultation and review .......................................................................................................... 12 11 Implementation of policy (including raising awareness) ......................................................... 12

12 Associated documentation ...................................................................................................... 12 13 References................................................................................................................................ 13

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Smokefree Policy

1. Introduction

1.1 Approach Gateshead NHS Foundation Trust is committed to providing a safe and healthy environment and acknowledges the health hazard and welfare issue of smoking and second hand smoke for patients, visitors, contractors and staff. NHS England and Public Health England jointly called for all NHS Trusts to become Smokefree as stated in the Tobacco Control Plan for England (2017). All NHS trusts must implement NICE Guidance PH48 Smoking Cessation in secondary care, acute, maternity and mental health services to qualify as Smokefree. Gateshead NHS Foundation Trust has committed to achieving smokefree status by 1 September 2019, and has signed the NHS Smokefree Pledge. The Smokefree Pledge commits the Trust to: • Treating tobacco dependency in patients and staff • Ensuring that smokers within the NHS have access to the medication and

support they need to quit • Creating environments that support quitting through implementing a

smokefree policy • Delivering consistent messages to smokers about harms from smoking

tobacco and the opportunities to quit, and • Actively working with local authorities and other stakeholders to reduce

smoking tobacco prevalence and health inequalities. This not only looks to ensure grounds are smokefree but that all patients who are admitted are treated for their tobacco dependency with medication. Gateshead NHS Foundation Trust will adopt a pragmatic harm reduction approach to e-cigarettes and vaping. Gateshead Health NHS Foundation Trust understands its responsibility as employers to provide a working environment that is safe, without risk to health, and adequate in regards to facilities and arrangements for staff welfare at work, as required by the Health and Safety at Work Act 1974. The Trust also recognises the need to protect staff, patients and visitors from second hand smoke. It is essential that all buildings and grounds are smokefree as required in The Management of Health and Safety at Work Regulations (1999). The NHS Long Term Plan (2019) highlights prevention as a way to save over 500,000 lives over the next 10 years and calls for the NHS to lead the way in reducing smoking by treating tobacco dependency. Within the plan the NHS has committed to offering support and treatment to everyone admitted to hospital who smokes.

1.2 Health Implications Smoking tobacco is the single largest cause of health inequalities and premature death (NICE, Smoking: Harm Reduction 2015). Smoking is responsible for 17% of

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deaths in people aged 35 years and above in England (Public Health England Health Matters: Smoking and Quitting in England 2015a). The Department of Health (2011) recognises smoking to be the primary cause of preventable illness, morbidity and premature death. In 2016 smoking was still accountable for almost 80,000 deaths in England per year (NHS Digital, Statistics on Smoking – England, 2018). Smoking has been identified as the single biggest cause of inequality in death rates between rich and poor in the UK. Death rates from tobacco are two to three times higher among disadvantaged social groups (Action on Smoking and Health, 2018a). The burden of smoking, illness, morbidity and mortality, in Gateshead is greater than in England (Public Health England, Tobacco Control Profiles, 2018b). The Tobacco Control Profiles for Gateshead show that smoking attributable deaths from heart disease, stroke, lung cancer and chronic obstructive pulmonary disease are significantly higher than the England average. The annual cost to the NHS in Gateshead due to smoking related hospital admissions is estimated at £9.8 million with a further £6.6 million in local social care costs (Action on Smoking and Health, 2018c). By embedding brief advice and referral for support and treatment for patients, staff and visitors there is a clear opportunity to achieve significant short term and long term gains (National Centre for Smoking Cessation and Training, 2014). Second hand smoke has been shown to be a hazard to health. Those exposed to second hand smoke are at increased risk of lung cancer and heart disease. In addition, second hand smoke can trigger or aggravate respiratory conditions such as asthma or bronchitis. It can also irritate eyes, cause coughs and headaches, generally it can make non-smokers feel ill. Exposure to second hand smoke is a major cause of childhood illness costing the NHS nearly £12 million a year (Royal College of Physicians, 2018). In addition, it is a major risk factor for the development of heart and respiratory conditions in adults and is also a risk factor for miscarriage, stillbirth and sudden infant death (Action on Smoking and Health, 2018b).

2. Purpose The purpose of the policy provides an operational framework for managers and staff to follow when supporting staff, patients and visitors in managing their tobacco dependency. This includes effective diagnosis and support to stop smoking or maintain temporary abstinence whilst on Trust premises (or in the care of the Trust). The policy also aims to provide a smokefree environment to promote the health of employees, patients and visitors. The restriction on smoking at Trust sites is particularly important because of the example that is expected from the NHS and its employees. As an NHS organisation the Trust leads by example in providing a tobacco free environment.

3. Aim of policy The aim of this policy is to:

Protect and improve the health of staff.

Protect and improve the health of patients, visitors and contractors.

Protect both smokers and non-smokers from the danger to their health of exposure to second hand smoke.

Set an example to other employers and workforces, particularly in health related locations.

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4. Duties (roles and responsibilities)

Role Responsibilities

Chief Executive

Overall responsibility for the implementation of this policy.

Director of Nursing & Quality Trust lead for the promotion of Smoking Cessation and implementation of this policy

Human Resources Department

Policy forms part of the Trust’s Terms and Conditions of Employment for all staff employed by the Trust; breaches will be dealt with through P11 Disciplinary Procedure

Occupational Health Service Offer an advisory support service for staff wishing to stop smoking.

Community Stop Smoking Team

Will provide Smoking Cessation to staff members and patients under the care of South Tees Hospitals NHS Foundation Trust.

QE facilities security. Will deal with any observed or reported breaches of current legislation or aggressive behaviour

Directors; Associate directors, service line managers, Clinical leads, Matrons and ward and department managers.

Are responsible for supporting the implementation of trust policies. Managers should consider use of the Trust disciplinary procedure in cases where staff do not comply with the terms of this policy.

All Staff Are responsible for compliance with this policy; observe the provisions of this policy at all times, and inform others of the policy if they are working, visiting or being admitted to a Trust site.

5. Scope

This policy covers all Gateshead NHS Foundation Trust premises. These include;

All buildings e.g. offices, hospitals, cabins, staff residences and entrances.

All vehicles e.g. pool cars, lease cars and personal cars on hospital grounds.

All grounds e.g. gardens, walkways, black path and car parks. This policy applies to;

All Gateshead NHS Foundation Trust employees

The wider NHS e.g. contractors, students, voluntary staff, personnel within honorary contracts (whether or not a uniform is worn)

All patients, including out-patients, day patients, in-patients and long stay patients.

All visitors or other people whose work, study or personal circumstances brings them onto Gateshead NHS Foundation Trust sites.

6. Definitions

Conformité Européene (CE)

European Conformity quality mark used on e-cigarettes.

E-cigarette A battery-powered device that converts liquid nicotine, propylene glycol and/or glycerine, and flavourings into a mist, or vapor, that the user inhales.

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Vaping / to vape The action or practice of inhaling and exhaling the vapour produced by an electronic cigarette or similar device.

Nicotine Replacement Therapy (NRT)

Products used to replace the addictive nicotine in tobacco.

Smokefree A place where people are not allowed to smoke combustible tobacco.

Stop smoking support (SSS)

Advice and guidance for smokers wishing to switch (to e-cigarettes) or quit.

7. Smoke Free Hospital policy

7.1 Staff

7.1.1 Smoke free Grounds: Staff All employees must be made aware that the Trust has a tobacco dependency policy and operates smokefree sites. The induction process for all new employees will include reference to the policy. Staff must not smoke tobacco anywhere on Trust premises. Staff must not smoke tobacco in the vicinity of Trust site entrances in identifiable Trust uniforms or with visible identification badges/lanyards. All staff are expected to be tobacco smoke free during paid working hours. This includes whilst travelling to and from meetings and appointments. Smoking breaks are not permitted. Staff who choose to go off site to smoke tobacco must do so during an official break and must change out of uniform, remove their name badge and ensure they are free from tobacco smoke (including the residual smell) on returning to work.

7.1.2 Smokefree environment Employment procedures recognise the importance of stating that the Trust is a Smokefree organisation in order that employees are fully aware of and comply with this policy. All job advertisements will include reference to the Trust’s Smokefree NHS / Treating Tobacco Dependency policy and indicate that all Trust sites are smoke free, by use of the following language: “Gateshead Health NHS Foundation Trust is a smoke free organisation in line with Smoke Free Gateshead”. When staff are on duty or wearing Trust uniform, insignia or badge they are not permitted to smoke tobacco in public. Staff are only allowed to smoke tobacco whilst off duty (in official unpaid break times), off Trust sites, out of uniform and with no Trust identifiers. Staff must not attend for duty smelling of tobacco smoke as this third hand smoke can present a health risk and be off-putting to patients and colleagues. Employees (including those who do not wear a uniform and those with non-public facing roles) should avoid smoking prior to starting work. Smoking tobacco is not permitted in all Trust vehicles including pool and lease cars.

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Sales of tobacco products are not permitted on Trust premises. The Trust will seek to promote the option to purchase Nicotine Replacement Therapy (NRT) products and e-cigarettes on site through QE Facilities pharmacy. The Trust will ensure that products have no affiliation to tobacco companies in line with the WHO Framework Convention on Tobacco Control. The Trust supports the use of e-cigarettes by staff during official breaks and before and after duty. Staff are permitted to vape on Trust premises (outdoors). As a courtesy, staff are asked to move away from main entrances and open windows.

7.1.3 Help and Support The Trust will actively encourage employees to quit smoking tobacco. Advice and support for quitting is available from the Occupational Health Department. Alternatively, staff can contact local stop smoking support, community pharmacy or their GP practice for advice and support. Staff should be supported to switch to e-cigarettes to quit smoking tobacco. Contact details for sources of stop smoking support are provided below:

Trust Occupational Health Department 0191 4455494

Stop Smoking Support (Gateshead) 0191 4333058

Smokefree National Helpline 0300 123 1044

7.1.4 Treating Tobacco Dependency

Employee responsibilities include being familiar with and observing the Smokefree NHS / Treating Tobacco Dependency policy at all times. Reliance is placed upon every employee to assist the Trust in the operation of this policy by undertaking agreed training and supporting smokers to quit or switch to e-cigarettes or maintain temporary abstinence whilst in the care of the organisation. Managers are responsible for ensuring their staff are familiar with the Smokefree NHS / Treating Tobacco Dependency policy and monitor the application of policies within their own area. Any breaches of the policy should be dealt with in accordance of the Trust disciplinary procedure.

7.2 Visitors, contractors and other NHS employees working on Trust premises All contracts placed by the Trust must include the requirement to meet obligations within this Smokefree NHS / Treating Tobacco Dependency policy at all times. If a visitor or contractor attempts to smoke tobacco, it is the responsibility of all staff to tactfully approach them and request that they refrain from smoking. Staff should signpost smokers to stop smoking support and highlight the availability (where applicable) of nicotine replacement therapy or e-cigarettes. Nicotine replacement therapy can also be purchased from community pharmacies and other retailers by visitors.

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7.3 Patients Hospital admission can be a key teachable moment where patients may be more receptive to advice and an offer of support to quit smoking tobacco as many are experiencing a period of heightened motivation due to ill health. Providing brief advice and support by treating tobacco dependency during hospital attendance or admission is an effective way to help smokers avoid withdrawal, manage addiction and be comfortable whilst in the care of the Trust. A referral to local community specialist stop smoking support should be provided for those who wish to make a quit attempt. The most cost effective intervention in treating patients who smoke is to treat tobacco dependency (National Centre for Smoking Cessation and Training, 2014). All patients who meet a health care professional should be asked their smoking status as an integral part of routine care. Patients who use tobacco should be offered medication (nicotine replacement therapy) and informed about how they can quit smoking tobacco (National Centre for Smoking Cessation and Training, 2014). Staff should refer to the patient group directives for inpatients and the Nicotine replacement therapy bundles within the electronic prescribing system. 7.3.1 Smoke free Grounds: Patients

Patients will be informed in writing of the Smokefree policy in pre-admission literature. Where patients insist on leaving the hospital site to smoke they should be informed that this is against advice and is not in their best interests; this should be documented in the patient record. First check that the patient has been offered nicotine replacement therapy as this may be an important opportunity to support the Trust’s smokefree approach. Trust employees should not accompany or escort patients who insist on leaving the ward to smoke tobacco. If a patient attempts to smoke tobacco on Trust premises they should be tactfully approached and reminded of the Smokefree policy and requested to refrain from smoking in the interests of health and safety. Staff should not enter into any confrontation that may put their personal safety at risk (Violence, Aggression and Lone Worker Policy). Tannoy announcements can be made at the main entrances of Queen Elizabeth Hospital, entrance to maternity and Bensham Hospital to remind visitors and patients of the Trust’s smokefree approach (Standard Operating Procedure: Activation of Smoking Tannoy Procedure).

7.3.2 Smoke free environment Staff who visit patients in their own homes may be at risk of exposure to second hand smoke. Patients should be asked to provide a smokefree environment by not smoking indoors in the hour prior to any appointment.

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7.3.3 Treating Tobacco Dependency Whilst in hospital all staff must complete Very Brief Advice (VBA) on admission, informing patients of the Trust’s Smokefree policy. VBA on smoking tobacco should follow this guidance: • Ask all patients about their smoking status and accurately record. • Advise tobacco dependent smokers that the most effective way of

quitting is with the combination of medication and support. • Act by offering patients nicotine replacement therapy and a referral to

stop smoking support. For patients who do not wish to quit smoking cigarettes but who have a tobacco dependency, nicotine replacement therapy should be offered (in line with NICE Guideline PH48) to facilitate temporary abstinence during their stay in hospital. Nicotine replacement therapy is available in all in-patient clinical areas in line with the agreed local formulary guidance for hospital in-patients. Nicotine replacement therapy is licensed for use in patients 12 years and over. Use of e-cigarettes should be promoted to patients who decline the offer of nicotine replacement therapy.

7.4 E-Cigarettes E-cigarettes are battery-powered devices that allow the user to inhale nicotine in a vapor rather than smoke and are currently the most popular aid used to quit or abstain from smoking tobacco (BMA, 2017). Unlike tobacco cigarettes, e-cigarettes do not contain cancer-causing tobacco or involve combustion. E-cigarettes appear to be effective when used by smokers as an aid to quitting smoking. The Royal College of Physicians has concluded that the hazard to health arising from long-term e-cigarette use is unlikely to exceed 5% of the harm from smoking, and switching completely from smoking to e-cigarettes conveys both substantial short-term and probable longer-term health benefits. In keeping with recent guidance the Trust recognise the reduction in risk by using e-cigarettes as opposed to continuing to smoke tobacco and will support staff and patients to switch to quit. E-cigarettes present an opportunity to significantly accelerate already declining smoking rates, thereby tackling one of the largest causes of death in the UK today. 7.4.1 E-cigarette usage on Trust premises

The use of e-cigarettes is permitted on Trust grounds, outside Trust premises. Users are asked to move away from entrances and open windows for the comfort of others.

7.4.2 Charging of e-cigarettes E-cigarettes may be charged on site if the device charger was supplied with the e-cigarette and displays the CE quality mark of European Conformity. The charger must be checked by a member of staff prior to using to confirm it is free from visible defects, cracks, burn marks or damage to cables. If the person charging the e-cigarette falls asleep or is away from their device then it should be unplugged. Once the e-cigarette is fully charged the device must be unplugged.

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E-cigarettes should not be charged or used where a patient is receiving oxygen treatment (European Industrial Gases Association, 2013; British Compressed Gases Association, 2014). This is in line with the approach to other portable electronic devices such as tablets, laptops and mobile phones (NHS Improvement Estates and Facilities Alert EFA/2018/007). The National Fire Chiefs Council (NFCC, June 2018) has published helpful guidance on e-cigarette use in smokefree NHS settings. Key messages from the NFCC are:

Buy e-cigarette devices from reputable retailers.

Facilitate opportunities for supervised charging of devices by staff in designated areas.

Advise staff and patients of the approved safe use of e-cigarettes and regularly audit/enforce, agreed protocols.

Ensure systems for review of any incidents related to recharging e-cigarettes (should they occur) are in place to promote learning.

When the charge is complete, disconnect battery and remove charger from USB port/socket – this is usually indicated by a light on the device.

Only use chargers designed for use with the specific device. Some chargers may overcharge the product, leading to an increased risk of fire.

Never leave an electronic cigarette charging unattended, and never leave them charging overnight.

Store batteries and chargers in a cool dry place at normal room temperature. Do not leave them in hot places such as direct sunlight.

Do not immerse batteries or chargers in water or otherwise get them wet.

Never use damaged equipment or batteries.

Never carry batteries, keys or coins in the same pocket or bag.

Never use a vaping device close to medical oxygen, flammable emollient creams or airflow mattresses.

Do not use counterfeit goods - batteries and/or chargers are unlikely to have overcurrent protection and could lead to batteries exploding.

Never modify or adapt e-cigarettes and their associated kit.

Never use damaged equipment or batteries.

7.4.3 Additional information about e-cigarettes Patients who solely vape (use e-cigarettes) are recorded as non-smokers/ex-smokers. It is illegal for any person under 18 to be sold or supplied an e-cigarette. Disposal of e-cigarettes should follow Waste Procedures for Waste Electrical and Electronic Equipment (WEEE). E-cigarettes should not be used whilst driving or when travelling by vehicle.

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8. Monitoring Compliance and Effectiveness Monitoring

Compliance with this policy will be monitored as outlined in the table below.

Compliance and Effectiveness Monitoring Table

Monitoring Criterion Response

Who will perform the monitoring?

Quality Improvement lead

What are you monitoring? Smoking status of patients Supply of nicotine replacement therapy Referral to stop smoking support Smoking at time of delivery Evidence of on site tobacco smoking Evidence of onsite e-cigarette use

When will the monitoring be performed?

Quarterly

How are you going to monitor?

Via audit and review of data held within Trust information systems.

What will happen if any shortfalls are identified?

Action will be taken to strengthen policy compliance.

Where will compliance be reviewed?

Safe care Council.

9. Diversity and Inclusion

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat staff reflects their individual needs and does not unlawfully discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). This policy aims to uphold the right of all staff to be treated fairly and consistently and adopts a human rights approach. This policy has been appropriately assessed.

10. Consultation and review

The following people / groups were consulted in the review of this policy: Stop smoking group, JCC policy sub-group. Health and safety committee, Nursing and Midwifery professional forum

11. Implementation of policy (including raising awareness) The policy will be issued in line with normal Trust processes and awareness will be raised by internal communication routes

12. Associated documentation Work Attire and Appearance Policy PP42 Lone worker policy OP48 Investigation and Disciplinary policy PP01

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13. References Action on Smoking and Health (2014) Secondhand Smoke: information and resources. http://ash.org.uk/information-and-resources/secondhand-smoke/secondhand-smoke/ Action on Smoking and Health (2018a) Information and Resources: Health Inequalities. http://ash.org.uk/category/information-and-resources/health-inequalities/ Action on Smoking and Health (2018b) Smoking in the Home: New solutions for a smokefree generation. http://ash.org.uk/wp-content/uploads/2018/11/FINAL-2018-Smokefree-Housing-report-web.pdf Action on Smoking and Health (2018c) The Local Costs of Tobacco: ASH Ready Reckoner 2018 Edition. http://ash.lelan.co.uk/ American Cancer Society (2017) Harmful Chemicals in Tobacco Products: Tobacco Smoke. https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/carcinogens-found-in-tobacco-products.html British Compressed Gases Association (2014) The safe use of electronic cigarettes and other electronic devices used near medical oxygen. Leaflet 16 – 2014. http://www.bcga.co.uk/assets/publications/L16.pdf British Medical Association (2017) E-cigarettes: Balancing Risks and Opportunities. https://www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/tobacco/e-cigarettes Department of Health (2011) Healthy Lives, Healthy People: A Tobacco Control Plan for England. https://www.gov.uk/government/publications/healthy-lives-healthy-people-our-strategy-for-public-health-in-england Department of Health (2017) Smoke-free Generation: Tobacco Control Plan for England. https://www.gov.uk/government/publications/towards-a-smoke-free-generation-tobacco-control-plan-for-england European Industrial Gases Association (2013) Safety Information: use of electronic cigarettes with homecare oxygen. Safety Info 32/13. https://www.eiga.eu/index.php?eID=dumpFile&t=f&f=180&token=66e3fb58fde56d8d07df35b1d5667551a9b4ee41 Health and Safety Executive (1999) The Management of Health and Safety at Work Regulations. http://www.hse.gov.uk/pubns/hsc13.pdf House of Commons Science and Technology Committee (August 2018) E-cigarettes: Seventh report of session 2017-19. HC505. https://publications.parliament.uk/pa/cm201719/cmselect/cmsctech/505/505.pdf National Centre for Smoking Cessation and Training (2014) Local Stop Smoking Services: service and delivery guidance. http://www.ncsct.co.uk/usr/pub/service_and_delivery_guidance.pdf The National Fire Chiefs Council (June 2018) Guidance note: e-cigarette use in smokefree NHS settings. https://www.nationalfirechiefs.org.uk/write/MediaUploads/NFCC%20Guidance%20publications/Health/E-cigs%20in%20NHS/Guidance_note_-_E-cigarettes_use_in_smokefree_NHS_settings.pdf National Institute of Clinical Excellence (2015) Smoking: harm reduction. https://www.nice.org.uk/guidance/qs92/resources/smoking-harm-reduction-pdf-2098965681349 NHS Digital (2018) Statistics on Smoking – England, 2018. https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2018/content

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NHS England (2017) Next Steps on the NHS Five Year Forward View. https://www.england.nhs.uk/publication/next-steps-on-the-nhs-five-year-forward-view/ NHS England (2019) The NHS Long Term Plan. https://www.england.nhs.uk/long-term-plan/ NHS Improvement Estates and Facilities Alert (December 2018) Fire risk from personal rechargeable electronic devices. EFA/2018/007. https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102809 Public Health England (2015a) Health Matters: Smoking and Quitting in England. https://www.gov.uk/government/publications/health-matters-smoking-and-quitting-in-england/smoking-and-quitting-in-england Public Health England (2015b) Research and Analysis. E-cigarettes: an evidence update. https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update Public Health England (2018a) Public Health Matters: Clearing up some myths around e-cigarettes. https://publichealthmatters.blog.gov.uk/2018/02/20/clearing-up-some-myths-around-e-cigarettes/ Public Health England (2018b) Local Tobacco Control Profiles. https://fingertips.phe.org.uk/profile/tobacco-control Royal College of Physicians (2018) Hiding in plain sight: Treating tobacco dependency in the NHS. A report by the Tobacco Advisory Group of the Royal College of Physicians. https://www.rcplondon.ac.uk/search?keys=hiding+in+plain+sight&sort_by=search_api_relevance&=Search