Response

We write in response to Dr Bergman’s insightful commentary on the use and regulation of vapes on in-patient psychiatric settings.^{Reference Bergman1} The central theme that nicotine vapes should be considered within the same framework as other drugs and prescribed on a drug chart is both thought-provoking and a necessary debate. The piece draws attention to the rapid cultural shift which has seen vaping become commonplace on wards, outpacing our ability to develop consistent governance. Dr Bergman’s reflections deserve recognition for initiating debate over a matter that psychiatry, and medicine more broadly, must continue to address.

Like the author, we have observed discrepancies between patients’ reported nicotine use and their subsequent pattern of vaping on the wards. We have regularly been involved in interviews where the patient has produced a vape and used it openly in the consultation room. The idea of a patient lighting a cigarette in the same setting would now seem extraordinary, yet the act of vaping is treated by many as casual and trivial, despite being against policy on National Health Service grounds. We note that this perception of harmlessness, shared by patients and possibly some ward staff, could risk normalising this behaviour. For some individuals, the vape can be as much a comfort object or a means to ease boredom, rather than being thought of as a nicotine delivery device. ^{Reference Borrelli, Weinstein, Endrighi, Ling, Koval and Quintiliani2} We argue that the casual nature of vaping can blur the distinction between habit and lifestyle, which may present us with resistance as clinicians if we attempt to intervene with their use.

We understand the rationale for Bergman’s comparison of vapes to readily available over-the-counter medicines such as paracetamol as justification for prescribing on in-patient wards. However, as alluded to by Bergman, the analogy is problematic. While paracetamol has been sold as an over-the-counter remedy since the 1970s, with decades of oversight and pharmacological scrutiny, vapes lack comparable longitudinal evidence or established quality-control standards. Although evidence suggests reduced harm from vapes compared with cigarettes, uncertainties remain regarding the evidence of long-term harm. ^{Reference Reali, Onorati, Koletzko, Størdal, Aparicio Rodrigo and Magendie3}

It is worth acknowledging that not all vaping products contain nicotine, and therefore the potential for long-term health impacts from these devices could be considered a less pressing issue. However, emerging evidence suggests that even nicotine-free vape products are not without risk, with research indicating a range of potential adverse health effects. ^{Reference Vyas, Bennett, Hamel, Beck, Thuku and Hersi4}

In our clinical experience we have witnessed how nicotine use can indirectly interact with patient autonomy, a key part of psychiatric practice. We have encountered situations where patients have requested to be discharged from hospital as they are unhappy with ward policies and wish to smoke cigarettes late at night when the doors are locked. The duty doctor may then have to consider whether detention under the Mental Health Act is required and appropriate to keep the patient in hospital. This scenario clearly illustrates how nicotine dependence can complicate in-patient psychiatric admissions. Nicotine restriction, for safety and clinical reasons, can also have a direct impact on least restrictive intervention, impacting the ordinary rhythm of ward life. This example highlights the need for improved addiction treatment options, where a proactive approach to prescribing nicotine replacement should be followed. Unsupervised use of vapes overnight could complicate clinical monitoring if these devices were ever considered as prescription items for in-patient use and lead to conflict between patients.

We anticipate that parallel conflicts may arise with vapes if these were to be the subject of similar restrictions and prescribed by medical staff. Nicotine restriction may also expose issues of tension on the ward, where removal or limiting vapes may precipitate aggression or agitation, which could expose both patients and staff to increased risk. A recent qualitative study of staff in a forensic psychiatry in-patient setting in London, by Bannerman et al, found violence and aggression to be themes associated with the use of e-cigarettes, particularly in relation to distribution and confiscation of devices. ^{Reference Bannerman, Oyebode, Stokes and Coronini-Cronberg5}

With the issue of prescribing vapes, we also considered practical issues which would require a degree of consideration. If they were prescribed, should they be given at set times or on an as required basis? How should strength/dose be determined, given the wide variety between devices and liquids available? Can we say a patient is vaping ‘too much’ and then reduce the prescription? Without robust protocols, the decision burden ultimately falls on nursing staff, potentially increasing workload and risk of conflict. Additional risks include tampering or the addition of illicit substances, including novel psychoactive substances such as synthetic cannabinoids. ^{Reference Cozier, Gardner, Craft, Skumlien, Spicer and Andrews6,Reference Craft, Sunderland, Millea, Pudney, Sutcliffe and Freeman7}

In some psychiatric in-patient settings, nicotine inhalators are already prescribed as a form of nicotine replacement therapy. These devices share obvious similarities with vapes, yet differ in licensing and regulation, meaning they are currently authorised as part of established prescribing frameworks. The contrast highlights the current gap between these regulated and evidence-based pharmacological aids and the largely unregulated nature of vaping products. We believe this underscores the need for clearer, government-led regulation and quality assurance of vaping devices if they are ever to be considered within formal prescribing frameworks.

The rapidly changing regulatory landscape adds another layer of uncertainty to governance discussion. In the UK, the government has already implemented a ban on disposable vapes, citing the environmental harms and use among youths as the main reasons for implementation. ⁸ Australia has taken this a step further with nicotine vaping products now largely restricted to prescription-only access for nicotine dependence. ⁹ This variability in the international sphere leaves psychiatric services uncertain and adds an additional challenge to the adoption of ward policies.

Bergman’s article provides valuable opportunity for discussion. The proposal raises an urgent question of whether vapes should ever be prescribed as medicines within psychiatric services. We have expanded on the piece by highlighting specific challenges within psychiatric services which would need to be confronted with a pragmatic and ethical approach. As clinicians working in psychiatry, we recognise that while patient autonomy is important, this issue should be approached cautiously until stronger evidence regarding safety and efficacy is available.