How a Sample of English Stop Smoking Services and Vape Shops Adapted During the Early Covid-19 Pandemic: a Mixed-methods Cross Sectional Survey


 Background: The early 2020 Covid-19 outbreak in England led to major changes in delivery of support via stop smoking services (SSS) and to the widespread temporary closure of bricks and mortar e-cigarette retailers, indicating serious disruption to the overall level of support available for smokers trying to quit. At the same time, there was a publicised public health campaign calling for smokers to ‘Quit for Covid’. The impact of disruptions across the smoking cessation support landscape has not been fully documented. The purpose of this study was to capture how SSS and vape shops in England were affected and adapted their ‘business as usual’ during the early months of Covid-19 outbreak.Method: An online cross-sectional survey was conducted between March-July 2020. Surveys were disseminated through online networks, professional forums and contacts. Open-ended qualitative responses were coded using thematic analysis.Results: SSS were able to adapt during this period. A high percentage (74.6%) of vape shops had to close and were unable to make changes; 71.2% report business declining. For both services qualitative data revealed practical challenges to adapting, but also new pathways to support and co-working. Conclusion: The closure of vape shops appears to have most impacted smaller bricks and mortar shops affecting businesses by decline in customers and impacting staff (furlough). For those services that could stay open there may be lessons learned in how to support vulnerable and disadvantaged smokers by considering new pathways to support.


Introduction
There is now emerging evidence from a living systematic review that smokers may be at greater risk of severe illness if they contract SARS-Cov-2(1) (Covid-19 herein). Recent evidence from a population survey clearly demonstrates that smokers are more likely to suffer a greater number of Covid-19 symptoms if infected, and more likely to be admitted to hospital as result of severe symptomatology (2). There is also some evidence of socioeconomic disparities in which smokers without post-16 quali cations are likely to become infected and less likely to adhere or be able to adhere to infection control guidance (3). Smokers also report being more concerned than non-smokers about being infected (3). In the early months of outbreak this led to several high-pro le public health campaigns targeted at smokers urging them to 'Quit for Covid'. It is estimated that since the start of the virus there have been over one million smokers making a quit attempt (an estimated additional 440,000) in Great Britain (4). However, social distancing and lockdown measures meant that the English NHS Stop Smoking Services (SSS), which offer the 'gold standard' treatment of combined behavioural and pharmacotherapy support (5), faced the unusual challenge of how to respond to the increased demand. At the same time, e-cigarettes were not deemed by Her Majesty's Government essential items, and vape shops had to close. E-cigarettes are now the leading preferred choice for smokers making a quit attempt in England (6), and there is growing evidence for their e cacy in trials (7). Given this, it is a fair assumption that many smokers engaging in a quit attempt during the Covid-19 pandemic would opt for an e-cigarette. Given the swiftly altered landscape of smoking cessation support, across both NHS SSS and less formal routes to support, such as vape shops, the purpose of this study was to capture, at the time, how SSS and vape shops in England adapted their 'business as usual' during the early months of the Covid-19 outbreak.
A recently published survey of local authorities in Great Britain by Action on Smoking and Health (ASH) (8), shows that at the time of survey (August-September 2020, 5-months after the rst national lockdown was announced), just 18% of SSS were offering face-to-face support but this was supplemented by 98% offering telephone consultations and ~ 60% offering online video support. The report highlights that the exibility of this support was welcomed by patients. Furthermore, the report highlights that the majority of services (59%) adapted service delivery for those patients recorded as vulnerable. We extend these ndings here and triangulate this data with our own ndings and by including a snapshot of how ecigarette retailers were also affected during early lockdown.
Vape shops were required to close in the UK. E-cigarettes were not deemed essential items and by law of the UK government, non-essential shops were required to close. For context, people could still purchase tobacco and e-cigarettes and liquids (often tobacco industry manufactured) from convenience stores and supermarkets. Although many vape shops have established online markets which were able to stay open, many smaller, locally based 'bricks and mortar' shops do not.
Smoking is more frequently observed in disadvantaged and vulnerable populations (9, 10), as well as those vulnerable to Covid-19 infection because of respiratory health comorbidities e.g., Chronic Obstructive Pulmonary Disease (COPD). Because many of these adults were advised by the government to shield or to isolate with minimal contact with others outside their homes, this would have presented both SSS and vape shops aiming to support these smokers with unique and unprecedented challenges.
The primary aim of this study was to survey how those working within front-line NHS and local authority commissioned SSS and vape shops adapted during the early Covid-19 pandemic (de ned here as March 2020 -July 2020), and to document what changes were made to usual practice. A further aim was to document how the needs of vulnerable smokers, de ned as those within the shielded list or with health and social needs that make them vulnerable to Covid-19, were being met during this period and to identify potential new ways of delivering services.

Methods
Design and setting: A cross-sectional online survey in England conducted between March and July 2020.
Registration: This study was preregistered on the Open Science Framework (https://osf.io/b3xcy/(11)). Participants: 52 individual responses from SSS and 70 vape shops started the survey; after discounting incomplete responses (with >5% of missing data) 46 SSS and 59 vape shops were included. Table 1 presents the percentage of services across English regions.
Procedure and measures: Both surveys were advertised by SC and CN online (Twitter/Facebook). The survey for SSS was also sent out by email to tobacco control and policy stakeholder contacts and disseminated through smoking cessation service networks. The vape shops survey was distributed through a list of vape retailer contacts. The Planet of the Vapes, a Vape website for consumers and businesses, also advertised the survey.
The surveys were run online using Qualtrics XM software. Once participants had consented, they were asked to complete the survey. We asked for only one response per business/service to avoid duplication. Participants were asked only to complete the survey if they had full knowledge of how Covid-19 had impacted their service. The survey was a mix of both multiple choice, and open text items. Open text responses allowed for people to explain in greater detail the processes and changes they had made (surveys used can be found at (11). Upon completion participants were thanked for their responses and debriefed.
Analyses: Quantitative data are presented as descriptive statistics. There were no planned comparisons. The open text questions were analysed using inductive thematic analysis led by CN (12), with veri cation of coding and further analysis by EW. Table 1 presents the quantitative data from the survey. There are several key ndings in relation to our primary aim.

Results
Staying open in some capacity and adapting the 'business as usual' service: The results show that SSS were likely to stay open in some capacity, even if only offering initially a telephone based remote service. SSS furloughed very few staff; this is likely to re ect the ability of SSS to be able to continue with the support of the local authorities. All surveyed SSS made changes to service delivery.
A high percentage of vape shops were impacted by the lockdown, see Table 1 (and have remained closed in further lockdowns), with the majority reporting business had declined ( Figure 1 shows how business was impacted by type of vape business.). Of the vape shops that were able to stay open 'in some capacity', these were online retailers (though one said they could not) and business was the same or doing better. Of those that closed 77.3% were bricks and mortar vape shops, either independent, part of a local chain of stores, and 20.5% were part of national chain. As predicted, vape shops furloughed a high percentage of staff; Figure 2 presents the average number of staff furloughed by vape business type, as can be seen, smaller single vape shops reported business being worse than usual and furloughing a higher number of staff.
A high percentage of both SSS and vape shops reported adapting their service for the needs of people who smoke who were deemed especially vulnerable (Table 1). However, only a small percentage reported working with other agencies or organisations. Both SSS and vape shops report an extra cost involved in implementing new changes.

Practical arrangements
Both vape shops (that were able to react) and SSS responded to the immediate pandemic crisis by implementing practical changes to service delivery, for example, offering remote telephone consultations for cessation support, and providing no contact 'click and collect' purchasing services for vape supplies via telephone as well as online orders (shops): "We made contact-free daily home deliveries and sanitised products before sealing them in packages. We also provided (and always have) text, telephone and Facebook support whenever needed. We also provided free of charge, hand sanitiser if requested, and brought food supplies to those who could not get items themselves." (Vape shop) SSS responded quickly by supplying longer than usual prescriptions of stop smoking medication, particularly for vulnerable clients and those self-isolating. Deliveries of stop-smoking products were also arranged by some services, and similarly some vape shops offered a delivery service to customers who were self-isolating or shielding -however noting that this arrangement created extra nancial costs for either the customer (if passed on) or the business.

New Pathways
Both SSS and vape shops adopted some innovative practices in response to the pandemic. SSS offered video conferencing meetings and appointments, and some even attempted group support delivered using video conferencing. A major service change brought about as a result of infection control measures was the abrupt stopping of all Carbon Monoxide (CO) monitoring. In response to this, SSS developed innovative ways of checking in with existing clients to establish smoking status: "No CO monitoring so we have used a breathing challenge identifying how long they can breathe in and out and hold and working to improving their lung capacity" (SSS) Some SSS staff were redeployed to deliver food parcels and medication within the community and took advantage of being able to make ad hoc 'welfare checks' to make contact with people who might be isolated. These ad hoc checks sometimes resulted in quit attempts that may not otherwise have been planned. Some SSS also described new pathways for joint working with vape shops to offer remote support for clients attempting to quit and stay quit from smoking. Equally, vape shops also described working with SSS, with some organising remote online seminars to explain products to SSS staff. Taking an innovative approach, some vape shops described using Facebook messenger or WhatsApp to send photos of devices to customers to explain processes such as how to use devices and how to change components.

Feedback from clients/customers
When asked about feedback from clients, both SSS and vape shops overwhelmingly reported that they had had positive feedback. Customers understood the di cult times, and the need for shop closures or remote support offers. They were hugely appreciative that services were able to continue to support them, and in the case of shops, to supply e-cigarette consumables, despite the challenges. Some customers actually preferred remote support, nding it convenient not having to travel to appointments or to make purchases. Others were extremely grateful for service continuation while they were having to self-isolate or shield: "Patients are so grateful that we care about them during the pandemic and I personally have learnt so much more about them their lives and interests than I normally would of." (SSS) Vape shops commented that remote provision was critical for enabling clients to remain smokefree, but also drew attention to the mismatch between tobacco being available to purchase through 'essential' shops that remained open. Vape supplies were harder to purchase due to shop closures, as vape shops were deemed 'non-essential'. There was real concern that clients may have relapsed to smoking as a direct result of this anomaly: "Many of our regular customers went back to smoking due to the easier availability of cigarettes when shops were closed and online delivery was chaotic across the country. Devices don't sell much online as people need the advice and personal consultation." (Vape shop) Implementation of long-term changes Both SSS and vape shops talked positively about changes that had been implemented that would be continued in the long term, including remote support provision, click and collect and online purchasing options, and the use of video conferencing for staff training, meetings and client support. Positively, there was also discussion of continued joint working between vape shops and SSS: "Ongoing efforts to strive to work better with smoking cessation stakeholders." (SSS) It was noted that there was an increased desire and willingness to promote digital support options for behaviour change, such as apps.

Discussion
The overall landscape of smoking cessation support changed substantially during the early phases of the Covid-19 pandemic. SSS quickly switched to remote service provision; and many vape shops without an online market were forced to close completely, but some were able to adapt by offering click and collect or delivery services for vape supplies. Overall, vape shops were more negatively impacted than SSS as evidenced by reports of business being worse than usual and furloughing staff. E-cigarettes not being deemed essential products appears to have impacted small independent shops in particular, who report struggling to adapt. Simultaneously evidence suggests that there was a surge of interest in smoking cessation (4), unfortunately implying that as more of the population were attempting to quit smoking, the support available to them both through NHS routes and less formal but popular routes, such as vape shops, was diminished.
There were many positive reported examples of good practice -SSS staff were able to offer remote appointments and engage in online training. Vape shops, particularly those connected to larger chains with a more secure infrastructure, were able to offer remote delivery options and also were able to use video conferencing software to explain products to customers; this is similar to what was reported in a report of SSS by ASH (8). For SSS staff there were redeployments to other areas of public health need, but our data positively demonstrate examples of how this enabled them, with their training, to identify people willing to quit and to promote smoking cessation at given opportunities.
Also positively, it was evident that both SSS and vape shops made particular efforts to meet the needs of vulnerable smokers. Delivery options were offered to the clinically vulnerable or those having to selfisolate. Many of the extra measures came with an additional cost, with smaller vape shops reporting having to pass this on to customers with 'low value' orders. E-cigarette use has increased in all >1 year smokers in England, however analysis by Kock et al (13) shows that use is highest amongst the most disadvantaged social grades (routine and manual). Thus, speculatively, the burden of taking on extra costs may not be evenly distributed across all social gradients. Furthermore, small independent vape shops are often located in the most deprived communities (14). This suggests that a valuable community smoking cessation asset was lost to some populations most at risk of continued smoking, and most susceptible to the worst impacts of the Covid-19 pandemic, just at a time when support was perhaps most wanted and needed. It is also a distinct possibility that recent quitters may have relapsed to tobacco smoking, as a more accessible way of using nicotine during lockdown than vaping. This unintended consequence of compulsory vape shop closures is a clear example of how sweeping population measures can have grave impacts for already disadvantaged communities, and how pandemic policy measures may serve to widen health inequalities. This study was limited by the brief cross-sectional nature of the data. The survey was targeted at SSS and vape shops across England and offers a 'snapshot', but the sample are self-selecting as only those motivated to complete the survey would have replied. It is likely therefore that the survey highlights particularly good practice or negative consequences and may miss the 'standard response' that may not have been deemed worthy of reporting back via a survey. Similarly, the qualitative data are illuminating and informative, but descriptive and limited by possible selection bias. Clearly there is a need to monitor smoking cessation service delivery, both through formal commissioned routes, and less formal community assets, as the pandemic continues. There is also a need to triangulate the self-report and qualitative data reported here with larger epidemiological data as it becomes available, and with both tobacco and e-cigarette sales data over the time of the pandemic.
The landscape of smoking cessation support has changed and adapted during the Covid-19 pandemic.
There are clear positive innovations that services may wish to continue to implement, such as outreach support, delivery services, and remote support via phone or video calls. There are also clear negatives that we must learn from. Vape shops offer a community based, less formal, route to smoking cessation and the support offered is often based within deprived communities. It is vital that vape shops for future lockdowns are deemed essential services so that they may continue to provide community-based support where it is needed most. As we move towards the 'tobacco endgame' of a smoke free 2030, we need to think, encourage and commission innovatively and creatively, to support community-based assets accessing the hardest to reach smokers, pushing intervention beyond the medical model of treatment seeking.

Declarations
Ethics approval and consent to participate Ethical approval was received from University of East Anglia REF: 2019/20-133.

Consent for publication
All authors consent to participate and approve the nal manuscript.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Competing interests SC has provided expert consultancy to providers of UK life insurance and the pharmaceutical industry on matters relating to smoking cessation aids. LR works for the Smoke Free app, is a clinical consultant for the NCSCT and is Vice Chair and mental health lead for the New Nicotine Alliance. EW and CN have no competing interests to declare.

Funding
No speci c funding was sought for this survey. SC receives salary support from Cancer Research UK (C1417/A22962).
Authors contributions SC and CN conceptualised the study. All authors developed the survey. SC and CN advertised the study. EW curated the data. SC, CN and EW analysed the data. SC wrote the rst draft. All authors contributed to the nal draft.  "Customers appreciated the same day delivery but could not understand why we were not classed as an essential service." "Some customers who used the Local Pickup Service have told us that it stopped them from buying cigarettes." "Absolutely. We have had countless 5-star Google and Facebook reviews during and after lockdown, all of which were positive. It has helped our business grow and has motivated the staff to continue to provide the best service possible to all our customers" "Many of our regular customers went back to smoking due to the easier availability of cigarettes when shops were closed and online delivery was chaotic across the country. Devices don't sell much online as people need the advice and personal consultation."  BUT savings on venue and staff millage "For those who were self isolating we either arranged for their pharmacy to post products to them or we advised the client to join the 'Good Sam' app and a volunteer would pick up their products.
We also arranged for those who were self isolating but who wanted Champix for the appendix 1 of the PGD to be completed by the pharmacist over the phone.
2 vouchers which is equal to a months supply of product were posted to clients so they didn't have to go to pharmacies as many times and stand in long queues." We are trying to Alternative to CO testing "We have the same quit conversion rate at 4 weeks as face to face consultations. A key factor is possibly client's do not miss many appointments, making it more likely they will quit even without the perceived bene t of face to face.
Clients get a quit guide and top tips in the post when they set a quit date, this was hit and miss before and dependant on the advisor. Similarly, at the 12 week quit point they get a certi cate, staying quit guide, evaluation form and sae which before was very hit and miss. We are now receiving a bene cial amount of evaluation forms back." "about half of our small team were redeployed to make welfare checks and were involved in emergency food parcel deliveries. We used the opportunity when speaking to people seeking stop smoking support to check they had access to food and basic necessities and referred them for emergency help if necessary."