A dramatic rise in the number of people using e-cigarettes is creating a dilemma for community pharmacy staff. We investigate why, and take a look at other smoking-related issues that are currently in the news

Electronic or e-cigarettes are now so popular that the word ‘vaping’ (inhaling the vapour of an e-cigarette) has been added to the online Oxford English Dictionary. In fact, more than two million Britons now smoke e-cigarettes – a figure that has grown threefold in the last two years.

A commercial opportunity?

E-cigarettes, which can be bought from outlets such as grocers, newsagents and petrol stations and from the internet as well as some pharmacies, could be viewed as a commercial opportunity, say some. But the Royal Pharmaceutical Society (RPS) believes that because e-cigarettes are currently unlicensed and do not have any standardisation in terms of safety, quality or efficacy, they should not be sold or advertised by pharmacies. This situation may change in the future, however, because the Medicines and Healthcare products Regulatory Agency (MHRA) will begin regulating e-cigarettes as medicines when the EU Tobacco Products Directive comes into force in 2016.

In the meantime, the General Pharmaceutical Council (GPhC) advises pharmacy owners and superintendent pharmacists to consider the guidance issued by the MHRA and the RPS when deciding whether e-cigarettes should be sold from their pharmacies.

Two points of view

Currently, community pharmacy is split into two camps. Multiples including Boots, LloydsPharmacy, Co-Operative Pharmacy and Tesco are already selling e-cigarettes, arguing that they can reduce the harm caused by tobacco and other toxins found in conventional cigarettes, such as tar, carbon monoxide and ammonia. But other pharmacy owners say that until they are licensed, they cannot be sure these products are not harmful. And the Pharmacists’ Defence Association advises that e-cigarettes should not be sold from pharmacies until a suitable licensed product is available.

A help or a hindrance?

Many people who are using e-cigarettes believe that they are helping them to stop or cut down their smoking of traditional cigarettes. Some studies show that e-cigarettes are proving more attractive to smokers than nicotine replacement products, while providing them with a safer alternative to cigarettes. And there is evidence to suggest that they can be effective in helping smokers to quit.

On the other hand, some people argue that e-cigarettes will encourage non-smokers to become addicted to nicotine. However, there is little indication that they are being used by people who have never smoked, and the number of children and young people regularly using e-cigarettes remains very low. In fact, research shows that their use is almost entirely amongst those who are current or ex-smokers.

A YouGov survey commissioned by the charity Action on Smoking and Health (ASH) found that just over a third (35 per cent) of British adults believe that e-cigarettes are good for public health, although around a quarter (22 per cent) disagree. E-cigarette advocates believe that the products have the potential to reduce and possibly even end traditional cigarette use by allowing smokers to switch to a safer habit. But experts who argue that e-cigarettes should be restricted believe that they have the potential to increase cigarette use by ‘renormalising’ smoking in three ways – by reducing the motivation of smokers to quit completely, by providing a gateway to smoking for nonsmokers, and by facilitating an increase in smoking prevalence.

Professor Robert West, who led a piece of research called ‘The Smoking Toolkit Study’, says: “Despite claims that use of electronic cigarettes risks renormalising smoking, we found no evidence to support this view. On the contrary, electronic cigarettes may be helping to reduce smoking as more people use them as an aid to quitting.” A scientific review of studies on the use, content and safety of e-cigarettes, published by the journal Addiction, has also concluded that the potential benefits of e-cigarettes outweigh the harm. Lead researcher of this study, Peter Hajek of Queen Mary University of London, says: “Healthcare professionals may advise smokers who are unwilling to cease nicotine use to switch to e-cigarettes. Smokers who have not managed to stop with current treatments may also benefit from switching to e-cigarettes.”

Electronic cigarettes may be helping to reduce smoking as more people use them as an aid to quitting

 

Pro-pharmacy sales

Sam Preston, a pharmacist at LloydsPharmacy, which has been selling Vype e-cigarettes since January, says the company took the decision to offer one highquality brand to its customers because it felt that e-cigarettes could reduce the harm caused by tobacco and other toxins found in conventional cigarettes. Vype is said to operate strict quality controls and be open with the ingredients used in its products.

“E-cigarettes have proven popular, and there are over 100 different unlicensed e-cigarette brands available,” says Sam. “As a pharmacy, we have a responsibility to ensure customers are aware of the ingredients, and what the reality of using the product is. By selling the Vype e-cigarette in a pharmacy environment we are able to provide customers with all the information and support they need from a trained healthcare professional to make an informed decision on whether or not to use e-cigarettes.”

John D’Arcy, managing director of Numark, says: “The debate over e-cigarettes brings into sharp focus the conflict facing community pharmacists in trying to balance their commercial and professional roles. Whilst e-cigarettes are not yet licensed products, their popularity and growing presence in the market cannot be ignored by pharmacy.” And he continues: “It is true that until these products are licensed they cannot be relied upon to be safe and efficacious. However, many people who do not want to, or cannot stop smoking, are turning to e-cigarettes as an alternative.

“Where they are sourced from reputable manufacturers, they have to be a better and safer alternative to ordinary cigarettes, which are loaded with harmful toxins. No one is suggesting that e-cigarettes should be included as part of a nicotine replacement therapy (NRT) programme, but whilst demand is high, they must surely have a place in pharmacy. Pharmacies are in a position to monitor sales of the products to the consumer and, where necessary, provide appropriate advice around stopping smoking completely. Surely that is more in the health interests of the consumer than buying them from a petrol station?”

Rob Darracott, chief executive of Pharmacy Voice, adds: “Pharmacists and community pharmacy teams play a key role in helping to reduce the considerable burden of harm that is associated with tobacco use, so where a pharmacy owner decides to sell e-cigarettes, we believe pharmacists should be free to exercise their clinical judgment, as they would normally do in the exercise of their professional practice.”

And against

There are, however, many pharmacists and pharmacy staff who are reluctant to stock e-cigarettes. Pharmacy assistant Gillian Nichol, who is head of the stop smoking service at the Edinburgh Road Pharmacy in Jarrow, says: “We are a healthy living pharmacy and the healthy living pharmacies are not selling them. If they were regulated we might, but at the moment there is not enough information about them. We are following the RPS advice.” Louise Lydon, managing director and pharmacist at Dixon and Hall, a group of four pharmacies in the North East, says: “We don’t sell e-cigarettes, but if people come into the pharmacy and tell us they are using them then they have probably decided they want to stop smoking so this is an opportunity to have an interaction with them to promote the smoking cessation message.

“We encourage these customers to come to our smoking cessation clinic because they are more likely to quit if they are getting smoking cessation counselling in combination with a nicotine replacement product. Customers often think they can do it on their own using e-cigarettes, but we are increasingly seeing them coming back a month or two later into pharmacy saying it hasn’t worked and asking if they can join the smoking cessation scheme.”

Leanne Beverley, pharmacy technician and supervisor at Monarch Pharmacy in Coventry says the pharmacy does not stock e-cigarettes, despite having newsagents on either side and a pop-up shop down the road which do sell them. She says she is concerned about the quality of the ingredients and how much nicotine the products contain. “If people are using e-cigarettes as a way of quitting smoking, I don’t think it is a good route for success,” says Leanne. “There is no structure – no step-down programme like there is with the nicotine replacement products we offer in our smoking cessation service. I think if people are left to their own devices with e-cigarettes, they will end up addicted to them rather than cigarettes. A lot of people are now saying that e-cigarettes are safer than cigarettes, but really, nobody knows.”

Points to consider

If your pharmacy does stock e-cigarettes, bear in mind the following points:

• Do not recommend e-cigarettes to people who want to quit smoking – recommend NRT, and your pharmacy’s smoking cessation service if you have one, instead
• Advise customers to store e-cigarettes safely, away from children and pets
• Advise people on oxygen therapy not to smoke e-cigarettes because of the risk of fire
• Advise customers to always use the charger supplied with the product
• Be mindful that it is not advisable to sell e-cigarettes to people under the age of 18
• Remember the following GPhC advice:“When a patient goes into a pharmacy seeking advice on giving up smoking, pharmacists and pharmacy technicians have an important role in explaining the options available, including the risks and benefits of different products, to help them make an informed choice.”