Pharmacists must retain healthy scepticism about e-cigarettes

Regardless of whether you believe, e-cigarettes should be recommended by healthcare professionals as a way to reduce tobacco use and help people quit smoking, their use is unlikely to end in the near future. In a previous article
^[1]
, Louise Ross supported the use of e-cigarettes among existing smokers to help them quit — or at least, to stop smoking traditional cigarettes.

Further reflection is needed on the evidence update, published in 2015, and associated policy on tobacco control from Public Health England (PHE) — an executive agency of the UK’s Department of Health — and the role of e-cigarettes. As a young people’s health advocate and pharmacist, I hope to highlight specific issues and challenges for both groups as we move forward.

The Public Health England approach

Rather than nicotine cessation and prevention, PHE is adopting a harm reduction approach to nicotine use based on the assumption that any adverse health effects of inhaled nicotine delivered by an electronic device are less serious than inhaling harmful tobacco smoke. An individual can say that they have “quit smoking” but continue to vape indefinitely – Louise Ross asserts that “nicotine can be enjoyed safely” and that quitting nicotine is not necessary^[1]
. Research also indicates an increase in dual use, where people use e-cigarettes and tobacco alternately^[2]
. For example, using an e-cigarette where tobacco is prohibited, or needing a different tobacco “hit” to satisfy cravings while reducing the overall number of cigarettes smoked.

If PHE pursues a permissive approach to e-cigarettes and a harm reduction strategy, there will be a proportion of tobacco-naïve “new entrants” who adopt nicotine use as a lifestyle choice. Most smokers start smoking as teenagers, and become dependent on nicotine, not tobacco smoke. The model underlying the PHE strategy must therefore assume that the benefit for people quitting tobacco and using e-cigarettes will outweigh the harm for people who start to vape and may even go on to smoke.

Yet an alarming trend is emerging in the United States: more young people are now using e-cigarettes than smoking traditional cigarettes^[3]
. Young people’s usage rates reported by countries tracking this issue — as diverse as the UK, Poland, New Zealand and Korea — suggest a small incidence of regular use but doubling or tripling adolescent use year on year^{[4],[5],[6],[7]}
. Research into e-cigarettes as a gateway to smoking is in its early stages. Emerging research in the United States shows small but exponentially rising use of e-cigarettes by young people, and some evidence of young people moving from e-cigarettes to tobacco^[8]
.

Caution required

The likely success of the PHE strategy depends on four factors. The first is the safety profile of inhaled nicotine in its own right. Although e-cigarette proponents insist that nicotine is only as harmful as caffeine to adults^[9]
, research on the effect of nicotine in individuals with rapidly developing brains — foetuses and teenagers — is less clear. Rodent-based studies, not yet confirmed in humans, suggest that nicotine use can disproportionately affect the adolescent brain and could be associated with the emergence of mental health problems^[10],[11]
. Further research is needed in this area.

The second factor is the effect of marketing and packaging. There is universal agreement, even among e-cigarette supporters^[12]
and in PHE’s own report^[13]
, that companies are marketing e-cigarettes to children and young people. Yet it took years to implement a restriction on age of sale to people aged over 18 years, which came into force on 1 October 2015 in England. The marketing of e-cigarettes is currently only mediated by a voluntary industry code and advertisements are commonplace. Extensive high quality research relating to traditional cigarettes indicates that marketing, packaging and role modelling are major causes of smoking initiation among young people^{[14],[15],[16]}
 — it is likely that there would be strong parallels for vaping. In January 2016, the US Centers for Disease Control and Prevention noted the alarming but not surprising association between a rise in e-cigarette advertising from US$6.4m in 2011 to an estimated US$115m in 2014 and a ten-fold increase in the number of high school students using these products (in the past 30 days) over the same period from 1.5% to 13.4%^[17]
. Brian Curwain highlighted this in a letter reflecting the same argument – that the industry is focused on new entrants, not ex-smokers^[18]
. The implementation of the EU Tobacco Products Directive (TPD)^[19]
, planned for May 2016, should, however, restrict UK marketing for these products.

The third factor is cultural acceptance of vaping. Vaping imagery is appearing in music videos and primetime broadcast dramas. The popular BBC drama ‘Death in paradise’ featured vaping in one episode, and the singer Lily Allen was paid to feature the E-Lite cigarette brand in her video for the song ‘Hard out there’^[20]
. Dedicated vaping shops and stalls are now common on high streets and in shopping centres. Qualitative research also provides early ethnographic evidence of youth culture adoption. A young people’s focus group report about e-cigarette use, linked with Trading Standards work in Merseyside, north east England, and entitled ‘Most people I know have one’, is sobering reading^[21]
. Young people reported that the devices were used as gadgets and status symbols, and compared the cocktail of flavours they had mixed with others. An insidious medium-term culture change, or perhaps reversal, is starting to happen, which public healthcare professionals must monitor carefully.

The fourth factor is the long-term safety of vaping, both for an individual user and the wider population. The declaration that e-cigarettes are 95% safer than tobacco products seems untenable when there is a lack of quality control for these products^[22]
. Reports of lung damage associated with vaping are starting to emerge in the United States^[23]
, and toxins such as diacetyl have been found in UK products^[24]
. We will not know the full adverse effects of e-cigarettes for several years, and the EU Tobacco Products Directive must improve regulation.

There are also concerns that clean air legislation will be eroded by e-cigarettes. By claiming that the vapour from e-cigarettes is less harmful than tobacco smoke, supporters deflect attention from a more important issue, which is that the vapour is more harmful than clean air. As the World Health Organization – whose policy is largely ignored in the current debate – has said: “Since the reasonable expectation of bystanders is not a diminished risk in comparison to exposure to second-hand smoke but no risk increase from any product in the air they breathe, electronic nicotine delivery system (ENDS) users should be legally requested not to use ENDS indoors, especially where smoking is banned, until exhaled vapour is proven to be not harmful to bystanders and reasonable evidence exists that smoke-free policy enforcement is not undermined.”^[25]
When claims are made that ‘there is no evidence of harm’, this should not be construed as evidence of absence of harm.

Sale of e-cigarettes in pharmacies

Pharmacists are familiar with harm reduction strategies through involvement with substance misuse and alcohol counselling. I visited some local community pharmacies in January 2016 to find out how e-cigarettes are displayed. A large multiple pharmacy in a shopping centre had no obvious sale at all of any e-cigarette product. Two regional multiple pharmacies (one health centre, one high street) stocked one brand each behind the pharmacy counter, positioned near nicotine replacement therapy products. A supermarket pharmacy had self-selection of three different e-cigarette brands built into its counter using plastic security cases similar to those used for DVDs. While two of the pharmacies had no smoking signs, none of them specified whether vaping was allowed or not.

There will be challenges for pharmacists. A colleague reported helping a young woman, who had switched from tobacco to e-cigarettes, to quit vaping. The woman recognised herself that she was vaping constantly and the pharmacy where she had originally been buying nicotine e-cigarette refills had started to refuse sales to her. She came back to visit my colleague, whom she knew from previous medicine consultations, to help her quit nicotine through a structured cessation programme. Better engagement between pharmacists and young people about smoking and vaping could limit the time, extent and damage of nicotine addiction.

Nicotine cessation

The UK Chief Pharmaceutical Officers have indicated jointly and publicly that they do not support the sale of unlicensed e-cigarettes through pharmacies^[26]
. Particularly for the sake of the next generation, pharmacists must consider whether we accept the harm reduction approach being taken by PHE or commit to a continuing focus on nicotine prevention and cessation without recommending e-cigarettes as an approach. The two may be able to coexist. Nicotine prevention can be achieved by treating all nicotine-containing products alike, with strict controls on advertising, packaging, quality standards and clean air legislation. A commitment to nicotine cessation rejects the notion that someone can quit tobacco smoking but continue vaping indefinitely. We must remember that this is an unregulated, burgeoning high-income industry that has fought against the EU Tobacco Products Directive^[27]
. Pharmacists should observe a vaping ban on their premises until the contents and effects of the vapour are better known and regulated. By monitoring the effect of e-cigarettes on smokers and non-smokers alike from their unique perspective at the interface of public health and consumerism, pharmacists may be able to minimise unintended adverse long-term consequences.