Should pharmacy sell e-cigarettes and encourage people to vape?

It’s been more than ten years since the UK’s public smoking ban pushed cigarette smokers out into the cold in 2007, and more than 3 million people in Britain have since traded the smoky outdoor shelter for the flavoured vapours of the electronic alternative: the e-cigarette.

But a lack of long-term data amid the fast-growing popularity of the nicotine-delivering device — invented by Chinese pharmacist and aspiring ex-smoker Hon Lik in 2003 — has divided health professionals.

The Royal Pharmaceutical Society “cannot support the sale of products with limited scientific evidence on safety”. Meanwhile, Public Health England considers e-cigarettes to be considerably less harmful than traditional cigarettes, and, owing to their success in helping people to give up tobacco, “believes there is compelling evidence that e-cigarettes be made available to NHS patients”.

Should Lik’s fellow pharmacists in the UK stock e-cigarettes in their pharmacies and recommend them to people who want to kick their smoking habit? A smoking cessation expert and a pharmacist weigh in.

Yes: Pharmacies should stock the harm-reducing e-cigarette devices

Louise Ross, clinical consultant, National Centre for Smoking Cessation and Training

No one expects any healthcare professional to encourage people who do not already smoke to vape, and if you look at survey data provided by Action on Smoking and Health (ASH), the number of never-smoking people who start vaping is negligible^[1]
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But we do need pharmacists to get the message across to smokers that switching completely to vaping will significantly reduce the damage they are doing to themselves — by 95%, as suggested by Public Health England (PHE)^[2]
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The divisive and myth-fuelled debate on vaping has raged for some years now, and while we argue our positions on the use of e-cigarettes as a stop smoking aid, more than 1.7 million people have stopped smoking with these devices, at no cost to the NHS^[1]
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During my time as manager of Leicester’s Stop Smoking Service — the first in the UK to adopt e-cigarettes to help smokers quit — we witnessed hundreds of successful quits using e-cigarettes, and with no adverse events. People who have quit with vaping have reported the same health improvements that quitters achieve with nicotine replacement therapy (NRT) or prescribed medicines, such as varenicline or bupropion.

If they are used exclusively, e-cigarettes can deliver nicotine in a way that satisfies and maintains a tobacco-free life

In a randomised controlled trial published in the New England Journal of Medicine, published on 14 February 2019, smokers who used e-cigarettes were twice as likely to remain smoke-free at 12 months, compared with those who used NRT^[3]
. They were also less likely to suffer with cough and phlegm. And, of smokers who combine e-cigarettes — the most popular quitting method — with face-to-face support from a local stop smoking service — the most effective method — around two-thirds can successfully quit^[4]
.

Pharmacists are in a unique position to encourage smokers to quit. Some will already be commissioned to provide a stop smoking service; and as noted in ASH’s report ‘A Changing Landscape’, services should encourage smokers to use e-cigarette as a stop smoking aid^[5]
. Pharmacists have the chance to influence smokers when conducting medicines use reviews or when they have the opportunity to give brief advice to clients when dispensing medicines. These opportunities shouldn’t go to waste. Telling a smoker to stop may well provoke a response of weary agreement that, “yes, I should, but I’ve tried everything and nothing works”. However, confident advice from a pharmacist about the use of e-cigarettes could make another ex-smoker.

Most weeks, there are inflammatory media stories about the harm vaping could cause, but most are based on supposition, poor science and gloomy predictions driven by a small number of people who cannot tolerate the idea of people using nicotine long term.

It should be remembered that clean nicotine is a protective factor against relapse to smoking and, if they are used exclusively, e-cigarettes can deliver nicotine in a way that satisfies and maintains a tobacco-free life.

Next time you speak to a smoker, ask them if they have tried vaping. Encourage them to use a high-quality device, which will be more satisfying than a cheap alternative they might have bought at a service station. Start stocking e-cigarettes in your pharmacy so that you can recommend them with confidence.

No: The risk to current and future public health is too great

Nicola J Gray, independent pharmacist researcher; regional liaison pharmacist, Royal Pharmaceutical Society (RPS), and vice president for Europe, International Association for Adolescent Health

Nicotine is a highly addictive substance. For more than 100 years, traditional tobacco cigarettes have been considered the best way to deliver nicotine, which activates the same pleasure centres as heroin and cocaine. But now, a multibillion dollar industry offers another, possibly more attractive, way to serve this addiction: e-cigarettes.

The e-cigarette industry is not a philanthropic public health foundation; its success depends on new consumers and long-term loyalty. None of the currently available e-cigarette products are medically licensed as quit aids — the first and only e-cigarette device to be approved by the Medicines and Healthcare products Regulatory Agency, eVoke, was quickly dropped by British American Tobacco in 2018^[6]
. Big Tobacco is beginning to develop partnerships with e-cigarette companies, and pharmacists should not associate with them^[7]
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Nicotine causes irreversible changes in rapidly developing brains, meaning the adolescent and the foetus are most vulnerable to harm

While the e-cigarette market is booming, there is no robust international body of scientific evidence to support the efficacy or safety of e-cigarettes for helping people to quit nicotine. As pharmacists, we already have a number of effective licensed nicotine replacement therapies (NRT) at our disposal, which can help people to truly quit both tobacco and nicotine^[8]
. There may be no imperative, however, to quit vaping, so the person remains addicted to nicotine, which studies suggest can cause cardiovascular, respiratory and gastrointestinal disorders and a reduced immune response^[9]
.

The main thrust of the pro-vaping argument is relative safety, compared with tobacco smoking — 95% safer, according to Public Health England (PHE)^[2]
. However, during questioning at the House of Commons Science and Technology Committee in April 2018, John Newton, chief knowledge officer at PHE, admitted: “We are trying to convey the extent to which e-cigarettes are likely to be much less harmful than smoking cigarettes. It is a useful figure, but it is not a precise scientific estimate^[10]
.” Yet the figure persists in the public consciousness.

Nicotine causes irreversible changes in rapidly developing brains, meaning the adolescent and the foetus are most vulnerable to harm, and using e-cigarettes in pregnancy still exposes the developing baby to nicotine-related problems^[11]
. A body of robust international evidence also establishes e-cigarettes as a clear gateway to tobacco use for young people^[12]
, but they are very unlikely to be used by young people to quit traditional smoking^[13]
. The Forum of International Respiratory Societies (FIRS) states: “It is the position of [FIRS] that nicotine in electronic cigarettes poses a great threat to youth and we must protect them from it”^[14]
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Even PHE, in its 2014 report on the marketing of e-cigarettes, agrees that the persuasive advertising of vaping appeals to children and young people^[15]
. Sweet-flavoured e-cigarette refills that are designed to look like children’s confectionery are available on the market in the UK, and the sweet flavours are appealing to young people^[16]
; pharmacists should not be complicit in the availability, advertising and recommendation of these products.

Pharmacists — as scientific professionals committed to public health — should not encourage vaping, but should lobby for e-cigarettes to be treated in the same way as tobacco products. Better still would be a proposal to ban e-cigarettes, unless a properly licensed and proven product is available and supplied only through dedicated stop smoking schemes.

• This a personal view and should not be seen as the policy position of the RPS.