Should pharmacies sell electronic cigarettes?

“In today’s climate, the vast majority of pharmacies need to offer a greater variety of products than ever before in order to remain competitive and commercially viable.”

Many pharmacists would agree with this sentiment as they try to balance the books and meet the needs of being a retailer and healthcare professional.

But how would you feel, knowing this statement came from Michael Clapper, the chief executive officer of the electronic cigarette company Vapestick and chairman of the Electronic Cigarettes Industry Trade Association?

The comments were made at a major debate at the Pharmacy Show in Birmingham on 6 October 2014, looking at whether pharmacies should sell e-cigarettes. The show was an eye-opener to those unfamiliar with the products. There were 21 e-cigarette stands, including brands such as Playboy, Diamond Mist, Vapestick and Shenzhen Lrider Tech, with some sales representatives “vaping” on site. Some of the stands were also promoting glamorous e-cigarette cases, reminiscent of those seen in 1950s movies.

Electronic cigarettes are promoted as a safer alternative to tobacco smoking, as is Voke, a cigarette-shaped nicotine inhaler that has become the first of its kind to be licensed as a medicine for use in the UK. Voke is owned by the world’s second largest cigarette manufacturer British American Tobacco, a company which also produces e-cigarettes.

There are some 2.1 million e-cigarette users in Great Britain so there is already a mass movement towards their use (see infographic). About one third of users are ex-smokers and two-thirds are current smokers. Worldwide, the electronic nicotine delivery systems industry, which includes e-cigarettes as the most common type, seems to be booming. Globally, there are 466 brands and $3bn was spent on them in 2013, with sales expected to grow by a factor of 17 by 2030^[1]
. In 2012, 7% of EU citizens aged 15 years and over had tried e-cigarettes, but only 1% of the total population uses them regularly^[2]
.

Pharmacists’ professional leadership body, the Royal Pharmaceutical Society, and the UK’s four chief pharmaceutical officers have not supported use of e-cigarettes as smoking cessation aids, preferring licensed nicotine-containing products. The World Health Organization thinks the same, and does not want them to be used indoors, until the exhaled vapour is proven to be not harmful to bystanders.

The Forum of International Respiratory Societies, which is made up of professional organizations and experts in respiratory disease, says it is prudent to restrict their use at least until their safety can be established.

While many pharmacies sell them, including large multiples such as Boots and Lloydspharmacy, others are either sitting on the fence or have rejected them as lifestyle products that have no place in pharmacy.

Clapper told the conference: “It’s not uncommon to walk into a local pharmacy these days to find all-sorts of gift-sets, stationery, crockery, toiletries, make-up, alternative medicines and homoeopathic remedies. When it comes to e-cigarettes, they are just an alternative category that naturally fits into any pharmacy.”

E-cigarettes are not quit smoking products — they don’t claim to be, he said. “They are not healthy products, of course, but they are no doubt healthier than the very product they are designed to replace.”

Pharmacy delegates were warned that if the growing army of “vapers” can’t buy their supplies from pharmacies, then they will go to a local convenience store or a supermarket instead. But because pharmacies are respected as a destination for quit smoking services, they have a far better opportunity than most to become the destination of choice for e-cigarettes and vaping supplies, he said.

According to Clapper, investment analysts predict that the sale of e-cigarettes will outstrip the sale of tobacco products within the next decade and that the retail margin for pharmacies is around 45-50%, so they are more profitable than selling nicotine patches.

Pharmacy leaders had mixed views on selling them.

Mark Koziol, chairman of the Pharmacists’ Defence Association, which represents individual member pharmacists, is very concerned about the future.

“If we wind ourselves forward, in 20 years’ time — where half the nation is now addicted to nicotine because of all these vape cigarettes and all the tobacco companies have stopped producing cigarettes because there are too many writs flying around because of lung cancer — the big question then will be how on earth do we get all these people off the nicotine addiction,” he told the conference.

The question will then be asked: what role can pharmacy play in this? And the response will be ‘well pharmacy was part of the problem as opposed to part of the solution’, he said.

Koziol thinks the answer to this conundrum is very simple: pharmacy can have a role to play but only as part of a smoking cessation programme.

“You have to get these things licensed so that pharmacy can play a proper role in smoking cessation services. We are not interested in selling [these products] to make a few extra quid with 55% margins because pharmacy is a healthcare profession.”

Anthony Cox, a lecturer in clinical pharmacy at the University of Birmingham, is also “against” the sale of these products in the pharmacy. “As scientists we should be looking for evidence-based treatments. So should we be selling unlicensed e-cigarettes in pharmacies? Would we lower the bar for any other product?”

As Cox was going around the stands at the Pharmacy Show, he felt that some of the products on display, including “shisha pipes” and playboy e-cigarettes, were “incredibly inappropriate” for pharmacy. “I’m not sure really that is where we should position ourselves. We should be looking for medicinally licensed products to help smoking prevention and reduce the harms from cigarettes. Not to try to jump on the back of the bandwagon that is obviously making a lot of money. ”

If pharmacies choose not to sell e-cigarettes, patients are not going to be denied them. “We need to establish whether we are pharmacies or off-licences. Do we want to sell recreational drugs or do we want to sell licensed medicinal products?”

The organisation that represents owners for three pharmacy national bodies took a “neutral” view on the issue. Rob Darracott, the chief executive of Pharmacy Voice, said e-cigarettes are continuing to evolve, as is the evidence base for their use. His organisation is trying to support health care professionals to make up their own minds by assessing the evidence, by providing them with a 100-plus-referenced paper on the subject.

An important part of the debate is the evidence surrounding these products. Martin Dockrell, tobacco control lead at Public Health England, says the evidence so far shows that they are not risk-free, “but they do appear to be much, much less risky than smoked tobacco”. And perhaps they are not quite as effective as nicotine replacement therapy (NRT) in helping smokers to quit, he added.

Dockrell also put the question to the conference as to whether pharmacies stocking these products might provide a new opportunity to engage with smokers about how they can reduce their harm.

Another question on many people’s minds is to what extent second-hand exposure to e-cigarettes will cause harm: but we will not know until we have “30 years of data”, according to Dockrell.

James Quekett, a GP and educational lead at doctors.net, would like to know exactly what people are inhaling, noting that some of the flavoured products have been withdrawn after launch, so there cannot be “100% certainty” on their safety.

What really worries him is that big tobacco companies own many e-cigarette brands. Although, he doesn’t think e-cigarettes are a likely gateway product to tobacco, they are a likely “gateway product to nicotine addiction”. The World Health Organization (WHO) notes that the tobacco industry’s internal documents suggest that flavouring agents have played an important role in the targeting of children and youth, and there is a concern that they could play the same role in the uptake of e-cigarettes in these age groups.

According to the WHO, given the economic power of the tobacco industry, recent moves to sue other companies alleging patent infringement may be an indicator of how difficult it will be for the sector to remain a niche business dominated by independent companies.

Quekett adds that the marketing of some e-cigarettes by big tobacco companies has been based on users being sexy and cool. How many of those products have got a young attractive woman vaping, he asks? “My 16-year-old daughter is unlikely to take up cigarette smoking, she knows the harms with that. But if this is being sold as a healthy alternative to smoking, she may be tempted into nicotine addiction down another route. So are big tobacco exchanging one addiction for the next?”

Action on Smoking & Health (ASH), a campaigning body, has studied whether these products have been taken up by young people and has not found reason to be concerned.

“Young people are not appearing to use these products regularly in any numbers at all. There is some level of experimentation but that usage is very much confined to young people who are already smoking and it is pretty low,” said Hazel Cheeseman, ASH’s director of policy. “Importantly, youth smoking rates are continuing to decline at a rate they have been and we have no reason to be worried about the entrance of the e-cigarette phenomenon in relation to young people.”

It would appear they are helpful to smokers and they certainly appeal to smokers in a way NRT hasn’t, she adds.

Cheeseman thinks it’s up to pharmacists whether they stock e-cigarettes. “There is a big question there whether you want to stock a product which is a licensed medicine but might be owned by a [tobacco] company whose objectives you feel uncomfortable with.” She would recommend the use of a product owned by a tobacco company if it will help someone quit smoking. “I would say use it. Quit smoking.”

But what about unlicensed products? “Pharmacies do sell unlicensed products and it would be down to the way your pharmacy works to whether it is appropriate to sell this product,” she says.

To her, the important question is how these products are sold and to what extent pharmacies can help people to quit smoking. “A smoker is coming into your pharmacy looking for something to help them quit smoking and you can have a conversation with them about that. Whether you sell them or not, what a great opportunity to encourage people to think about their smoking.”