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E-cigarettes: a controversy in public health and in pharmacy

The safety profile of e-cigarettes is incomplete and their long-term health and societal impact requires further research and monitoring. We do not choose to sell other unlicensed drugs over the counter, so why make an exception for nicotine?

In my role as an English Pharmacy Board member I recently attended a joint meeting of the All-Party Parliamentary Group (AAPG) on Smoking and Health, APPG on Heart Disease and the APPG on E-cigarettes. The Royal Pharmaceutical Society strongly supports the Medicines and Healthcare products Regulatory Agency’s decision to license e-cigarettes as medicinal products.

We have concerns about the quality of products, the advertising of e-cigarettes towards young people and the re-normalisation of smoking habits. There is also a vigorous debate about the potential for e-cigarettes to act as a gateway to tobacco smoking. This meeting revisited these arguments and highlighted the evidence gaps we currently have on both sides of the debate.

Despite sometimes nuanced disagreements, it is clear that there is a pragmatic view that e-cigarettes carry an overall public health benefit. Rob Darracott, chief executive of Pharmacy Voice, suggested at the event that the rapidness of the uptake of e-cigarettes means that pharmacy has to deal with an entire social movement.

Those on the more pro-e-cigarette side of the debate are concerned about over-regulation damaging the public health benefits of e-cigarettes.

However, it was clear from the Government advisers present and the deputy chief medical officer’s comments that there is qualified support for e-cigarettes. There has never been a view that e-cigarettes should be banned.

What is emerging is a dual market of e-cigarettes in the UK. One sector of e-cigarettes will be regulated under the European Tobacco Products Directive (TPD), the other sector will consist of MHRA-licensed e-cigarettes for nicotine replacement therapy.

E-cigarettes without a licensed indication are essentially a recreational product, not a medicinal product, even if they have a net public health benefit. Indeed, it is possible that the medicinally licensed products may end up containing higher doses of nicotine to ensure effectiveness than those regulated under the TPD.

No drug is safer without regulation and that includes nicotine. Licensed e-cigarettes used as part of pharmacists’ smoking cessation role would be a step forward. Concern at the meeting that e-cigarettes were becoming an “easy fix” was supported by suggestions that smoking cessation services were not being renewed on the basis that e-cigarettes had solved the problem. Pharmacists need to defend the added value of those services and ensure e-cigarettes are an option when we have a licensed product.

In the meantime, we cannot support the sale of unlicensed e-cigarettes in pharmacies. This places pharmacists in a difficult position of selling an essentially recreational product with no licensed medicinal claim. There is potential for variation in dosing with unlicensed e-cigarettes, without the regulatory oversight of quality and safety the MHRA provides.

Pharmacists should be empowered to use their professional discretion about whether to sell unlicensed e-cigarettes if pharmacy owners stock them. Just because we accept that e-cigarettes provide a net public health benefit for those who use them recreationally as a substitute for tobacco, this does not mean that pharmacies should stock them.

Citation: The Pharmaceutical Journal URI: 20065685

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