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E-cigarettes are one of the most controversial products ever to hit pharmacy shelves -- but do they belong there? Chris Chapman investigates

BACKGROUNDER

Regardless of where you stand on the e-cigarette issue €“ and it's certainly a hugely controversial issue that has divided pharmacy €“ there's little doubt that they've taken the UK by storm. E-cigarettes have hit the shelves in Boots, LloydsPharmacy, Tesco, Superdrug and Asda and, increasingly, independent pharmacies are getting in on the act too.

According to market research company IRI, the e-cig market in the UK is worth a staggering £100m in just traditional pharmacy and grocery outlets alone. And, with pop-up shops, market stalls and other, less traditional operators grabbing a slice of the action, it's likely the market value is far higher.

€They are a godsend for independent grocers,€ remarks IRI's retail head of strategic insight Martin Wood, €but e-cigarettes are still a pin-prick in the tobacco market.€

The market

Context is key. The £100m seen in community pharmacy and grocery outlets is almost a match for traditional stop-smoking products (worth around £125m in the UK) but only about 5 per cent of the total e-cigarette market. However, that is nothing compared with the tobacco market, worth anywhere between £15bn and £25bn a year.

This growth area is attracting major players who may be unwelcome bedfellows on pharmacy shelves; for example, Vype is owned by British American Tobacco.

€You have to set the e-cigarette market's [growth and] size against the lack of growth in the OTC market, and the contracting but enormous tobacco market,€ Wood explains. €Now the big boys are muscling in.€

With such heavy hitters €“ with heavy advertising budgets €“ ready to enter the market, pharmacists will need to ask themselves whether they are comfortable about where their money goes when they stock e-cigarettes.

This growth area is attracting major players who may be unwelcome bedfellows on pharmacy shelves

Effectiveness

Another thorny issue is that of effectiveness. Currently e-cigarettes are not health products regulated by the MHRA and make no claims about helping smokers to quit. Yet advocates are clear that they consider e-cigarettes a reduced-harm option that can help people quit smoking for good. This is a situation only likely to be compounded by the EU's Tobacco Products Directive, which will see e-cigarettes not sold and regulated as medicines classed as tobacco products.

The problem is that, as yet, the evidence doesn't support this concept. Last month a longitudinal analysis of 949 smokers, of whom 88 were using e-cigarettes, was published in JAMA Internal Medicine. It found that although 85 per cent of smokers using e-cigarettes reported using them to quit, they were no more successful in their quit attempts than non-users a year later.

The dilemma

Effectiveness and concerns about their safety aside, there is a clear consumer demand for the products that shows absolutely no signs of lessening. And while major tobacco companies are taking over the market, this is ultimately a side issue: there is little doubt e-cigarettes are less harmful than traditional tobacco cigarettes themselves.

The question facing the profession is whether they have any place in community pharmacies today €“ or whether we wait to see what the MHRA, and the evidence, says.

YES -- Graham Phillips, pharmacist and contractor, Hertfordshire

I believe community pharmacy has a bright future based upon our core safe-supply role, combined with medicines optimisation and public health.

Key to the last of these is smoking cessation €“ a passion of mine since NRT first went OTC in the 1980s, at a time when the NHS abdicated any responsibility for cessation. My local primary care group (PCG) established smoking-cessation services more than 10 years ago, and I was the smoking lead, training local GPs. So it may surprise you that I believe pharmacies should stock e-cigarettes.

I want pharmacy to be the 'go to' place for quitting. And while I'm entirely in favour of licensing e-cigarettes, if we wait for licences to be granted we will have missed the boat. Consumers €“ they don't see themselves as patients because they are not ill €“ will simply go elsewhere for the products and we will lose out, just as we have in the vitamins and health food markets.

If we wait for licences to be granted we will have missed the boat

Let's have a nationally-commissioned pharmacy smoking cessation service. Why do we need 100 variations of what is essentially the same service? And let's have a national NHS PGD for varenicline. That said, we must remember not to take a paternalistic attitude to the public's health, or we render ourselves irrelevant as healthcare providers. We don't just lose the sales; we lose the opportunity to help people make healthy choices.

Pharmacy has a wider tendency to be over-cautious. We sometimes seem so worried about not doing harm that we risk not doing good. This is the same risk-averse psychology that allowed nurses to be NHS prescribers years before pharmacists; we lacked confidence.

Many of us will remember when NRT could not be supplied to pregnant women due to the concern about risk to the unborn child. This was looking through the wrong end of the telescope. The question we should have asked then was: €Which is safer in pregnancy: continuing to smoke or using NRT?€

Today's question should be: €Which is safer €“ smoking or e-cigarettes?€ It's a no-brainer.

NO -- Hayley Johnson, senior medicines information pharmacist, Newcastle-upon-Tyne

Selling cigarettes for the treatment of asthma was not, with hindsight, pharmacy's greatest moment. But sell them we did, and they were, staggeringly, a pharmacy staple until 1985.

Of course, we know now that smoking cigarettes is more likely to significantly worsen asthma than treat it, thanks to the emergence of robust, scientific research and consensus. Asthma cigarettes are now an interesting €“ if embarrassing €“ part of pharmacy history.

Could e-cigarettes be leading the profession down a similarly dangerous path? At the moment, we just don't have enough research to know for certain. We can reasonably theorise that they are probably safer than cigarettes, but without good, robust safety and efficacy data, we simply don't know.

Are all the cries of €probably safer€ and €maybe more effective€ enough for us as a profession to hang our hats on?

The more we know about e-cigarettes, the less rosy the picture is looking. Several studies have suggested that they often contain different levels of nicotine to that claimed.

A small German study suggests they may cause indoor air pollution. Cases of fatal ingestion of e-cigarette refill liquid have been emerging in the medical literature. Poisons centres worldwide are dealing with cases of accidental nicotine poisoning due to ingestion of nicotine refills. Propylene glycol and other excipients known to be harmful through inhalation are present in many e-cigarette products, and their long-term safety is unknown.

The more we know about e-cigarettes, the less rosy the picture is looking

Under what circumstances can we sell these products in a pharmacy? They aren't regulated as medicines, so we can't make any claims that they act as nicotine replacement therapies. We are therefore selling them for recreational use. Is this a suitable precedent to set for pharmacy? It leaves us in an awkward ethical situation.

While e-cigarettes are undoubtedly a useful product for many €“ there is a vociferous, passionate community supporting their use €“ their unregulated nature is limiting their promise. As healthcare professionals, we should be vocally supporting the need for research before encouraging their wider adoption by the public.

At the moment, the e-cigarette situation leaves us with more questions than answers. We should be demanding the evidence before we throw ourselves headlong into another potential asthma cigarette situation.