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E-cigarettes are currently battling for a place on pharmacy's shelves €“ but do they belong there? Report by Chris Chapman

In the past few weeks the debate around e-cigarettes has ignited, forcing pharmacists to confront a difficult problem €“ should they be selling them or not?

Last month the European Parliament passed the new EU Tobacco Products Directive, a raft of policies to standardise cigarette packaging and ban flavoured cigarettes. Included in the changes was a regulatory framework for e-cigarettes. Devices containing less than 20mg/ml of nicotine will be classed as tobacco products; those above the threshold will be counted as medicines.

For those against e-cigarettes the measures don't go far enough. For the supporters, they are a near-criminal restriction on a vital stop-smoking aid.

Regardless of where you stand on the debate, there is no doubt that the use of e-cigarettes is on the rise. According to stop smoking charity ASH, around 9 per cent of the UK population had used e-cigarettes in 2010, a figure that almost trebled to 35 per cent in 2013. Currently around 1.3 million people use the devices. But what constitutes an e-cigarette?

Simply put, it is device that heats up a volatile liquid to produce a vapour, which is then inhaled. The vapour usually contains nicotine and, supporters argue, this means it produces a nicotine fix with fewer of the downsides of smoking €“ most notably the additional carcinogens in conventional tobacco products. This creates an attractive proposition for some public health experts.

Hostile response

E-cigarettes ignore all current no-smoking restrictions and €“ supporters argue €“ can be used as a stop-smoking aid. In a MHRA consultation on the products, 924 e-cigarette users responded, of whom 83 per cent said they'd used the products to help give up smoking - which means they fall under the authority of the MHRA.

In June 2013 the drugs watchdog called for the products to be regulated as medicines. €Any non-medical product which claims or implies that it can assist in giving up smoking is considered by the MHRA to be a medical product.€

It is a position that has attracted a hostile response from e-cigarette supporters. €Reclassifying these consumer products as medicinal products would have a negative impact on public health,€ warns the Electronic Cigarette Industry Trade Association (ECITA). €It would require a change in the operation and performance of the products, and would reduce their appeal and effectiveness for consumers.€

ASH disagrees. The charity points out that as medical products, they would be more widely available. Products would be available on prescription and only 5 per cent VAT would be levied compared with the current 20 per cent - making them cheaper.

Advertising

The debate highlights a central issue: advertising and access. Currently e-cigarette brands side-step MHRA regulation by not claiming to be a stop- smoking aid. While smoking advertising is banned in the UK, e-cigarette adverts have appeared on buses, billboards and TV €“ none mentioning quitting smoking.

These adverts are a cause for concern, says the BMA. €The advertising frequently makes positive associations with recreational activities and can incorporate celebrity endorsements,€ it says, adding the €devices commonly resemble tobacco cigarettes in terms of appearance, flavouring and styling that are potentially highly attractive to children€.

This aspect of the debate is set to change. Products under the 20mg/ml nicotine threshold will be unable to advertise as they count as tobacco products, and those over the limit will be restricted on how they advertise, just like any other medicine. 

E-cigarette timeline...

Where's the evidence?

So perhaps the biggest issue is evidence €“ or absence of it. Currently there is a confusing picture due to the lack of studies and available evidence.

For example, the MHRA states there is evidence that €young adults are more aware of e-cigarettes... possibly as they are promoted through social media and online advertising€. However there is €little evidence to suggest [they normalise smoking]€, ASH warns, and €little evidence to suggest that anything more than a negligible number of non-smokers regularly use the product€.

The same can be said for the evidence that the products help smokers quit, or that they pose a health risk through the vapour they produce. In fact the only overall consensus is that e-cigarettes are less harmful than their tobacco counterparts.

Selling e-cigs "unhelpful" says NHSE

Pharmacies that sell electronic cigarettes have been labelled €unhelpful€ by NHS England's deputy chief pharmaceutical officer Clare Howard.

Talking to Pharmacy Magazine, Ms Howard stated: €My personal view would be that at a time when we are working really hard to secure the place of community pharmacy as the first port of call and the role of healthy living pharmacies in all of that, I think it is unhelpful for pharmacies to be selling e-cigarettes.€ She urged community pharmacies to reflect on MHRA and RPS guidance that make it clear that there are already licensed products available for pharmacists to support patients in giving up smoking.

€Public Health England has also said that it can't support the use of these products for smoking cessation because the current evidence suggests that e-cigarettes are no more effective in quitting than supportive methods for which we already have the safety data,€ she said.

Pharmacy's dilemma

So should pharmacies stock e-cigarettes? The answer seems to be a professional judgement call. Currently NICE shies away from the question, looking to update its guidance if and when the MHRA regulates the products; its latest advice is to tell patients that €safety and quality cannot be assured... [but they] are likely to be less harmful than cigarettes€.

Until the MHRA's decision to license nicotine-containing products as medicines comes into force, expected in 2016, it's up to each pharmacist to decide what's in the best interests of his/her patients €“ and whether e-cigarettes are a good quit option or harm reduction approach, or, in fact, a potential public health risk.