E-cigarettes have been around for some time, but a debate still rages over whether they are an acceptable option for smoking cessation. Kathy Oxtoby reports…

“The government must embrace the promotion of vaping as an effective tool to help people to quit smoking tobacco. We know vapes are not a ‘silver bullet’ nor are they totally risk-free, but the alternative is far worse.”

That was the message from a government-commissioned review into smoke-free policies published this June.¹‘The Khan review: Making smoking obsolete’ makes 15 interventions to help the government meet its 2030 smoke-free target. The report recommends that if pharmacies sell vapes “they should do so alongside an offer of behavioural support for smoking cessation”.

The review is one of a number of recent recommendations and guidance concerning vaping and how it fits into the smoking cessation armoury A response to the review by ministers is expected to be published as part of the government’s Health Disparities White Paper.²

In October 2021, the Medicines and Healthcare products Regulatory Agency (MHRA) updated its guidance for licensing e-cigarettes, paving the way in England for them to be available on NHS prescription for tobacco smokers who wish to quit.^{3, 4}

The MHRA invited e-cigarette manufacturers to submit their products for approval to be medically licensed. If approved by the regulatory body, healthcare professionals could then decide on a “case-by-case basis” whether to prescribe the e-cigarette to NHS patients to help them quit smoking.⁴

The National Institute for Health and Care Excellence (NICE) - working with Public Health England - also updated its guidance on e-cigarettes in 2021.⁵ NICE found the evidence shows that nicotine-containing e-cigarettes can help people to stop smoking and are “similarly effective to other cessation options such as a combination of short- and long-acting nicotine replacement therapy (NRT)”.⁶

NICE now recommends that “people should be able to use e-cigarettes as one of several options to support smoking cessation, if they so choose”.⁶ It advises practitioners “give clear, consistent and up-to-date information about nicotine-containing e‑cigarettes to adults who are interested in using them to stop smoking”.

This includes explaining that “there is not enough evidence to know whether there are long-term harms from e-cigarette use”, and that use of these products is “likely to be substantially less harmful than smoking”.

People using e-cigarettes should also “stop smoking tobacco completely”. Length of e-cigarette usage and how to stop their use should also be discussed, NICE recommends.⁵

“E-cigarettes are one of several harm reduction options in the short-term to encourage smokers to stop using tobacco products, and they should be accessible to adults who smoke and wish to stop,” says Claire Anderson, president of the Royal Pharmaceutical Society.

“We should always have the ultimate aim of supporting the patient to stop using e-cigarettes and to be free of nicotine addiction. If e-cigarettes are chosen by the patient to support them to quit tobacco smoking, then it is important that they are informed that they are not risk-free until more is known about the potential risks of e-cigarette use,” she says.

However, there is an ongoing debate within the pharmacy profession as to whether pharmacies should be selling ‘vapes’ or sticking to more traditional approaches, such as nicotine replacement patches and gum.

Ade Williams, lead pharmacist at Bedminster Pharmacy, Bristol, who has helped design a smoking cessation service, views e-cigarettes as “an effective tool to reduce harm from smoking”. He says pharmacists should “accept the fact that these products can help our patients, and that it is incumbent on us to give them these options to help them to be ‘smoke-free’.”

However, Lila Thakerar, superintendent pharmacist at Shaftesbury Pharmacy in Harrow, chooses not to sell vaping products. “There are so many products and brands – it’s a minefield. And we need to ensure they are correctly marketed, regulated, and safe to use – some can catch fire or explode if left charging unattended,” she says.

The “correct smoking cessation support” is nicotine replacement therapy (NRT) and monitoring people’s carbon monoxide levels on a regular basis to ensure that therapy support is working, she says.

Some pharmacists, like Lindsey Fairbrother, owner and superintendent pharmacist at Goodlife Pharmacy, Hatton, chooses not to stock e-cigarettes because she ‘doesn’t see people coming to us as their destination for such items, which are sold in supermarkets and garages," she says.

While the evidence from recent reviews suggests e-cigarettes are significantly less harmful than smoking tobacco, “they are not without risk”, says Ms Anderson. “The RPS supports the need for more research and safety data on the long-term risks and benefits.

“While many of the substances used in e-cigarettes may be considered safe for oral ingestion, little is known about the long-term effects of inhalation, or how the heating process can alter their chemical composition,” she says.

E-cigarettes “should not be used indoors, in enclosed places, or near children”, she advises. “This exposes other people to the negative effects of poorer air quality, particularly when groups of people are using e-cigarettes in the same place at the same time. Non-smokers should not have to inhale e-cigarette vapour without their permission.”

But as a quit smoking aid, e-cigarettes also have their advantages. “Making the switch from smoking to e-cigarettes has the benefit of harm reduction. And we can advise patients that if they can’t quit smoking without support, e-cigarettes have helped many people,” says Mr Williams.

Ms Thakerar says e-cigarettes have the benefit of being easy to use and easily available. “They also give that support of holding something that’s like a dummy cigarette, but without the same chemicals,” she says.

It would be “helpful if some e-cigarettes had a medicinal licence, as regulation of these products would allow healthcare professionals to safely recommend and prescribe e-cigarettes and offer another option for patients wishing to stop smoking,” says Ms Anderson.

Ms Thakerar’s advice on pharmacists stocking e-cigarette products is to “make sure they are safe to use and ensure that you are able to stand by that product if anything goes wrong. Stock a product that you are confident in selling. You have a professional reputation to maintain. And advise customers that they are not to smoke and vape at the same time.”

As a profession safeguarding the health interests of patients, pharmacy should be “part of the conversation about the standards of these products, across the board, including what needs to be improved”, says Mr Williams. And, crucially, pharmacists need to “keep reviewing the evidence” so that they can have conversations with patients explaining the harms and risks of these products, he says.

As to whether pharmacists should stock e-cigarettes - “they need to take a professional view on this”, says Ms Fairbrother. “It’s down to the individual pharmacist to do their research, to understand if a product is safe or not, and to decide if they feel comfortable advising patients about e-cigarettes.”

References

1. Khan J (2022) The Khan Review. Making Smoking Obsolete. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1081366/khan-review-making-smoking-obsolete.pdf
2. DHSC (2022) Government launches landmark reviews to tackle health disparities. https://www.gov.uk/government/news/government-launches-landmark-reviews-to-tackle-health-disparities
3. MHRA (2021) Guidance for licensing electronic cigarettes and other inhaled nicotine-containing products as medicines. https://www.gov.uk/guidance/licensing-procedure-for-electronic-cigarettes-as-medicines
4. DHSC (2021) E-cigarettes could be prescribed on the NHS in world first. https://www.gov.uk/government/news/e-cigarettes-could-be-prescribed-on-the-nhs-in-world-first
5. NICE (2021) Tobacco: preventing uptake, promoting quitting and treating dependence. NICE guideline [NG209] https://www.nice.org.uk/guidance/ng209/chapter/recommendations-on-treating-tobacco-dependence#stop-smoking-interventions
6. NICE (2021) NICE and PHE publish comprehensive draft guideline to tackle the health burden of smoking. https://www.nice.org.uk/news/article/nice-and-phe-publish-comprehensive-draft-guideline-to-tackle-the-health-burden-of-smoking