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The UK’s e-cigarette market in the UK is booming, increasing by 340 per cent to reach £193 million in 2013. Victoria Goldman considers the arguments for and against the novel stop smoking aid

There are now over 2.1 million e- cigarette users in the UK. Figures published last month by the Health and Social Care Information Centre reveal that nearly a third of current adult smokers have used an e-cigarette in the past, and three per cent of adults said that they were currently using e-cigarettes.

Over the past 12-18 months, e-cigarette sales have extended from websites into retail stores, including supermarkets, specialist ‘vape’ shops and some pharmacies. A debate at the Pharmacy Show last October looked at whether pharmacies should be selling e- cigarettes to their customers.

“Most pharmacy bodies – but in particular the Royal Pharmaceutical Society – are opposed to e-cigarettes and suggest to pharmacies that they don’t stock them whilst they remain unlicensed,” says John D’Arcy, managing director of Numark. “No one is suggesting that e-cigarettes should be included as part of a NRT programme, but whilst demand is high, they must surely have a place in pharmacy. A refusal to stock them – or indeed a refusal to acknowledge them – will simply point people away from pharmacies and towards outlets where no healthcare advice or information is available.”

E-cigarettes have become a way of life for many people

But independent pharmacist Sid Dajani believes it is unethical for pharmacists to jump on the bandwagon simply to make a quick buck. “E-cigarettes have become a way of life for many people, so we can’t ignore their existence and need to be able to inform customers about them,” he says. “But selling e-cigarettes is a different story. This is the wrong message for pharmacists to give, as pharmacists are regulated through ethics and law. We don’t yet know if e-cigarettes are safe, they can be variable in delivery and some may even be dangerous devices.”

Rob Darracott, chief executive of Pharmacy Voice, says that his organisation is trying to help pharmacists make up their own minds. “The worst position for a healthcare professional to be in is to say they don’t know much about e-cigarettes or can’t discuss them as these are not licensed products,” he says. “Pharmacists need to be clear about what e- cigarettes are, what they are used for, how they work and the evidence for them, which is why we are providing the relevant background information.”

Product choices

The proportion of adults in the UK who smoke cigarettes has fallen to 19 per cent. According to GlaxoSmithKline, the smoking cessation category is worth £213m in the UK within the OTC and prescription sectors combined. “Research suggests that smokers are four times more likely to quit when they use medication such as NRT in combination with behavioural support programmes,” says Shauna Lenagh, marketing manager for NiQuitin. “According to research, more smokers purchase NRT products over the counter in their quit attempt than go to their GP or a specialist stop smoking service and therefore it’s important that pharmacists offer a wide range of products and formats.”

Graham Phillips, superintendent pharmacist of Manor Pharmacy Group, says pharmacies need to add value to NRT products with a combination of smoking cessation and harm reduction advice. “If customers enjoy smoking, telling them not to smoke at all isn’t the answer,” he says.

“Replacing some of their daily cigarettes with NRT, or even e-cigarettes, may be what works for them. We treat e-cigarettes as an alternative to NRT when advising customers – it’s just a different format, in the same way that a customer may choose to use an NRT inhalator rather than a patch. Our sales of NRT versus e-cigarettes are around 50:50. The more committed quitters (eg, customers with health conditions or pregnant women) are probably choosing to use the more traditional NRT, as this is a more medical approach. Customers who choose to use e-cigarettes tend to be more casual about quitting.”

Time for a revamp?

Sean Woodward, independent community pharmacist in Longton, Stoke-on-Trent, suggests that maybe it’s time to revamp the smoking cessation category with new technology. “Pharmacists have been offering customers the same smoking cessation products for the last 10 to 15 years, with different strengths, products and formats of NRT,” he says. “I am forward-thinking enough to realise that e-cigarettes will be the next step for pharmacies, but these need to be regulated first. I do recommend e-cigarettes to some customers, as heavy smokers in particular may find them more helpful than NRT. But I am not ready to stock e-cigarettes until they are licensed products and I won’t yet recommend individual brands.”

E-cigarettes appeal to smokers by mimicking the sensation and appearance of smoking. They are marketed as a safer option for smokers as they deliver nicotine vapour without harmful tobacco smoke. But the evidence for their safety remains inconclusive. Last May, Public Health England stated that, while the doses of nicotine delivered by e- cigarettes are extremely unlikely to cause significant adverse events, there is evidence that e-cigarettes and their vapour may contain carcinogenic substances and some toxic metals such as cadmium, nickel and lead.

“We still don’t know if e-cigarettes cause harm, especially in the long term,” says Brian Curwain, pharmaceutical consultant and ex- pharmacist. “There is no control over the manufacture of e-cigarettes at present, and heavy metals have been detected in some e- cigarette vapours. E-cigarettes are also hazardous to have around the house; there have been cases of very young children dying after drinking liquid nicotine from e-cigarette refills.”

The Medicines and Healthcare Products Regulatory Agency is expected to license e-cigarettes as medicines from 2016. Anthony Cox, lecturer in clinical pharmacy at the University of Birmingham, is against the sale of e-cigarettes in pharmacies until then. “Pharmacists are healthcare professionals and should be selling medicines, not unlicensed products,” he says. “You can’t deny the health benefit of harm reduction with e-cigarettes, but you can use NRT for this as well. The e- cigarette market is growing but it could be perceived that people selling e-cigarettes don’t have the same interest in people coming off them as those supplying NRT. I would like to see e-cigarettes licensed as a medicine as part of a smoking cessation scheme.”

Marketing dangers

There are concerns that e-cigarettes could encourage more young people to take up smoking, tempted by a ‘healthier alternative’ to cigarettes. Data from the Office for National Statistics indicates that those who used e-cigarettes in 2013 were almost entirely current or former smokers. However, a Welsh Government survey published last December revealed that six per cent of 10-11 year-old children have used e-cigarettes (compared with two per cent who have smoked tobacco versions) and most children who said they had used e-cigarettes had never smoked tobacco cigarettes. The British Medical Association said that first television adverts for e-cigarettes in November 2014 breached guidelines by glamourising ‘vaping’ and targeting children.

Mr Woodward worries that e-cigarettes are beginning to normalise smoking again. He says: “E-cigarettes are promoted mainly by cigarette companies, which makes me uncomfortable, and it feels like the aim is to get a new generation smoking again.”