Smoke signals

Timeline of events

...continued

Harnessing vaping

Pharmacy has had an uncertain relationship with vaping ever since electronic cigarettes appeared in the UK just over a decade ago. A lot of this uncertainty revolves around safety. 

“We advocate the precautionary principle approach to minimise exposure to e-cigarette vapour until more safety data becomes available,” says Royal Pharmaceutical Society chief scientist Parastou Donyai. 

“While e-cigarettes are considered likely to be significantly less harmful than smoking tobacco, more research is required on the long-term effects of inhalation of e-cigarette constituents to establish their absolute risk.

“Although 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. The full picture of health risks from smoking tobacco products did not emerge until decades after cigarettes were first introduced.”

Professor Donyai says that “pharmacies should offer a full range of smoking cessation options to help smokers quit their addiction to nicotine”, but the associated statements have left many in the sector feeling conflicted about where they stand on vaping as a quit tool. 

“Pharmacy didn’t deal with e-cigarettes very well when they first appeared and that led to them going into unregulated premises, such as vape shops, instead of coming under a healthcare framework,” says Ade Williams, superintendent pharmacist and clinical lead at Bristol’s Bedminster Pharmacy.

Hung up

“We got hung up on the potential harms instead of looking at the potential good, which was – and is – that vaping offers people an alternative way of accessing nicotine to smoking, and we know smoking to be extremely harmful. 

“By not engaging with e-cigarettes early on, we missed the opportunity not only to help smokers in this way, but also to shape the way that the vaping industry unfolded in terms of putting in safeguards, regulations and clear guidance.

“Now people are more likely to go into a vape shop than a pharmacy for e-cigarettes, and the staff there will certainly encourage people to move from smoking to vaping because it is a commercial opportunity, not because they are concerned about their health. 

“These places aren’t offering the same level of care, advice and support smokers can get from pharmacists and their staff. Even though there is now a lot of evidence supporting vaping as a stop smoking tool, and that is reflected in the NICE guidance which we should be following [see panel], the offer still isn’t clear to the profession
– so how can it be to the public?”

OHID verdict

Anyone left in any doubt about vaping would do well to look at the evidence summary published by the Office for Health Improvement and Disparities. 

The OHID report, the eighth in a series aiming to track the growing evidence base for vaping in order to inform policy and regulation, opens with the line: “Alternative nicotine delivery devices such as vaping products can play a vital role in reducing the huge health burden caused by cigarette smoking.”

As director general of the UK Vaping Industry Association (UKVIA), John Dunne is an advocate of vaping but stresses that there is a technique to using the products which users need to be shown. “To get the best experience from their device, people need to be counselled on the difference in technique between smoking and vaping,” he says. “They need to inhale for two to two-and-a-half seconds to get the device to produce the vapour and deliver the nicotine, compared to just one second with a cigarette. 

“And then it is important to get the strength right – most come in 18-20mg and 10mg, so most regular smokers would need to start at the higher level, then reduce down over time. A disposable device is a good starting point, as these are relatively inexpensive, easy to use and come in a range of flavours, but if they feel vaping is a good fit for them, they are likely to want to move onto a pod or open tank system as they last longer and are more cost-effective.”

Healthcare professionals should not wait for an e-cigarette that is a licensed medical product, says Dunne. “A product that is going through licensing won’t emerge ... for four or five years but is likely to become obsolete within six months of being submitted because the technology is moving so fast. In my opinion, it is commercially risky for manufacturers to go down this route, especially when good devices are already commercially available.”

That said, it is vital that the risks – both known and unknown – are spelled out to users, as part of wider efforts to stop vaping replacing smoking as a societal norm. Vaping is rising among young people. Action on Smoking and Health (ASH) data showed an increase in 11 to 17-year-olds from 4 per cent in 2020 to 7 per cent in 2022. 

Wrong restrictions

John Dunne also thinks that current advertising restrictions aren’t finding the right balance. “E-cigarettes can’t be promoted on TV, radio or in newspapers – the channels used most by the older demographic that is looking to give up smoking, so that’s a missed public health opportunity. 

“On the flip side, ‘soft advertising’ such as influencers on social media platforms such as TikTok with poor age gating are showing vapes to a young audience, and this isn’t well regulated or enforced at all. What would work well would be pre-approved switching messages that the industry could use across all media.”

Government inaction doesn’t surprise UCL’s Professor West. “Vaping has made a significant dent in smoking rates, so it definitely has a role, but it isn’t enough on its own. The Khan Review describes other measures that would probably make an even bigger contribution – increasing the age of sale or raising the price of cigarettes, for example – and shows that the Government needs a comprehensive strategy, including regulations that are targeted and matched to problems as they arise. At the moment, there doesn’t seem any sign that England’s government, at least, is going to do that.”

There is significant public momentum to do more. An ASH report published this summer showed that over two-thirds of people supported the inclusion of information on quitting in cigarette packets and the printing of health warnings on cigarettes themselves. In fact, all the recommendations made in the Khan Review gained majority support, regardless of socio-economic status, political allegiance or even smoking status. 

It is vital to capitalise on this impetus. As Javed Khan says in his review: “Without further action, England will miss the smoke-free 2030 target by at least seven years and the poorest areas in society will not meet it until 2044… if we do nothing different, by 2030 over half a million more people in England will have died from smoking.” 

While societal change will, for the most part, be driven by government policy, those on the ground – including pharmacists and their teams – still have a valuable role to play in supporting individuals to become smoke-free.