What do pharmacists need to know?

Australian researchers have reviewed the evidence behind nicotine vaping products as a harm reduction tool and provide advice for pharmacy staff

Pharmacists play a critical role in delivering harm reduction interventions, but not all are confident in providing guidance on the use of nicotine vaping products (NVPs), say researchers.

A recent survey conducted in Brisbane found more than one in three pharmacy staff (39%) had been asked about ‘e-cigarettes’ by their customers.

Meanwhile nearly all pharmacy staff (91%) reported that they felt uninformed and needed more information regarding the safety, efficacy and regulation of NVPs.

Vaping products containing nicotine are currently illegal to sell in all states and territories unless approved by the TGA or supplied via a pathway for accessing unapproved goods.

Nicotine is classified as a ‘dangerous poison’ (Schedule 7) unless used to help quit smoking in which case it is a ‘prescription only medicine’ (Schedule 4).

Preparations such as nicotine patches, gum or mouth sprays, however, are unscheduled and can be sold by general retailers.

Smokers can import nicotine liquid for use as a smoking cessation aid if they have a medical prescription.

Researchers from the University of Queensland’s schools of pharmacy and public health have reviewed the latest evidence of nicotine vaping products as a harm reduction tool among smokers.

Here are 5 key points found in their review:

1. While nicotine is a highly addictive substance, exposure to low concentrations in the absence of tobacco smoke is not associated with an increase in risk of heart attack, stroke or death. While long-term nicotine use is insufficient, experimental studies indicate that nicotine alone is not carcinogenic.

2. Long-term health risks of NVPs have not yet been established. There is evidence that most e-cigarette products contain and emit numerous potentially toxic substances. However the evidence also strongly indicates that these products are much less harmful compared to combustible tobacco cigarettes and offer smokers the opportunity to reduce tobacco-related harm, if they are unwilling or unable to quit smoking by other methods.

3. The current literature regarding the efficacy of NVPs as a smoking cessation aid is not conclusive. However the evidence base is growing with randomised controlled trials indicating that NVPs are equally or more effective than nicotine replacement therapies (NRTs) for smoking cessation. It is important that smokers using NVPs are encouraged to stop smoking completely rather than using NVPs as a partial substitute, as there may be little health benefit from NVP use without stopping smoking.

4. The recent outbreak of lung injuries in the US was associated with illicit vaping products containing THC with vitamin E acetate, not licit NVPs. Vitamin E acetate is not present in licit NVPs available on the market.

5. First-line treatment for smoking cessation continues to be behavioural counselling accessible for free via Quitline combined with TGA-approved smoking cessation products such as NRTs, bupropion and varenicline.

“While completely stopping the use of nicotine in any form is the best decision a smoker can take, continuing to use nicotine in a substantially less harmful product, such as NRTs or NVPs, provides an opportunity to reduce smoking-related death and disease for smokers who are unable to achieve abstinence from nicotine,” say the researchers in the journal Research in Social and Administrative Pharmacy this month.

Under no circumstances should smoking be considered less harmful than vaping.

“Due to being a relatively new product, the risks from long-term use of NVPs are uncertain and not fully quantified,” they say.

“However, vaping is likely to be much less harmful than long-term use of smoked tobacco. The lowest risk option is to use NVPs for a limited time until the former smoker is confident they can stop without relapsing to smoking.”

Some public health academics have expressed concerns that while use of NVPs may lead to abstinence of tobacco, use of NVPs may be ongoing, adding that this is dangerous due to the lack of knowledge about the health risks regarding long-term use of NVPs.

For example, a January 2019 randomised trial including 886 participants, published in the New England Journal of Medicine (NEJM), found that one-year abstinence in the e-cigarette group was 18%, compared with 9.9% in the NRT group (RR 1.83; 95% CI 1.30 to 2.58, p<0.001).

However the study also found that among participants with sustained abstinence at one year, 63 out of 79 (80%) in the e-cigarette group were still using e-cigarettes, whereas only four of 44 (9%) in the NRT group were still using nicotine replacement.

“This differential pattern of long-term use raises concerns about the health consequences of long-term e-cigarette use,” say Dr Belinda Borrelli and Dr George O’Connor from the Boston University School of Medicine, in an accompanying NEJM editorial.

Overall population health risks or gain from long-term use of NVPs is still uncertain.

“The net public health gain or loss from NVP use, however, will ultimately be contingent on who uses them and how they are used, for example, how many smokers fully switch to NVPs and how many non-smoking youths engage in persistent long-term use,” say the researchers from the University of Queensland, who have provided a guide for pharmacy staff on discussions with customers regarding NVPs.

“These outcomes can be influenced by the regulatory framework that is adopted, with the highest benefit likely realised when NVPs are regulated in a way that will discourage access to and uptake by youth and non-smokers, while encouraging smokers to switch to them,” they conclude.

An example of such regulation is the United States’ countrywide ban on most flavoured e-cigarettes amid concerns about vaping among teens, with exceptions that benefit adults who use the nicotine-delivery devices.

One vaper’s experience

Hayden Dwyer, a systems administrator from Sydney, says he’s glad he made the switch from smoking tobacco cigarettes to using nicotine vaping products in 2011.

“Cigarettes are expensive, smell bad and are unhealthy. Vaping still let me experience the hand-to-mouth actions and the nicotine hit without worrying about those three things,” Mr Dwyer tells AJP.

“Well, smelling bad and expensive definitely. It’s definitely healthier than smoking, though I’m willing to admit we don’t know by exactly how much.

“I never intended to quit nicotine, but I do consider vaping as having quit smoking – just as quitting energy drinks might involve switching to coffee, for example.

“I have used nicotine gum and Swedish snus before and both leave an unpleasant burning sensation in your throat.”

Mr Dwyer says that while switching to vaping has been relatively simple despite the regulatory and legal hurdles, he wishes government policy was more consistent.

“I’ve sourced nicotine e-liquid from American companies in the past but I currently get it from New Zealand. I would say it’s marginally more difficult than buying a pair of shoes from New Zealand, with Australian customs being the biggest bottleneck,” he says.

“I think [the government] should either ban all nicotine products or none – with my opinion heavily weighted towards banning none.

“It’s widely said in the ‘vaping community’ that the only reason it’s not legalised is because it’s a lot harder to tax than cigarettes, and the government has come to rely on the tax dollars from smokers,” says Mr Dwyer.

“Once they find a way to tax it and keep that revenue from tobacco they will.”

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