Electronic cigarettes: Community Pharmacists’ Perception

1. Electronic cigarettes: Community Pharmacists’ Perception Ana Marques Gomes Mpharm, MRPharmS Shereen Nabhani Gebara, PharmD, BCOP

2. Multidisciplinary research group • Collaboration between Pharmacists, Pharmaceutics expert and Analytical Chemists • Currents projects include • Public perception study (Poster presentation) • Role of e-cigarettes in the patient care pathway • Analysis of content and distribution patterns of e-cigarettes and e-refills

3. E-cigarettes “I used to be a big smoker myself and knowing the harmful effects associated with it very well, I told myself I couldn’t go on like that. I tried nicotine patches but […] I missed the effect of the sudden impact, the act of smoking, the sensation of smoking. So I started thinking of a way to create vapor containing nicotine, similar to cigarette smoke but not as harmful for the organism.” Ruyan Ltd. (Mr. HonLik, Co-founder) introduced it in China in 2004 as an aid for smoking cessation and replacement. Ruyan America's Chairman, Mr. Hon Lik Ruyan literally means "Resembling smoking".

4. Design 40 years later -http://www.thevapestore.com/pages/how-does-it-work [Accessed on line in April 2014] -Patent no. US3200819 A. Gilbert Herbert A. 17 Ago 1965.

5. Regulations • Over 2 million consumers now regularly use electronic cigarettes • In 2013, the MHRA announced they will be regulated by 2016 • The Royal Pharmaceutical Society and The Chief Pharmaceutical officers in the UK strongly supported the MHRA’s decision • The EU Parliament voted for a dual supply route: medicinal products (if marketed as quitting aids) and tobacco products -http://www.ash.org.uk/media-room/press-releases/:over-2-million-britons-now-regularly-use-electronic-cigarettes [Accessed on line in May 2014] -SukkarE. PJ online (1 March 2014), 292, 223-4. -Ridge KW, et al. Opinion/Letter section. PJ online (3 May 2014), 292, 473.

6. Why regulation? Grana, et al. E-Cigarettes: A Scientific Review Based on analysis of 82 studies Nicotine and toxins, including carcinogens, were identified in the exhaled aerosol The nicotine content of the cartridge e-liquid revealed poor concordance of labelled content Major injuries have resulted from e-cigarette use, including explosions and fires Cytotoxicity varied among products There is little evidence of harmful effects in the short to medium term from repeated exposure to propylene glycol Grana, et al. Circulation 2014; 129: 1972-86

7. What is the evidence? • Bullen C, et al. • RCT Investigating whether e-cigs are more effective than nicotine patches or placebo e-cigarettes at helping smokers to quit • n= 657 • Verified abstinence at 6 months after quit date • Nicotine e-cigarettes group (7.3%) vs • Patches (5.8%), p-value= 0.46 • Placebo e-cigarettes (4.1%), p-value= 0.44 • Concluded that among smokers wanting to quit, nicotine e-cigarettes might be as effective as patches for achieving cessation at 6 months. • Identified no difference in adverse events Bullen C, et al. Lancet 2013; 382: 1629-37

8. What is the evidence? • Brown et al. • A large cross-sectional survey of the English population. • n= 5863 adults who had smoked within the previous 12 months and made at least one quit attempt during that period with either • e-cigarette only • NRT bought OTC only • no aid • Higher self reported abstinence with e-cigarette Brown J, et al. Addiction 2014 Accepted Article

9. Aim and objectives • The aim of this study was to gauge community pharmacists’ current experience and perceptions of electronic cigarettes • Objectives: • To evaluate the community pharmacists current experience with e-cigarettes • To gauge their perception on safety and current use • To gauge their perception on the upcoming MHRA regulations • To find out their training needs to be able to counsel patients

10. Methods • Self-completion questionnaire was designed • Drop off-pick up method • Data was entered and analysed using MS Excel.

11. RESULTS & DISCUSSION

12. Sample Profile • 92/154 participants: 66% male; 34% female • 11% of sample from big chains; the rest is small, independent 49% - Full time 37% - Locum 5% - Part time 5% Manager 3% - Superintendent

13. Sample Profile • Number of patients currently enrolled on smoking cessation services • 73% of surveyed pharmacies sell e-cigarettes. • Of these only 3% of all e-cigarettes sales are nicotine-free.

14. Adverse effects • ≈ 20% of our sample came across side effects from e-cigarettes reported by patients

15. Perception on use • Ranking: • Smoking Cessation Aid • Relapse prevention • Public use (‘dual use’) • Social, recreational use

16. Safety and effectiveness • The design of e-cigarettes encourages smokers to give up • Nicotine delivery is more efficient with e-cigarettes than NRTs • Manufacturing of e-cigarettes is unreliable • E-cigarettes are safe for users • E-cigarettes do not cause any side effects

18. Comparative Effectiveness

19. Perception of regulations • 97% of pharmacists are in support of the regulations announced for 2016 • Major benefits from regulations were ranked as: • Reassurance of safety for users • Regulated as an established NRT • Increase profit for retail pharmacy • Prevent the possibility of misuse

20. Stricter regulations are required for:

21. Training needs • 83% of the survey pharmacists said they felt ready to stock and supply e-cigarettes under the new regulations. • There’s a need for training to support counselling

22. Training content Safety Dosage instructions Adverse events Implementation into smoking cessation patient care pathway

23. Conclusion • Widespread availability in pharmacies • Regulations welcomed • E-cigarettes perceived as effective with a potential role as a smoking cessation aid • Side-effects have been reported • Training needs

24. Acknowledgements • Research Group • Dr Gianpiero Calabrese • Dr Reem Kayyali • Dr Steve Barton • Zohra Yasmin

25. Thank you for your attention