This month sees the return of Stoptober. The message of the NHS’s annual smoking cessation campaign typically takes a similar form: refrain from smoking for at least 28 days and you are five times more likely to stop for good. Make use of the initiative’s motivational support and local smoking cessation services, which can recommend licensed medicines, and your chances will be greatly improved.

But this year’s Stoptober campaign is different. In a somewhat controversial move, it is the first to condone the use of e-cigarettes, following an independent review of their safety and efficacy commissioned by Public Health England (PHE). Published this year, E-cigarettes: an evidence update examines the latest evidence on the role and impact of e-cigarettes, which are not yet licensed as medicines. 

In a nutshell, the review estimates that e-cigarettes are 95% less harmful to an individual’s health than tobacco cigarettes and – when supported by a smoking cessation service – help most smokers to quit altogether. 

It seems logical, therefore, that PHE has backed the use of e-cigarettes in smoking cessation services. But the decision leaves many unanswered questions for pharmacists. PHE gives no guidance on when e-cigarettes should be recommended, nor does it advocate individual products to the public – advising them to seek “expert advice and support” from their local smoking cessation service. So what advice should pharmacy teams give customers this Stoptober?

A change in mindset

For public health experts, it’s all about a change in attitude towards e-cigarettes. One of the authors of PHE’s report, Ann McNeill, believes pharmacists “have an important role to play in encouraging smokers to stop”. As a smoking cessation expert in King’s College London’s addiction department, she encourages pharmacy teams to view e-cigarettes as “another tool in their toolkit for helping people to quit”.

“We know that many smokers find it difficult to stop [despite] having tried existing products available, but now there is a new product – e-cigarettes – and pharmacists can suggest they try them,” says Professor McNeill. They are a popular form of support “so they shouldn’t be ignored”, she advises. 

It’s a sentiment that Mimi Lau, Numark’s director of pharmacy services, agrees with wholeheartedly. Until the PHE report was published, she says there was no compelling evidence over the use of e-cigarettes, which has caused “much confusion among pharmacists”. 

But the publication of the report calls for a shift in thinking, she believes, “to stop the inaccurate perception that e-cigarettes are as harmful as cigarettes”. 

She says it should “give pharmacy the confidence” to offer them to smokers – especially those who have tried other smoking cessation methods without success. “In terms of harm reduction and as an aid to quitting, e-cigarettes have an appropriate role,” she argues.

Too much, too soon?

Not all pharmacists share this view, though. Terry Maguire, owner of Maguire’s Pharmacies in Belfast, feels e-cigarettes are a valid means of harm reduction and “game-changers” in public health. But he says there is not enough evidence to say that they help people kick the habit entirely – he worries people who use e-cigarettes “probably won’t stop”.

And Mr Maguire won’t stock them until they have been through regulation to become licensed as medicines next year. It is easy to see his point of view – in 2013, the Medicines and Healthcare Regulatory Agency revealed some products on the market contained contaminants and leaked nicotine. The more recent PHE report says there is no risk of nicotine poisoning from e-cigarettes when used as intended, but Mr Maguire remains cautious over advocating them as a first-line therapy.

“Before we can start selling them, will need some agreed form of regulatory process so we can estimate whether it’s in the best interest of patients to supply them,” he says. Otherwise, he fears they pose a liability: “We have to look after the best interests of patients.”

Mr Maguire is certainly not alone in his view. Last year, the Royal Pharmaceutical Society (RPS) warned pharmacists against stocking e-cigarettes until they become licensed medicines – and has shown no sign of changing its position.

Leanne Beverley, accuracy checking technician and smoking cessation advisor at Monarch Pharmacy in Canley, Coventry, believes the RPS is right to be wary. “At the moment, I wouldn’t advise a customer to buy an e-cigarette,” she says. “We don’t know how safe they are or how much nicotine they contain, so I’m not able to endorse them fully.”

As a result, Ms Beverley says she will continue to recommend nicotine replacement therapy (NRT), combined with behavioural support this Stoptober.

The practical approach

Faced with two such conflicting arguments, it is difficult for pharmacists to know what to do. Should you always recommend NRT or is there a case for suggesting e-cigarettes to patients who have struggled to quit?

Reading between the lines, it seems pharmacists are best-advised to stick with NRT in the first instance. Martin Dockrell, head of PHE’s tobacco control programme, says pharmacists should simply be “open to a conversations about e-cigarettes, alongside the extra help of medicines and behavioural support” – rather than recommending them outright.

But he stresses the importance of letting patients make their own informed decisions about e-cigarettes. “Pharmacy staff can let smokers know that the current evidence suggests they are much safer than smoking and that they can be a useful quitting tool, but they are not currently licensed as medicines,” Mr Dockrell says. And it is important to bear in mind that people who use e-cigarettes to quit with “additional support” have “very high” rates of success.

Talking therapy

But, as Mr Dockrell points out, e-cigarettes “aren’t a magic bullet”. Whatever form of smoking cessation product they use, people will always need support to help them quit successfully. And this is where pharmacy teams come in. 

Numark’s Ms Lau stresses that pharmacies can get behind the “fantastic” Stoptober campaign by making sure they offer more than just products. “Selling a product along with motivational advice should support the quitter to quit and stay smoke-free. This approach will differentiate you from non-pharmacy retailers and very likely mean a customer for life,” she argues.

It’s both an emotionally and commercially rewarding prospect – so how can pharmacies make this reality? Mr Maguire recommends taking a proactive approach to identifying would-be quitters. “You ask the question when a customer has a troublesome cough, or asks about a respiratory problem, for example,” he says. “Then you talk about the advantages of change and the disadvantages of not changing.”

Once the customer has made a decision to quit, more in-depth work can begin. At Monarch Pharmacy in Coventry, Ms Beverley helps run a three-month stop-smoking support programme. This involves weekly chats with a stop-smoking advisor to talk through the patient’s progress, any problems and cravings, and to monitor their NRT.

“It’s all about people being ready to stop, and then changing their habits and routines. Some people might not be ready to quit and will continue to smoke, but at least you can support them to try to stop,” says Ms Beverley.

And those who do kick the habit – regardless of which smoking cessation products they use – can make your career as a pharmacist feel truly worthwhile. As Mr Maguire says: “It’s so rewarding when you meet someone on the street, someone you haven’t seen for five or 10 years, and they thank you for helping them to give up smoking.”