Ecigs and pharmacist autonomy

The surge in the use of ecigs has taken the health sector, including professional bodies, the pharmaceutical industry and regulators, by surprise. It’s a fascinating rise of a novel new delivery system, which has happened outside of the normal regulatory process.

This post isn’t about the evidence as to whether ecigs are harmful, whether they are a gateway to smoking, or whether they are an effective form of smoking cessation therapy (in future, they may have a role, but that should be after normal scientific evaluation and regulatory processes), but about the issues of professional autonomy they raise for pharmacists, and whether they are a good test case for exerting that autonomy.

Yesterday the Chief Pharmacists of the UK published an open letter raising concerns about ecigs. Their main points were:

  1. Health, safety and well-being of patients must be the first concern of pharmacy owners and superintendent pharmacists (as it is for pharmacy staff)
  2. Pharmacy staff should be empowered to exercise their professional judgement in the best interest of patients and public
  3. They point out ecigs are unlicensed and have limited scientific evidence
  4. They say they do not support their use as smoking cessation aids and that they should not be presented as having any therapeutic value

The response from companies who have decided to stock ecigs is interesting. Boots have agreed with concerns, suggesting that their decision to spend two years developing a ecig offering with a company is a responsible way forward. They hope to be the first to get a licensed preparation. Before that happens, Boots seem happy to sell an unlicenced product with no proven therapeutic value. Lloyds has said it is not selling ecigs as nicotine replacement therapy. Which begs the question what are they selling them for? None of this counters the concerns of chief pharmacists about the suitability for ecigs as a product pharmacy sells. At best, it is mitigation for a wrong decision to stock an unlicensed ecig in the first place.

Individual pharmacists are faced with the fact that their companies, and their superintendent pharmacists,  are happy to stock a product that is:

  • Not proven to have a therapeutic benefit
  • Is unlicensed
  • Is unsupported by the Royal Pharmaceutical Society
  • Is strongly felt should be a licensed product by the government and the MHRA
  • Is a matter of concern for all the Chief Pharmacists in the UK
  • Is also a matter of concern to the GPhC, who feel the RPS and MHRA guidance should be considered.

They should ask themselves if they are equally happy about this (and some may be).

They could of course, just ignore the ecigs and follow the advice that they tell patients they are not a smoking cessation aid. That still leaves them in the position of supplying a product they might not have personally stocked in the first place.

It is arguable that if acting as the responsible pharmacist within a pharmacy you could make a good case for removing any ecigs from display within the registered pharmacy premises on the grounds of maintaining the health, safety and well-being of patients. Certainly, you have the GPhC, the RPS, the MHRA, and all the Chief Pharmacists to support your stance. The fact that the superintendent of the company has a different opinion, does not invalidate your own professional judgement. In reality, it isn’t that simple. There may be local pressure from non-pharmacist managers who do not feel it is the place of pharmacists to make this decision – after all they have material from head office saying this is a perfectly OK product. The pharmacist may be putting themselves in a difficult position in terms of future performance reviews.  It would be nice if superintendent pharmacists actually issued a statement that such action would be permissible, that the professional autonomy of individual pharmacists on stocking such products was key and that no detriment would come to pharmacists who made this professional judgment.

As for regulators, in a recent case of MUR fraud the GPhC recently said:

“What we have to ask ourselves is whether, when there are pressures [and] mistakes, as inevitably there will be, can we have confidence that the registrant might be able to stand up and not ‘buckle’?”

Should it always be down to individual pharmacists having to exert their professional independence in a battle of wills? Is that the best we can do? Hope people don’t “buckle” when they are under immense work pressures? Is it time for regulators to regulate the industry in a manner that reduces the toxicity of this commercial environment, and help create a more supportive environment for individual acts of professionalism? Of course individuals need to take responsibility, but it is naive to think that the environment they practice in has no influence. Recent NHS scandals note both the role of individuals and the culture of organisations. Could the GPhC exert more control over superintendents? Could they make it clear that employee pharmacists should have the professional autonomy as individual pharmacy owners to remove items from sale they feel are incompatible with the best interests of patients and the public? Ecigs make a great test case for what actual control pharmacists over the materials they provide to the public, just as GPs have control over what they prescribe to the public.

And from there we might make some other steps forward on OTC medicines and homeopathy….

Photograph: Creative Commons from Vap in Liberty.

8 thoughts on “Ecigs and pharmacist autonomy”

  1. As long as pharmacies stock homeopathic “medicines”, stupid preparations like NiciBloc, and sell chocolates, sandwiches and fizzy pop, they are in no position to rail against ecigs. As ASH will confirm, they ARE a massively less risky alternative to smoking the real thing, and there fore do a service to the user and her bystanders. To remove them, therefore, from the shelves is to promote a health harm, frankly. This posturing by the RPS is actually working against the Public Health, and should be resisted by any and all means.

  2. Professor Robert West:”E-cigarette users seen to be victims of a propaganda war being waged by some of my colleagues.”

    His latest research suggests that NRT is no more effective than ‘cold turkey’.Champix is linked with over 1,000 deaths world-wide and many thousands of ‘adverse events’.

    The ‘date of guilty knowledge’ was coined in relation to second-hand smoke but it could equally apply to the propaganda warriors.Do your own research – it matters.

  3. Interestingly, Anthony, you have categorized this article under “quackery”; a perfect description of much of the “science” (in reality little more than ideologically driven opinion) levelled against e-cigarettes by people such as Professors Stanton Glantz and Martin McKee.

    You mention a lack of therapeutic benefit vis. e-cigarettes, and none is claimed. As David Dorn points out, many of the products sold in pharmacies have a similar lack of therapeutic benefit. I would go further and make the point that there are many cases of pharmacies dispensing licensed medicinal products with proven and serious side effects, such as varenicline; probably better known by its trade name Champix.

    Exercising caution is both sensible and understandable, but to warn pharmacists against stocking and selling e-cigarettes whilst at the same time approving of the dispensing of products known to cause harm has an air of hypocrisy about it. Of course, whilst you make your academic standpoint clear, pharmacy owners are making their position as business people abundantly clear and are in many cases supplying e-cigarettes regardless of academic opinion. Three cheers for free market solutions.

  4. “Boots seem happy to sell an unlicenced product with no proven therapeutic value.”

    What, homeopathic medicine?

  5. The potential conflict of professional ethics and business or other pressures is an important and interesting one. Though something that professionals of all kinds are faced with on a very regular basis indeed.

    Ultimately, all the professional can do is to rely on both their ethical standards and all of the fact based evidence available to them to come to a decision they can live with. We cannot all rely on the great ‘Regulator in the Sky’ to solve our ethical problems. We just have to get on with it and live with the real-world consequences.

    In this particular case, you seem to value your professionalism above the evidence available about the product you have cited, i.e., e-cigarettes. You have clearly limited the scope of your research to the ‘easy’ information available; that from professional bodies/government departments/QUANGO’s, etc. If you took just a little longer to look at the wealth of respected scientific research and opinion, you will see that you would not have any ethical concerns by supplying e-cigarettes in a pharmacy. Quite the opposite, you might, quite possibly save or extend people’s lives. Imagine that? You would be doing so much more for the human condition than those so-called ‘doctors’ and ‘professors’ who let ideology and dogma get in the way.

    Perhaps you would like to repeat this exercise with some of the other ‘medicine’ you supply on a regular basis? I think you might be more than a little concerned at what you find out.

  6. Slightly disappointing to see this post hijacked by the vaper community. As I noted at the start of the article:

    “This post isn’t about the evidence as to whether ecigs are harmful, whether they are a gateway to smoking, or whether they are an effective form of smoking cessation therapy (in future, they may have a role, but that should be after normal scientific evaluation and regulatory processes), but about the issues of professional autonomy they raise for pharmacists, and whether they are a good test case for exerting that autonomy.”

    So I would prefer if the remainder of comments were about the substantive issue in the post, rather than the heated debate about evidence.

    1. It seems to me that ecigs are a strange aspect to use to question professional autonomy. They are proven to be safe and effective when there are plenty of other products that companies like Boots sell that definitely aren’t. Like Dave Dorn pointed out, Boots sell homeopathic products that have been proven to be no better than placebo.

      NRT has been found worse than cold turkey – Ecigs have been found by ASH to be 60% more effective than cold turkey and the most effective way of stopping smoking.

      I hope you can see why the ‘vaping community’ might see this as at least a strange thing to do, at worse a back handed attack on ENDS.

      Certainly to me it’s like asking if weapons dealers are unscrupulous because they print their emails… Yes they might be unscrupulous, but printing emails probably isn’t the best example available to you.

    2. Well, this is a problem:

      “in future, they may have a role, but that should be after normal scientific evaluation and regulatory processes”

      We don’t want e-cigs to be regulated as a medicine, so if you seem to be advocating that it’s going to attract a response.

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