2. Materials and Methods

3. Results and Discussion

Sixty-six responses (13.2%) were received from the duty pharmacist working in the pharmacies that were invited to recruitment. See Table 1 for participant demographic information. Seventeen out of the 66 respondents sold e-cigarette, indicating a sales-prevalence of 25.76% of e-cigarette.

Onward analysis relates to the 17 respondents who sell e-cigarettes. Three participants were from independent pharmacies whereas 14 (out of the 17) were from national chain pharmacies.

• a) Availability of NRT and smoking-cessation services.

    NRT was available for sale in most pharmacies (n=16, 94.1%), missing (n=1, 5.9%). Cessation services were less frequently available (n=7, 41.2%), or not available (n=9, 52.9%), missing (n=1, 5.9%). While NRT is sold in retail spaces, pharmacy smoking cessation services are often commissioned by local or central government and provided by accredited professionals. Cessation services have been credited with reducing the inequalities in smoking prevalence. (Bauld et al., 2007) There have been recent cuts to public-health funding (Anderson et al., 2018; British Medical Association, 2019; Iacobucci, 2018) and the data reflects that, the choices available to potential quitters are fewer from pharmacy. Absent services may impact communities, as pharmacists are able to make sales but cannot provide motivational support. This leaves customers making decisions based on price, shop-placement, or promotion rather than evidence-based strategies.

• b) E-cigarette users and their purchases.

    Respondents believed that ‘daily smokers’ were most likely to use e-cigarette (n=8, 47.1%), followed by ‘former smokers’ (n=5, 29.4%), missing (n=4, 23.5%). E-cigarette customers were: 25-34-year-old (n=6, 35.3%), 35-44-year-old (n=5, 29.4%), 18-24-year-old (n=2, 11.8%) and older than 65 years of age (n=1, 5.9%), missing (n=2, 11.8%). Accessories were sold daily to 0-2 people (n=13, 76.5%), 3-5 people (n=2, 11.8%) and 6-8 people (n=1, 5.9%), missing (n=1, 5.9%), χ² p=2.454 x 10-4. Some pregnant women (or women of reproductive age) purchased e-cigarettes (n=4, 23.5%), while many do not (n=13, 76.5%), One-Sample Binomial Test, p=0.049.

    ‘Daily’ and ‘former’ smokers were most likely to use e-cigarettes, which follow national and international trends. 25-44-years-old were frequent consumers, with few older than 65-years. (McKeganey and Dickson, 2017) Accessory sales were small and fits the ‘impulse’ buy strategy employed.

    Of those who sell e-cigarettes, 23.5% of pharmacists sold e-cigarettes to pregnant women or women of reproductive age. While the ONS does not collect pregnancy data, it is difficult to confidently quantify the number of pregnant women affected. From this data, a crude estimate of 699 women buy such products from pharmacies in England (11,539 English pharmacies x 0.2576 e-cigarette sellers x 0.235 sales to pregnant women or women of reproductive age). Reasons behind this are documented elsewhere. (Whittington et al., 2018) Pharmacists employ their professional judgement in making sales to an overtly pregnant women, but they have limited guidance and may consider moral and professional liability to guide decisions.

• c) Point-of-sale placement, pricing, and concentrations.

    E-cigarette were placed on top (n=7, 41.2%), exclusively behind (n=5, 29.4%), in front of the counter (n=2, 11.8%) and then in multiple locations within the shop (n=1, 5.9%), missing (n=2, 11.8%). NRT products were placed in multiple locations (n=7, 41.2%), in front (n=5, 29.4%), exclusively behind (n=3, 17.6%) and then on top of the counter (n=1, 5.9%), missing (n=1, 5.9%). This placement reflects ‘impulsive sales’ strategy.

    NRT was available for self-selection in most cases (n=14, 82.4%), One-Sample Binomial Test, p=0.004 and not sometimes (n=2, 11.8%), missing (n=1, 5.9%). Staff-assistance was required for NRT sales (n=12, 70.6%) versus otherwise (n=4, 23.5%), missing (n=1, 5.9%). This is a potential barrier to NRT sale.

    The cheapest e-cigarettes included Nvee® e-liquid (n=5, 29.41%), Vype® (n=3, 17.65%), Gamucci® (n=1, 5.88%) and generic (n=1, 5.88%), missing (n=7, 41.17%). Ten respondents provided a range of e-cigarettes and prices: Nvee® 18mg/ml, 10ml (£11.99, £14.98, £20), Vype® for 0 mg/ml, 6 mg/ml, or 12mg/ml in variable sizes (£18.99), Infinity® vapour in 50 watts with 50 puffs (£20), Blu Ace® in 50 watts with 50 puffs (£29.99), Vype® Epen x 2 cartridges 18mg/ml (£19.99) and Gamucci® for 2% nicotine and 360 puffs (£10.99).

    Cheapest NRT Products and prices available for sale from five respondents were Nicorette® gum 2mg unreported pack-size £4.25, Nicorette gum 4mg unreported pack-size £4.99, Nicorette Invisi® patchx7 25mg £7 (“currently half price normally £14”), Nicorette® gum 2mg 105 pieces £10.00, Nicorette® gum 2mg 105 pieces £14.96. Similarly, expensive NRT included Nicorette Qmist® £20.41 1mg/150sprays, Nicorette® gum 4mg 210 pieces £26, Nicorette Qmist® £29.99 1mg 2x150 doses, Nicorette Qmist® £32.24 1mg 2x150 doses, Nicorette® Spray £35.99 1mg 2x150 doses. The narrower range of prices for e-cigarette (£10.99 to £29.99) vs NRT (£4.25 to £35.99) is of note. Thirteen respondents indicated concentration of nicotine cartridges sold in Figure 1, missing (n=4, 23.5%).

    Different sales practices between e-cigarette and NRT, suggest economic forces can be influential in ‘if and how’ people quit smoking, especially in deprived areas and with absent cessation services.

    Pharmacies place ‘expensive’ items behind the counter for fear of theft. Data shows that requiring staff assistance can be a psychological barrier to access (Trainor and Leavey, 2017) and can be due to decision fatigue (Thompson et al., 2005), anticipated regret/regret aversion (Brewer et al., 2016; Conner et al., 2006) and lack of trust. (Esterberg and Compton, 2005; Ismailov and Leatherdale, 2010; Lucksted et al., 2000; Missen et al., 2013) These practices hinder NRT sale and by its virtue, tacitly promote e-cigarettes as they are placed on top of the counter. (Herrera et al., 2019) The overall range of prices for e-cigarettes was £19 (£10.99 to £29.99) vs £31.74 for NRT (£4.25 to £35.99) potentially make e-cigarettes more affordable, per-unit of equivalent bioavailable nicotine.

    Potential visibility of e-cigarettes to children in pharmacies is concerning. Tobacco display bans in England reduced the exposure of children to cigarettes in shops and coincided with a reduction in the proportion of regular child smokers reporting that they bought cigarettes in shops. (Laverty et al., 2019) Similarly, e-cigarettes visibility to children is questionable. This comes in light of e-cigarette maker Juul, who has agreed to settle a lawsuit with a US state that accused the firm of marketing its products to young people. (“Juul to pay $40m in US lawsuit over teen targeting claims,” 2021)

• d) E-cigarette packaging and labelling.

    Pharmacists’ experience of handling medicines makes their opinion on packaging valuable. A dichotomous ‘packaging and labelling’ opinion scale was created (Figure 2).

    Many labelling and packaging features were attractive (One-Sample Binomial Test, p=0.049), fashionable, colourful (One-Sample Binomial Test, p=0.049), healthy and energising. Such descriptors breach the Directive. Scales’ Cronbach Alpha of 0.780, demonstrates validity. Packaging and labelling were found to be in breach of TPD.

• e) E-cigarette counselling.

    All respondents (n=17, 100%) provided counselling with NRT, (One-Sample Binomial Test p<1 x 10-8). However, less than half (n=8, 47.1%) provide counselling with e-cigarettes, while more than half (n=9, 52.9%) did not. Respondents believed only 29.4% (n=5) of e-cigarette users went on to quit smoking, while 58.8% (n=10) did not, missing (n=2, 11.8%). Counselling was less frequently provided with e-cigarettes. Primarily this could relate to ‘professional bias’s towards e-cigarettes. (Barrett, 2019) As a category, e-cigarettes are licenced as consumer products and they are not traditional regulated items such as ‘medicine’, ‘food’, ‘cosmetic’ or ‘supplements’. Consequently, they may be considered ‘safe’ self-care consumer items, even though nicotine can cause harm. Secondly, pharmacists may not invest in counselling due to lower perceived quit rates, thought this seems to be higher in deprived areas. Equally, these consumers may have lower health literacy, financial ability, may have pre-decided on e-cigarettes use and may not be open to counsel.

• f) Impact of flavouring.

    Eight respondents, describe 22 flavours: 4 cherry, 3 tobacco, 3 mint, 2 menthol, 2 apple, 1 watermelon, 1 mint ice crystal and 1 grape. Respondents reported a better mouth feel/taste (n=5, 29.4%), social impact (n=2, 11.8%) and variety and customisation (n=1, 5.9%), missing (n=9, 52.9%). Flavouring is linked to e-cigarette’s social appeal, especially for children. (Vasiljevic et al., 2016) The TPD, mentions ‘candy’ flavours to be an area of concern - this study finds pharmacies selling cherry, apple, watermelon and grape flavours, which seems questionable professional-practice.

    TPD Article 7 prohibits member states from placing on the market of tobacco products with a characterising flavour. However, TPD does not harmonise all aspects of e-cigarettes or refill-containers. As a current/recent EU Member, the UK is free to permit the placing on the market of flavoured products.

• g) Geospatial analysis.

    Respondents were from greater London, Manchester, Brighton, Leeds, Royal Wootton Bassett, Barton le Clay, and Market Weighton, representing a good mix of urban, suburban, and rural communities. Respondent’s IMD decile’s mean was 4.47, SD 2.809 and a SE 0.681, reflecting national average consumers. Dispensing data descriptive statistics (Table 2) show respondents to be representative of invitees.

    The data was stratified by decile (See Table 1 in Appendix B by all respondents, Table 2 in appendix B by aggregate deprived (deciles 1-4) versus affluent (deciles 5-9)). An absence of responses from decile 10 was noted.

    Deprived versus affluent aggregate data are presented below respectively, because they represent 52.9% versus 47.10% of responding participants who were pharmacists . Nine versus eight pharmacists sold e-cigarettes, NRT was equally available (8 versus 8) in the pharmacies, five versus two pharmacists offered smoking cessation services, eight versus five pharmacists sold e-cigarettes or related accessories daily to 0-2 people.

    With respect to customer’s age, an equal number of responding pharmacists came from both deprived and affluent postcodes. However, sub analysis reveals differences: one respondent from deciles one and eight had sold such products to 18 to 24-year-olds. One versus five respondents sold these products to 25 to 36-year-olds in affluent areas. Four versus one respondent sold these products to 35 to 44-year-olds in deprived areas. Daily smokers were less likely to use e-cigarettes in deprived areas (3 versus 5), but never smokers are more likely to use e-cigarettes and be from deprived areas (three versus two).

    Three versus two placed e-cigarettes exclusively behind the counter in deprived areas, five versus two placed a cigarette on top of the counter, one versus one placed e-cigarette in front of the counter and only one in an affluent area placed it in multiple locations. Two versus one placed NRT exclusively behind the counter. None vs one place NRT on top of the counter, one versus four placed NRT in front of the counter, and six vs one placed NRT in multiple locations. NRT was available for self-selection equally easily. NRT was most often behind the counter in deprived areas (7 versus 5).

    Respondents from deprived areas found the packaging attractive (7 versus 6), fewer found it fashionable (5 versus 6), fewer found it colourful (6 versus 7), and it was equally perceived as healthy (5 versus 5), fewer founded it energising (3 versus 4). Fewer responded sold these items to pregnant women in deprived areas than affluent areas (1 versus 3). Respondents evenly provided counselling (4 versus 4). Those likely to quit smoking using e-cigarette were more likely to be from deprived areas (4 versus 1). Flavour was perceived to impact mouth-feel in deprived areas (3 versus 2). Wider range of concentrations were available in deprived areas (low, medium, and high). More smoking cessation services are provided in deprived area, though commissioning rates are low. (Rosemary Hiscock and Linda Bauld, n.d.) They are likely to have fewer GPs and pharmacies maybe the sole source of healthcare. (Action on smoking and health, 2019) In deprived areas, more flavours and concentrations of e-cigarettes were sold, on the counter-top, with lower access to NRT. (George et al., n.d.) Young-adults use e-cigarette in deprived areas, but established smokers use them less frequently. Affluent young women use e-cigarettes, potentially as cigarettes substitutes, while potentially deprived young women continue to smoke.

Figure 1.

Concentration of nicotine cartridges sold by respondents.

Figure 2.

Opinions scale on labelling and packaging by respondents.

3. Conclusions

Pharmacies have ease of access and offer an opportunity for consultation with a registered professional in areas of deprivation, which may or may not be served by vape shops. While a quarter of pharmacies sell e-cigarettes in England, there were variations in offering compared to NRT, sales strategy and counselling levels. In deprived areas, packaging and labelling was potentially in breach of the TPD. No evidence was found that conventional cigarettes smokers are using e-cigarettes as an aid for quitting but find support of non-smokers initiating use. Pharmacists help their patients as best as they can but have limited support. This study makes recommendations to improve practice. Findings of this study are limited by its small sample size and a more robust larger study is required to validate findings. The international research community is encouraged to use this study survey to report their findings.