By Public Health Expert 08/09/2016 6


Professor Nick Wilson, Professor Janet Hoek, Frederieke Sanne van der Deen, Associate Professor George Thomson, Professor Richard Edwards

e-cigarettesThe NZ Ministry of Health is currently consulting on options around making nicotine-containing e-cigarettes available in NZ.

This Perspective Blog briefly examines possible pros and cons of two plausible licensed retail options: pharmacies and vape shops. It also highlights the need for a very well-considered approach, given consecutive NZ Governments’ poor track record in making policy to regulate addictive substances and reduce harm to public health.

The Ministry of Health is inviting comment on a proposal to allow nicotine-containing e-cigarettes to be sold in New Zealand.* It appropriately covers many potential regulatory issues – but not the important ones of who should be able to sell such products and retailer licensing. In this Perspective Blog, we argue the need for a regulated retail environment, such as should apply to all addictive substances (and indeed already strongly applies to prescription medicines that can produce dependence/addiction). Furthermore, we argue that any moves to make nicotine-delivering e-cigarettes more widely available requires an analysis of how combustible tobacco needs further controls at the retail level (as recommended by the Māori Affairs Select Committee – and not yet acted upon (1)).

Current regulations allow any retailer who wishes (eg, dairies, supermarkets, petrol stations, liquor stores etc) to sell tobacco. This model has resulted in over 6000 outlets throughout the country and has seen problems such as not infrequent law breaking, eg, illegal sales to young people by outlets such as dairies. As a further example of non-compliance with the law, a 2006 survey found that 64% of tobacco retailers had at least one breach of the then point-of-sale regulations (2).

Existing nicotine supply arrangements are thus a historical anomaly that seriously undermine the Government’s smokefree 2025 goal and need to be urgently addressed. Recent studies, including NZ modelling work examining the phasing down of tobacco retail outlets (3), and surveys examining public support (4,5) show measures restricting supply are likely to be both effective and well-supported. Furthermore, evidence from various overseas jurisdictions shows that registered or licensed businesses are more likely to comply with tobacco regulations, and that introducing a licensing system, including annual licence fees, could on its own reduce the number of outlets selling tobacco (6-8).

Moves to alter the current restrictions on the sales of e-cigarettes containing nicotine thus present an important opportunity to introduce a licensing system for both product types (tobacco and e-cigarettes). Licensing for e-cigarette retailers would bring many benefits, including a requirement to demonstrate how minimum age of purchase (eg, 18 years) conditions are met. In addition, licensing systems could require retailers to demonstrate that their staff are competent to deliver advice on e-cigarette use to support smoking cessation; they should also demonstrate knowledge of the ABC model smoking cessation, and support referral systems. Similar types of requirements could be specified for tobacco retail licensing. Within a licensing system for e-cigarettes, there is the question of what type of retail outlet should be licensed to sell e-cigarettes and e-liquids?

Pharmacy-only sales

Restricting e-cigarette sales to only community pharmacies would frame this product as a smoking cessation aid or, at the very least, a harm-reduction strategy for long-term users. Importantly, it would ameliorate perceptions of e-cigarettes as a recreational drug and could therefore probably help reduce youth experimentation. Other advantages include that most pharmacists already give smoking cessation advice on a regular basis and sell such products as nicotine replacement therapy. They are also experienced in other harm reduction programmes such as the provision of methadone maintenance and providing clean needles and syringes for injecting drug users (a very successful programme that prevents HIV/AIDS and hepatitis C). In general, pharmacy staff are used to a strict regulatory environment for the supply of addictive substances. Furthermore, there are nearly 1000 community pharmacies in NZ, and they are relatively well distributed around the country.

Another likely advantage of pharmacy-only sales is that it would simplify any future moves to phase-out e-cigarettes, should that become a consideration once smoked tobacco sales have fallen to minimal levels. Because pharmacists are health professionals whose core business would not depend on e-cigarette sales, they would have less commercial incentive to prolong sales of a category that had fulfilled its useful public health function.

A possible down-side of pharmacy-only sales might be that staff could be less knowledgeable about transitions from smoking to vaping than vape shop personnel. Also some pharmacies might only stock a limited range of devices (though regulations could require a minimal range to help address this issue, and ensure appropriate staff training).

E-liquids in an overseas vape shop. Credit: Flickr / Lindsay Fox.
E-liquids in an overseas vape shop. Credit: Lindsay Fox / ecigarettereviewed.com.

A survey of 30 Wellington pharmacists provides preliminary evidence for the acceptability of selling e-cigarettes among pharmacists in NZ. This research found that if the sale of nicotine-containing e-cigarettes in NZ were restricted to pharmacies, around two thirds of pharmacists would be very to extremely likely to sell these products [yet to be published work by one of us, FSvdD].

Licensed vape shops only

Licensed vape shops might offer better service than pharmacies by featuring a more extensive product range and providing first hand advice on e-cigarette use. Enthusiastic “vapers” who work in existing vape shops could offer important experience, given the complex nature of some e-cigarette devices. Vape shops with a large product range might benefit from economies of scale and be able to reduce prices for customers. With licensing, which would restrict sales to vape shops meeting specified criteria, it would be easier for government agencies to act against any rogue traders (eg, ones that made e-cigarette sales to youth).

But possible downsides might be:

  • Such shops would in theory have a major economic incentive to continue and expand the market for e-cigarettes and their supplies, including sales to non-smokers. If so this might erode potential health gain relative to a pharmacies only approach.
  • There might not be the market to sustain the number of licensed vape shops to reach the numbers seen with pharmacies (especially in small towns).
  • Vape shops might not attract the diverse customer base that would reach smokers as effectively as pharmacies. That is, the existing NZ ones selling e-cigarette devices often appear to convey a counter-culture, pro-drug use ambience. But if the law permitted nicotine-containing products, such stores might become more mainstream in order to adapt to a wider customer base.

A brief summary table

Attribute/issue Pharmacies Vape stores
Product array Likely to be more limited Likely to be more diverse and include the newest products
Product expertise Less likely to have personal experience and specific product expertise More likely to have personal experience and specific product expertise
Tobacco cessation expertise Staff likely to be trained in smoking cessation support Staff more likely to require formal cessation support training
Experience with regulations Accustomed to dealing with regulation of restricted substances Less experience in dealing with regulation of restricted substances and of advertising restrictions
Profit motivation Less incentive to sustain sales beyond cessation? More incentive to sustain sales beyond cessation?
Outlet numbers and locations More outlets covering greater proportion of NZ Fewer outlets, may have limited reach in some areas
Pricing May have lower sales volumes and be less price competitive (except perhaps if pharmacy chains were involved). May have higher sales volumes enabling lower prices – but potentially lower purchasing power than pharmacy chains.
Customer profile Likely to be more diverse Likely to be less diverse
Monitoring costs for regulators Low as pharmacies are already fairly regulated and should be highly motivated to sustain their reputations Potentially higher given the potential profit motivation (as per above)

Caution is definitely required

Clearly there are complex pros and cons of pharmacies and vape shops being allowed to be licensed e-cigarette retailers. There might even be some advantage of licensing both, with ongoing monitoring and research to compare them. Then if one type of outlet was particularly problematic (eg, covert advertising or sales to youth) further regulations could constrain it or even eliminate it from the market. Again, however, the vape shop industry would have strong incentives to resist such moves and so this could be harder for a government to achieve.

Furthermore, caution is required with all new policy around addictive substances given that serial NZ Governments have a poor track record in this area. This is shown by:

  • Sub-optimal tobacco control policy to date (eg, the largely unregulated retail environment, the largely unregulated product design, and the absence of a strategy to get to Smokefree 2025).
  • Poor alcohol control policy (the lack of substantive response to the Law Commission Report on alcohol (9)).
  • The problems with the Psychoactive Substances Act (10) which have meant it has not yet become operationalised in permitting any “low-risk” products.
  • Inability of many NZ governments to thoughtfully review the wide range of options around the law on cannabis and other illicit drugs in the light of new international evidence on how to minimise harm to both society and public health.

*Note: We acknowledge that terminology is complex and rapidly evolving, but for simplicity we are using e-cigarettes as a term to cover the different types of vaping devices and nicotine-containing e-liquids.

 References

1. Ball, J., et al., Is the NZ Government responding adequately to the Maori Affairs Select Committee’s 2010 recommendations on tobacco control? A brief review. N Z Med J, 2016. 129(1428): p. 93-7.

2. Quedley, M., et al., In sight, in mind: retailer compliance with legislation on limiting retail tobacco displays. Nicotine Tob Res, 2008. 10(8): p. 1347-54.

3. Pearson, A.L., et al., Theoretical impacts of a range of major tobacco retail outlet reduction interventions: modelling results in a country with a smoke-free nation goal. Tob Control, 2014. 24: p. e32-e38.

4. Gendall, P., et al., Public support for more action on smoking. N Z Med J, 2013. 126(1375): p. 85-94.

5. Whyte, G., P. Gendall, and J. Hoek, Advancing the retail endgame: public perceptions of retail policy interventions. Tob Control, 2014. 23(2): p. 160-6.

6. Fry, R., et al., Selling tobacco anywhere, anytime: harmful not helpful. 2013, Cancer Council New South Wales: Sydney.

7. Halonen, J.I., et al., Proximity to a tobacco store and smoking cessation: a cohort study. Tob Control, 2013.

8. Bowden, J.A., et al., What happens when the price of a tobacco retailer licence increases? Tobacco Control, 2014. 23(2): p. 178-180.

9. Sellman, D. and J. Connor, Too many risky drinkers; too little alcohol law reform. N Z Med J, 2014. 127(1401): p. 6-9.

10. Wilson, N., et al., Could New Zealand’s law on “New Psychoactive Substances” provide lessons for achieving the Smokefree 2025 Goal? N Z Med J, 2016. 129(1432): p. 94-6.

Feature image: Flickr / Ecig Click


6 Responses to “Perspective: Options for licensed retailing of nicotine-containing e-cigarettes in NZ”

  • While there is some case for also allowing pharmacies to sell e-cigarettes, access to e-cigarettes via dedicated vape shops is essential to realise the full potential of the devices to minimise harm among the smoking population.

    If both are allowed, the majority of the market will get their more advanced, greater options (of power pack, tank, coil & liquid with flavours) leaving pharmacies to sell their very limited range of cigalikes to those few smokers who explicitly want the ‘stamp of medical approval’.

    As an ex smoker / current vaper from Australia, I can confirm that one of the attractions of e-cigarettes is that they are not provided by a pharmacy or marketed as a ‘smoking cessation’ device. I had no intention of ‘giving up smoking’ – I merely upgraded to the alternative that is far better in all but one respect (it is slightly more hassle to vape than it is to blaze up a cigarette).

    It is time that Public Health embraced the concept of harm minimisation, as any signatory to the WHO FCTC has an obligation to do (under article 1d). Medicalising e-cigarettes will kill them and making them yet another (largely ineffective) smoking cessation therapy. With varenicline, bupropion & NRT already on the market, most smokers neither need nor want yet another option to be available under the banner of ‘therapy’.

    Give harm minimisation a chance.

  • At the risk of being seen to ‘attack’ researchers, on the issue of licensing retailers, I note the comment and reference:

    “As a further example of non-compliance with the law, a 2006 survey found that 64% of tobacco retailers had at least one breach of the then point-of-sale regulations (2).”

    Using a reference that is now a decade old risks giving the wrong impression of retailer compliance with the Smokefree Environment’s Act. In a response to an OIA request submitted this year, the Ministry of Health stated the following:

    Q. What is the total number of infringement notices issued against retailers for breaches of the Smokefree Environments Act for the 2013, 2014, 2015 and 2016 year to date.

    A. The total number of infringement notices issued against retailers were: 85 notices in 2013, 75 notices in 2014, 85 notices in 2015 and 14 notices in 2016.

    Q. What is the total number of prosecutions for a tobacco sale to a person under the age of 18 for the2013, 2014, 2015 and 2016 year to date?

    A. The total number of Smokefree prosecutions for tobacco sale to a person under the age were: 2 prosecutions in 2013, 1 prosecution in 2014, No prosecutions in 2015, No prosecutions in 2016.

    The authors push for a regulated retail environment on that basis that “…over 6,000 outlets throughout the country and has seen problems such as not infrequent law breaking, e.g. illegal sales to your people by outlets such as dairies…” I suggest this may be described as a slight exaggeration.

    While in an ideal world there would be 100% compliance, the number of actual infringement notices issued against retailers for breaches can be best described as very low. A similar situation applies to actual prosecutions against retailers.

    To suggest retailers of ‘not infrequent law breaking’ when the facts demonstrate otherwise, doesn’t help their argument.

    Carrick Graham

  • As someone who spends a lot of time trying to get regulatory action taken against what appear to be clear breaches of legislation (although in a different sphere to this one – I target misleading information about ineffective health products and services), I’m very aware that there is often a huge difference between the number of breaches of the law and the number of infringement notices (or equivalent) issued.

    Without some reasonable estimate of what proportion of breaches result in an infringement notice, there’s no real way to compare these two statistics. The same numbers from different years can be compared to themselves though, in order to see how much they change from year to year.

    With the three data points (no point including a partial year) the numbers you’ve provided haven’t backed up your assertion that “the facts demonstrate otherwise” regarding the number of infringements. If anything, they seem to imply that the numbers might be pretty stable from year to year.

    Although it’s certainly possible there has been a change in the 10 years since the 2006 data was collected, as far as I’m aware there isn’t any particular reason to believe there has been a substantial decrease.

  • much though it pains me, I think I agree with Carrick on his point (holds back bile rising…). The evidence for wild disregard of the law in tobacco retail is not great – certainly not enough to dismiss these retailers entirely as profiteers and habitual lawbreakers.

    I’d add that its a long stretch to claim that pharmacists (and by this I assume you mean retail chemist shops) have a moral high ground and less profit motive. A quick glance at their herbal remedy shelves and cosmetics counters would confirm that moral authority is questionable and profit motive, as in all retail, is strong.

  • Infringement notice data are indeed likely to be a very poor indicator of law breaking behaviour – as it depends on the level of reporting and investigations. An analogous situation is that vastly greater numbers of people break driving speed limit laws relative to those who get prosecuted. Even NZ schools break the law and don’t get prosecuted (ie, most lack the required smokefree signage at main entrances as per this survey [1]).

    Other relevant evidence suggesting illegal sales from tobacco retailers comes from NZ surveys of youth aged 14-15 years [2]. Those surveyed who smoked at least monthly reported “I brought them from a shop” at a little over 10% of the time (for each annual survey for 2006 to 2012, with no statistically significant trend over time [See question details below]) [2]. But for “regular smokers” the figure was higher eg, 20.5% brought them from a shop in 2012.

    What might this mean in approximate numbers of illegal sales per month? Well in this period “regular” smoking in this age-group was 21% [2], and we can use the shop purchase level of 20.5% (as above). If we apply these figures to all 14 to 17 year olds in NZ (using 2006 census population data: 241,000) then this suggests around 10,400 illegal sales per month to those under 18 year around NZ. This would average out at 1.7 illegal sales per tobacco outlet per month (NZ has at least 6000 tobacco retail outlets) – but in reality it is probably concentrated at certain outlets. That is, the international evidence is that adolescent smokers meet their growing need for nicotine by “cultivating willing retailers who are less likely to require them to provide ID before making tobacco sales” [2]. For an example of this international evidence from the UK see: [3].

    Fortunately, adolescent smoking keeps declining in NZ so the current situation around illegal sales might have improved somewhat – but I will consider analysing and presenting updated survey data on youth sales by retailers in a forthcoming blog.

    Of note is that a systematic review has reported that “that access restriction interventions may produce significant reductions in the rate of illegal tobacco sales to youth. However, lack of enforcement and the ability of youth to acquire cigarettes from social sources may undermine the effectiveness of these interventions [4]. Hence a potential strategy for NZ is to start phasing out all tobacco outlets with a sinking lid on retail licences, as suggested in some NZ specific modelling work [5]. This process may work best if nicotine containing e-cigarettes were available in a regulated environment in NZ (eg, pharmacy-only and/or licensed vape shops) – so as to minimalised illegal e-cigarette sales to youth by other retailers.

    Appendicised note on question asked in annual youth surveys in NZ [2]:
    During the past 30 days (1 month) how did you usually get your own cigarettes?
    From 2006 to 2010 four response options were provided:
    1. I bought them from a shop;
    2. I got them from friends;
    3. I got them from my parents or caregivers;
    4. I got them some other way.
    (Additional categories were added in 2011-2012).

    References

    1. Wilson N, Thomson G, Edwards R. The potential of Google Street View for studying smokefree signage. Aust N Z J Public Health. 2015;39(3):295-6. doi: 10.1111/1753-6405.12361. PubMed PMID: 25904043.
    2. Gendall P, Hoek J, Marsh L, Edwards R, Healey B. Youth tobacco access: trends and policy implications. BMJ Open. 2014;4(4):e004631. doi: 10.1136/bmjopen-2013-004631. PubMed PMID: 24742976; PubMed Central PMCID: PMCPMC3996823.
    3. Robinson J, Amos A. A qualitative study of young people’s sources of cigarettes and attempts to circumvent underage sales laws. Addiction. 2010;105(10):1835-43. doi: 10.1111/j.1360-0443.2010.03061.x. PubMed PMID: 20840202.
    4. Richardson L, Hemsing N, Greaves L, Assanand S, Allen P, McCullough L, et al. Preventing smoking in young people: a systematic review of the impact of access interventions. Int J Environ Res Public Health. 2009;6(4):1485-514. doi: 10.3390/ijerph6041485. PubMed PMID: 19440530; PubMed Central PMCID: PMCPMC2681197.
    5. Pearson AL, van der Deen FS, Wilson N, Cobiac L, Blakely T. Theoretical impacts of a range of major tobacco retail outlet reduction interventions: modelling results in a country with a smoke-free nation goal. Tob Control. 2014;24:e32-e8. doi: 10.1136/tobaccocontrol-2013-051362. PubMed PMID: 25037156.

  • I struggle to see the point of damaging the “brand image” of pharmacies by making them stock a product that the authors think is bad for people, at a retail outlet that usually dispenses medications that are good for people.

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