Electronic nicotine delivery systems (ENDS), also known as vapes or e-cigarettes, are devices that deliver vaporized nicotine via inhalation. These devices are sold in the United States without a prescription and are readily available for purchase at pharmacies, convenience stores, and grocery stores among other places. Xiao and colleagues have found that common reasons for ENDS use include flavoring, perception that they are safe, tobacco cessation, limitations to public smoking, affordability, and social acceptability but these reasons vary based on socioeconomic status and other user demographics.1 The most recent large-scale data available to date suggests the prevalence of ENDS use in the United States is decreasing overall, but is still increasing in young adults aged 18–24 years old.2,3 According to the Centers for Disease Control and Prevention (CDC), ENDS can cause neurological harm during this crucial time of brain development in young adults.4 According to surveillance data published by CDC investigators, there have been 2,668 cases of e-cigarette or vaping use-associated lung injury (EVALI) reported in the United States between August 2019 and January 2020 with most cases occurring in the 18–24 age group.5 Community pharmacists frequently interact with the public and may be a critical touchpoint to educating patients regarding the facts about ENDS for them to make an informed decision about their use.
The United States Food and Drug Administration (FDA) has not approved ENDS as a nicotine or tobacco cessation therapy.6 FDA-approved tobacco or nicotine cessation products are either prescription or available without a prescription over the counter. In the United States, prescription tobacco cessation products include oral tablets such as varenicline or bupropion. There are also two nicotine replacement therapy (NRT) products that are available by prescription only, the nicotine inhaler and nicotine nasal spray. Over the counter NRT consists of the nicotine patch, lozenge, or gum. In Texas, community pharmacists do not have a state-wide standing order to prescribe tobacco cessation products without a provider’s prescription. Other states such as Idaho, Colorado, and New Mexico have statutes or regulations that allow pharmacists to prescribe tobacco cessation aids without a collaborative practice agreement.7 However, pharmacists may verbally recommend and provide counseling on over-the-counter NRT such as the nicotine patch, lozenge, or gum.
There has been significant investigation into the attitudes and perspectives of ENDS for American physicians, dentists, and nurses, but there is little information from community pharmacists.8 In 2016, Marques Gomes and colleagues collected comprehensive survey data from 92 community pharmacists in London that focused on their attitudes of ENDS and concluded that pharmacists had safety concerns, sought additional education, and recommended clear clinical practice guidelines regarding ENDS.9 ENDS are considered a legitimate therapy to tobacco cessation in the United Kingdom and this was reflected in the survey questions and makes extrapolation to the United States landscape difficult.10,11 Erku and colleagues issued a cross-sectional survey to 64 pharmacists and 76 pharmacy assistants in Queensland, Australia. The perceptions of pharmacy staff were evaluated regarding safety of ENDS compared to combustible cigarettes and NRT and most respondents believed patients would be interested in ENDS as a smoking cessation aid.13 The ENDS use landscape in Australia is also different than in the United States as the vape liquid is prescription only in Australia.14
In 2019, Hagan and colleagues published survey results of ENDS knowledge and perceptions of 255 pharmacists’ ENDS counseling comfort, knowledge, and perceptions of harm in California.15 While no conclusions were drawn from the study, the authors found that pharmacists’ ENDS knowledge of regulator status was accurate, the pharmacists did not see ENDS as a therapeutic option for smoking cessation, and ENDS cessation counseling was not reported by pharmacists in any setting.7 While the study is valuable, it lacks community pharmacist specific data and leaves many knowledge, attitude, and comfort questions unanswered .
To date, the current data regarding American pharmacists’ perceptions, knowledge, and comfort related to ENDS comes from one limited study that is not focused on community pharmacists. Other, more comprehensive survey studies are available outside the United States, but perceptions may differ due to the differing landscape. The aim of this study was to determine Texas pharmacists’ perceptions regarding ENDS. There were two objectives by which the study planned to accomplish this aim: 1) to identify consensus on perceptions and comfort among community pharmacists in Texas and 2) assess basic knowledge of the ENDS use landscape in the United States.