We are what we sell and some unintended consequences
By Dr. Terry Maguire, a Northern Irish Community Pharmacist, senior lecturer at School of Pharmacy (Queens University Belfast) and Belfast LCG member.
In the UK over recent months the fault lines between “professional pharmacy” and “commercial pharmacy” are firmly entrenched around the products sold in our pharmacies. Commercial pharmacy; multiples, some independents and commodity traders masquerading as pharmacies, are unwilling to compromise and insist on selling any products that can legally and ethically be sold. Most independents remain confused. Many aspire to a professional marketing mix but harbour confused ideas that steer them emotionally toward profit rather than professionally towards the best interests of the public.
I attended two meetings in February one in London and one in Belfast and both focused on a greater public health role for community pharmacy within the NHS. At both meetings these fault lines quickly emerged. The London meeting discussed public health pharmacy and like World Peace, a greater public health role for community pharmacy is something everyone at the meeting wanted. But; and it’s this “but” that began the unmasking of the real culture of community pharmacy. Contractor pharmacists, those who do not practise, quickly lined up to defend merchandising freedom; “e-cigs are only a positive for public health” they asserted. Contractors who practise were more amenable to the view that the sale of some products damages our reputation and stops us moving forward. Employee/locum pharmacists were passionate supporters of getting rid of the dross that keep us, in the view of some and as one GP called me during a radio interview, “purveyors of hot water bottles”.
But it’s not the hot water bottles that worry me. Rather it’s; the e-cigarettes, the sugar-based confectionary and caffeine fortified drinks and low factor sunscreens. I could go on; dubious sliming aids that keep people obese rather than support them to lose weight, homeopathic remedies, certain baby foods.
At the Belfast meeting when we discussed questionable products a well meaning but exacerbated contractor pharmacist assertively told me that if a child was in her pharmacy and was crying inconsolably she could see no problem giving it a “Chup-a-Chup”. She was displeased when I suggested that the reason the child was crying in the first place might be to alert its parent that it had spotted, and was not taking no for an answer, the “Chup-a-chups” pharmacy staff had so expertly merchandised.
Professional regulation of E-Cigarettes.
And this at a time when Boots the Chemists and Lloyds Pharmacies – the two biggest multiple pharmacies have unilaterally decided to sell e-cigarettes in their pharmacies. I am keen to understand why these powerful pharmacy groups enjoy certain exemptions from the professional ethical framework that applies to me and other independents. UK Professional guidance, at this time, is not to sell these products. In N. Ireland the Pharmaceutical Society (PSNI), following a commitment from the medicines regulator to regulate, promptly and definitely, stated its position e-cig sales in pharmacies is unethical. In England the Royal Pharmaceutical Society issued interim guidance last year that was very conditional in its use of language but in essence it would be difficult to interpret it as a rallying cry to fill your shelves with e-cigs and menthol-flavoured filling oils.
For those who justify the profits they make from sale of e-cigarettes saying this will reduce tobacco deaths I need them to appreciate this might not be the case. Evidence is already emerging that e-cigarettes are a gateway to cigarette smoking for a whole new generation. Unintended consequences frequently block our paths to perfection.
Cut (and) the booze
Here’s a good example. My good friend Professor David Hallam, Chair of the National Obesity Forum, with whom I wrote “The Obesity Epidemic” (buy a copy and double the annual sales!) was quoted in a Sunday newspaper suggesting that a significant number of people who undergo bariatric surgery, mainly procedures that reduce stomach size, hit the booze. David’s comment that patients initially addicted to food – why they were obese in the first place – following surgery cannot tolerate solid food so they choose a new addiction; in this case alcohol. But, like the logic that e-cigs cuts smoking deaths – just losing weight by surgical means is seldom a perfect solution.
I would offer an alternative hypothesis based on a phenomenon that has been widely recognised in drug addiction for many years and involves the speed of delivery of the drug to the brain. (If you don’t like the science bit skip now to the last paragraph). Getting a large bolus dose of a psychoactive agent into the brain in a very short time is directly correlated with the risk of addiction. Chewing coca leaves, as many indigenous peoples of South America regularly do, does not risk cocaine addiction whereas smoking crack-cocaine, the free base of the molecule, is about the most highly addictive thing a human can do. Similarly, the humble cigarette is a much more addictive nicotine delivery system compared to; chewing tobacco, pipe or cigars and also the range of licensed NRT products. In the case of the cigarette, the smoke is alkaline and therefore no absorption in the bucal cavity as happens with other forms of tobacco and NRT. These latter forms are acidic. The alkaline smoke from a cigarette once inhaled into the lungs, where the surface area is huge, allows rapid access to the blood stream and ultimately the brain.
In this case it seems plausible that with removal of the bulk of stomach tissue (and volume) the individual has lost the effect of alcohol dehydrogenase; the enzyme that metabolises about 20- 40% of an alcohol dose. In addition, without stomach volume, the alcohol is dumped into the small intestine where adsorption is much more rapid. This higher blood dose is likely to saturate the liver microsomal enzymes system (the protective first-pass effect) and the overall net effect is a more rapid delivery of a higher than normal alcohol dose to the brain.
This effect, if verified, would be a very important finding. But my main point is that too often commercial vested interests, often sold as medicine, offer to solve one problem only to create another. There is no substitute to the boring; stop smoking, take more exercise, eat healthly and don’t drink too much alcohol recommendations. These is the only real way to address our public health challenges.
