Pharmacist-only supply of nicotine vaping products: proposing an alternative regulatory model for Australia.

Regulation of nicotine vaping products (NVPs) is an ongoing challenge across the world. Australia currently has a globally unique NVP regulatory model that requires a medical prescription to purchase and use NVPs, with further restrictions in progress in response to evidence of widespread illicit NVP sales. Against this background, we examine the new measures and consider a modification of the model to pharmacist-only supply as an option for increasing access to NVPs for smoking cessation, while retaining health practitioner oversight of supply. We describe the strengths and challenges of implementing a pharmacist-only NVP supply option in Australia. Compared with the current prescription-only model, pharmacist-only supply could increase access to a lower exposure nicotine product in a highly regulated therapeutic context while addressing youth access and purchasing for non-therapeutic use, reduce demand for illicit products for smoking cessation purposes and avoid overburdening medical services with consultations to obtain NVP prescriptions. This approach can also accommodate current government goals such as eliminating NVP advertising, youth-focused branding and supply from grocery and convenience stores.

Restricting supply of tobacco products to pharmacies: a scoping review.

OBJECTIVE: We synthesised the published literature on proposals to restrict tobacco supply to pharmacies, covering (1) policy concept/rationale/attempts, (2) policy impact and implementation and (3) policy and research recommendations. DATA SOURCES: We searched eight databases (PubMed, CINAHL, Scopus, Web of Science, Embase, IPA, ProQuest and OATD) for publications with at least an English-language abstract. We searched reference lists of included publications manually. STUDY SELECTION: One author screened all publications, and a second author reviewed a 10% subset. We focused on approaches to restrict the supply of tobacco products to pharmacies, without any restrictions on study design, location, participants or publication date. DATA EXTRACTION: Data extraction adhered to the JBI Scoping Review Methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. DATA SYNTHESIS: We included 18 publications. Among the 13 studies conducted in specific geographical contexts, 8 were from Aotearoa/New Zealand. Most publications (n=8) focused on effectiveness domains, indicating potential reductions in retailer density, smoking prevalence, disease burden, cost and increased opportunities for cessation advice. Seven explored policy acceptability among experts, pharmacists and people who smoke. Publications noted that pharmacy-only supply aligns with other programmes involving pharmacists, such as needle exchange programmes, but conflicts with efforts to phase out tobacco sales from the US and Canadian pharmacies. CONCLUSIONS: Progress in tobacco retailing policy (eg, licensing, retailer incentives) and research (eg, assessment of policy equity and durability, application in other geographical contexts) are needed before a pharmacy-only tobacco supply model would be feasible.

Evaluating the implementation of a prescription only regulatory model for nicotine vaping products: A qualitative study on the experiences and views of healthcare professionals.

BACKGROUND: Deciding how to regulate nicotine vaping products (NVPs) is a challenge for many countries. Balanced regulation should consider the potential harms to young people from uptake of NVPs alongside the possible benefits of NVPs as a smoking cessation aid. One option is to make NVPs only available via medical prescription to adults who smoke. From October 2021, Australia adopted a unique model that allows prescription access to NVPs that meet a product standard without requiring the NVPs to be approved as therapeutic goods. This research explored the impact of this regulatory model on the smoking cessation practices of health professionals, and their views on the model. METHODS: Semi-structured interviews were conducted with 39 Australian health professionals recruited from professional networks and social media. Health professionals were eligible if they provided smoking cessation advice as part of their role, and included medical practitioners (n = 9), pharmacists (n = 9), and other health professionals that provided smoking cessation counselling (n = 21). Interviews were mostly completed by phone and online teleconferencing software. Questions focused on smoking cessation practices, advice and information provided to patients about NVPs, views about the effectiveness of the model for supporting use of NVPs for smoking cessation and preventing youth uptake, and barriers and facilitators to prescribing and dispensing NVPs. Coding and analysis used a combination of inductive and deductive approaches. RESULTS: Findings indicated a lack of consensus amongst the participants about NVPs as a cessation or harm reduction tool. Participants broadly agreed that the model has not been effective in improving quality control of NVPs, or in reducing youth access. Many participants eligible to prescribe or dispense NVPs felt that the current regulatory model placed an undue time and responsibility burden on clinicians. CONCLUSION: Our research identified several limitations associated with the current Australian prescription-only regulatory model. These were perceived by healthcare professionals to limit the potential for the regulations to reduce youth use and to increase access to safer NVP products for people who smoke to use for smoking cessation.

Improving Wastewater-Based Tobacco Use Estimates Using Anabasine.

In wastewater-based epidemiology (WBE), nicotine metabolites have been used as biomarkers for monitoring tobacco use. Recently, the minor tobacco alkaloids anabasine and anatabine have been suggested as more specific biomarkers for tobacco use since nicotine use can be from both tobacco and non-tobacco sources. This study aimed to provide an in-depth evaluation of the suitability of anabasine and anatabine as WBE biomarkers of tobacco and subsequently estimate their excretion factors for WBE applications. Pooled urine (n = 64) and wastewater samples (n = 277), collected between 2009 and 2019 in Queensland, Australia, were analyzed for nicotine and its metabolites (cotinine and hydroxycotinine), as well as anabasine and anatabine. Anabasine performed as the better biomarker, showing a similar per capita load in pooled urine (2.2 ± 0.3 µg/day/person) and wastewater samples (2.3 ± 0.3 µg/day/person), while the per capita load of anatabine in wastewater was 50% higher than its load in urine. It is estimated that 0.9 µg of anabasine was excreted per cigarette smoked. Triangulation of tobacco sales data and tobacco use estimated from either anabasine or cotinine showed that anabasine-based estimates were 5% higher than sales data, while cotinine-based estimates were between 2 and 28% higher. Our results provided concrete evidence to confirm the suitability of anabasine as a specific biomarker for monitoring tobacco use by WBE.

A systematic review on methods for developing and validating deprescribing tools for older adults with limited life expectancy.

OBJECTIVES: A number of deprescribing tools are available to assist clinicians to make decisions on medication management. We aimed to review deprescribing tools that may be used with older adults that have limited life expectancy (LLE), including those at the palliative and end-of-life stage, and consider the rigour with which the tools were developed and validated. KEY FINDINGS: Literature was searched in PubMed, Embase, CINHAL and Google Scholar until February 2021 for studies involving the development and/or consensus validation of deprescribing tools targeting those aged ≥65 years with LLE. We were interested in the tool development process, tool validation process and clinical components addressed by the tool.Six studies were included. The approaches followed for tool development were systematic review (n = 3), expert-literature review (n = 2) and concept data (n = 1). The content included a list of disease-non-specific medications divided with or without recommendations (n = 4) and disease-specific medications with recommendations (n = 2). The tool validation was performed using the Delphi method (n = 4) or GRADE framework (n = 2) with panel size ranging from 8 to 17 and 60-80% consensus agreement with or without a rating scale. LLE targeted were ≤1 year (n = 2) or ≤3 months (n = 1). SUMMARY: There is a limited number of deprescribing tools with consensus validation available for use in older adults with LLE. These tools are either targeted for disease-specific medication/medication class guided by the GRADE framework or targeted for a list of medications or medication classes irrespective of disease that are developed using a combination of approaches and validated using a Delphi method.

Higher blood nicotine concentrations following smokeless tobacco (pituri) and cigarette use linked to adverse pregnancy outcomes for Central Australian Aboriginal pregnancies.

BACKGROUND: In central Australia, Aboriginal women use wild tobacco plants, Nicotiana spp. (locally known as pituri) as a chewed smokeless tobacco, with this use continuing throughout pregnancy and lactation. Our aim was to describe the biological concentrations of nicotine and metabolites in samples from mothers and neonates and examine the relationships between maternal self-reported tobacco use and maternal and neonatal outcomes. METHODS: Central Australian Aboriginal mothers (and their neonates) who planned to birth at the Alice Springs Hospital (Northern Territory, Australia) provided biological samples: maternal blood, arterial and venous cord blood, amniotic fluid, maternal and neonatal urine, and breast milk. These were analysed for concentrations of nicotine and five metabolites. RESULTS: A sample of 73 women were enrolled who self-reported: no-tobacco use (n = 31), tobacco chewing (n = 19), or smoking (n = 23). Not all biological samples were obtained from all mothers and neonates. In those where samples were available, higher total concentrations of nicotine and metabolites were found in the maternal plasma, urine, breast milk, cord bloods and Day 1 neonatal urine of chewers compared with smokers and no-tobacco users. Tobacco-exposed mothers (chewers and smokers) with elevated blood glucose had higher nicotine and metabolite concentrations than tobacco-exposed mothers without elevated glucose, and this was associated with increased neonatal birthweight. Neonates exposed to higher maternal nicotine levels were more likely to be admitted to Special Care Nursery. By Day 3, urinary concentrations in tobacco-exposed neonates had reduced from Day 1, although these remained higher than concentrations from neonates in the no-tobacco group. CONCLUSIONS: This research provides the first evidence that maternal pituri chewing results in high nicotine concentrations in a wide range of maternal and neonatal biological samples and that exposure may be associated with adverse maternal and neonatal outcomes. Screening for the use of all tobacco and nicotine products during pregnancy rather than focusing solely on smoking would provide a more comprehensive assessment and contribute to a more accurate determination of tobacco and nicotine exposure. This knowledge will better inform maternal and foetal care, direct attention to targeted cessation strategies and ultimately improve long-term clinical outcomes, not only in this vulnerable population, but also for the wider population. NOTE TO READERS: In this research, the central Australian Aboriginal women chose the term 'Aboriginal' to refer to themselves, and 'Indigenous' to refer to the broader group of Australian First Peoples. That choice has been maintained in the reporting of the research findings.

Impact of deprescribing dual-purpose medications on patient-related outcomes for older adults near end-of-life: a systematic review and meta-analysis.

INTRODUCTION: The decision to deprescribe medications used for both disease prevention and symptom control (dual-purpose medications or DPMs) is often challenging for clinicians. We aim to establish the impact of deprescribing DPMs on patient-related outcomes for older adults near end-of-life (EOL). METHODS: This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Literature was searched on PubMed, EMBASE, CINAHL, PsycINFO and Google Scholar until December 2019 for studies on deprescribing intervention with a control group (with or without randomisation); targeting ⩾65-year olds, at EOL, with at least one life-limiting illness and at least one potentially inappropriate DPM. We were interested in any patient-related outcomes. Studies with similar outcome assessment criteria were subjected to meta-analysis and narrative synthesis otherwise. The risk of bias was assessed using Cochrane Risk of Bias and ROBINS-I tools for randomised controlled trials (RCTs) and quasi-experimental non-randomised controlled studies, respectively. RESULTS: Five studies covering 689 participants with mean age 81.6-85.7 years, the majority (74.6-100%) with dementia were included. The risk of bias was moderate to low. The deprescribing of DPMs lowered the risk of mortality (risk ratio (RR) = 0.59, 95% confidence interval (CI) = 0.44-0.79) and referral to acute care facilities (RR = 0.40, 95% CI = 0.22-0.73), but did not have a significant impact on the risk of falls, non-vertebral fracture, emergency presentation, unplanned hospital admission, or general practitioner visits. No significant difference was observed in the quality of life, physical and cognitive functions between the intervention and control groups. CONCLUSION: There is some evidence that deprescribing of DPMs for older adults near the EOL can lower the risk of mortality and referral to acute care facilities, but there are insufficient good-quality studies powered to confirm a benefit in terms of quality of life, physical or cognitive function, health service utilisation and adverse events. PLAIN LANGUAGE SUMMARY: What is the health impact of withdrawal or dose reduction of medication used for disease prevention and symptom control in older adults near end-of-life? Introduction: Older adults (aged ⩾ 65 years) with advanced diseases such as cancer, dementia, and organ failure tend to have a limited life expectancy. With the progression of these diseases towards the end-of-life, the intensity for day-to-day supportive care becomes increasingly necessary. The use of medications for symptom management is a critical part of such care, but the use of medications for long-term disease prevention can become irrelevant due to the already shortened life expectancy and may become harmful due to alterations in physiology and pharmacology associated with age and frailty. This necessitates the withdrawal or dose reduction of inappropriate medications, the process called deprescribing. The decision to deprescribe medications used for both disease prevention and symptom control (DPMs) in this population is often challenging for clinicians. In this context, whether deprescribing of DPMs can improve patient-related health outcomes is unknown.Methods: Evidence from the literature was reviewed and analysed, and the quality of studies was assessed. Five studies were identified, which had 689 participants with an average age above 80 years and mostly suffering from dementia.Results: The analysis of these studies showed deprescribing of DPMs lowered the risk of death and referral to acute care facilities at 12 months but had no significant impact on falls, non-vertebral fractures, emergency presentations, unplanned hospital admission, general practitioner visits, quality of life, physical and mental functions.Conclusion: In conclusion, there were insufficient numbers of high-quality studies powered to confirm whether deprescribing of DPMs reduces adverse events, health service use, or improves the quality of life or functioning in older adults near the end of life.

Does the content and source credibility of health and risk messages related to nicotine vaping products have an impact on harm perception and behavioural intentions? A systematic review.

AIMS: To systematically review the literature on (i) whether and how various risk messages about nicotine vaping products (NVPs) alter harm perception and behavioural intentions of smokers and non-smokers and (ii) how trust in sources of NVP risk communication affects message reception and behavioural intentions. METHODS: Seven electronic databases and reference lists of relevant articles were searched for articles published up to April 2020. Experimental and quasi-experimental studies on message effects and cross-sectional studies on source credibility were included. The Newcastle-Ottawa Scale and the Evidence Project Risk of Bias Tool were used to assess the quality of observational and intervention studies, respectively. For each outcome variable, we indicated whether there was an effect (as a 'yes' or 'no') and used effect direction plots to display information on the direction of effects. RESULTS: Nicotine addiction messages resulted in greater health and addiction risk perceptions, relative risk messages comparing the health risks of NVPs to cigarette smoking increased the perception that NVPs are less harmful than combustible cigarettes, and a nicotine fact sheet corrected misperceptions of nicotine and NVPs. Smokers' intention to purchase, try or switch to NVPs was higher when exposed to a relative risk message and lower when exposed to nicotine addiction warnings. Trust in NVP risk information from public health agencies was associated with lower odds of; (i) NVP use and (ii) perceiving NVPs as less harmful, whereas those who trusted information from NVP companies were more likely to perceive NVPs as less harmful than combustible cigarettes. CONCLUSIONS: Relative risk messages may help improve the accuracy of harm perceptions of nicotine vaping products and increase smokers' intentions to quit smoking and/or to switch to vaping, although the literature is nascent.

Factors that affect health-care workers' practices of medication administration to aged care residents with swallowing difficulties: An Australia-wide survey study.

OBJECTIVES: To understand the barriers and facilitators of medication administration to aged care residents with swallowing difficulties. METHODS: Health-care workers in aged care facilities across Australia involved in medication administration to residents completed an online survey. RESULTS: Of 355 respondents, 90.9% reported 'everyday' encounters with residents with swallowing difficulties and 94.1% modified medications to facilitate administration. Time constraints (63.4%) and workload (69.0%) were common barriers. Only 39.0% believed swallowing abilities are considered at the prescribing stage. Pill size (95.8%), polypharmacy (75.2%) and lack of alternative formulations (74.9%) contributed to these challenges. Support from other health-care professionals (91.5%) and training (85.9%) were the most favoured facilitators. CONCLUSION: Health-care workers are faced with various challenges when caring for residents with swallowing difficulties. Promoting multidisciplinary collaborations, provision of training and medication review services, and improving skill mix and staffing composition in aged care facilities are needed to address these challenges.

Factors affecting Australian aged care facility workers in administering oral medication to residents with swallowing difficulties.

Swallowing difficulties are common in older people and can complicate the administration of oral medications. The aim of this study was to explore factors affecting healthcare workers in their practices of oral medication administration to aged care residents with swallowing difficulties. A purposeful sample of 17 healthcare workers composed of clinical/care managers, registered nurses (RNs), enrolled nurses (ENs), and assistants in nursing (AINs) from three aged care facilities in Queensland, Australia participated in semi-structured interviews. Leximancer was used for quantitative content analysis. The responses centered on three main factors. Participants discussed workprocess-related factors including time, workload, and stress and frustrations resulting from work processes. Medication-related factors included strategies to facilitate medication administration, uncertainties around modifying medications, availability/cost of alternatives, multidisciplinary medication management, prescribing considerations, and polypharmacy. Resident-related factors were discussed around individualized needs of residents especially those with dementia-associated swallowing difficulties. Ideas differed among the four groups of participants. Managers discussed workprocess-related factors pertaining to staff and facility. RNs focused on how clinical aspects of the medication practices were affected by work processes. ENs were task-oriented and their responses focused on work processes. AIN responses centered on reliance on RNs in performing medication tasks. The findings suggest that healthcare workers' practices of medication administration to residents with swallowing difficulties are affected by various factors associated with work processes, medications, and resident characteristics. Although these factors affect all levels of healthcare workers, the needs of each group vary depending on their level of training and responsibilities.

How are nicotine vaping products represented to pharmacists? A content analysis of Australian pharmacy news sources.

BACKGROUND: With the growing popularity and use of nicotine vaping products (NVPs), it is important that pharmacists have evidence-based information in order to provide guidance to their customers. The news media can play an important role in shaping how pharmacists think, feel and act regarding NVPs. This paper examines how NVPs are portrayed and framed in Australian pharmacy news sources. METHODS: Four leading Australian online pharmacy professional news sources were searched for articles published between 2007 and August 2019. A combination of qualitative and quantitative methods was employed to explore how the safety, efficacy and regulation of NVPs was communicated. RESULTS: We identified and analysed 103 relevant articles. Academic research findings and/or expert opinions were either cited or referenced most often, appearing in a total of 59% of articles analysed, followed by government sources quoted in 41% of articles. Health effects and safety issues of NVPs were the most frequently mentioned topic appearing in a total of 79% of the stories, followed by NVP-related regulatory issues (47%). The majority of NVP-related articles were framed in a loss rather than gain contexts, with more emphasis given to the concern that NVPs have the potential to addict youth to nicotine and undermine Australia's progress in tobacco control. CONCLUSION: Australian pharmacy news media have more often reported the potential risks than the potential benefits of NVPs. Such portrayal is likely to contribute to misperceptions about the relative harm of NVPs. Pharmacy staff need access to unbiased and evidence-based guidance on how to handle customer enquiries regarding NVPs.

Nicotine vaping products as a harm reduction tool among smokers: Review of evidence and implications for pharmacy practice.

With the growing popularity and use of nicotine vaping products (NVPs, also known as e-cigarettes) as a way to quit smoking, pharmacy staff are frequently asked by smokers for advice about NVPs. In Australia, there are currently no clear guidelines or policy statements provided by any of the professional organisations for pharmacists on how they should handle customer enquiries about NVPs, or on extemporaneous compounding of prescriptions for nicotine solution for use in NVPs as a smoking cessation aid. This commentary summarises the current evidence surrounding the safety and efficacy of NVPs, the Australian regulatory landscape, and provides a guide for pharmacy staff to use in discussions with customers regarding NVPs. Evidence strongly points to NVPs being considerably less harmful than smoking tobacco cigarettes and that they can be effective for smoking cessation. The maximum benefit from using NVPs as a harm reduction tool, however, will only be realised if smokers completely stop smoking rather than using NVPs as a partial substitute, because even low level smoking still confers substantial health risk. Vaping products containing nicotine are illegal to sell in Australia but users can still legally access nicotine e-liquid through some limited pathways if they hold a valid prescription from a registered medical practitioner. It is important that pharmacy staff keep abreast of the current evidence surrounding these products and provide evidence-based advice to customers.

Framing and scientific uncertainty in nicotine vaping product regulation: An examination of competing narratives among health and medical organisations in the UK, Australia and New Zealand.

AIMS: To compare the policy positions of health and medical organisations across Australia, New Zealand, and the UK as they relate to sale and supply of nicotine vaping products (NVPs) and evaluate factors that have informed the differences in policy recommendations among these countries. METHODS: We used mixed methods to analyse data from position or policy statements published by health and medical organisations regarding NVPs (n = 30) and consultation documents submitted to government committees regarding policy options for the regulation of NVPs (n = 26). Quality assessment of included documents was conducted using the six-item Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers, and findings were presented narratively. Qualitative data were coded using NVivo 12 software and analysed using thematic analysis. RESULTS: An overwhelming majority of health bodies, charities and government agencies in the UK and New Zealand portrayed NVPs as a life-saving harm reduction tool. In contrast, concerns about addicting non-smoking youth to nicotine, a perceived lack of clear and convincing evidence of safety and efficacy and the potential to undermine tobacco control progress continues to define attitudes and recommendations towards NVPs among Australian health and medical organisations. Although the profoundly divided views among stakeholders seem to arise from empirical uncertainties and disagreements over the level and credibility of evidence, the source of most of these disagreements can be traced back to the fundamental and irreconcilable differences in the framing of the NVP debate, and varied tolerability of risk trade-offs associated with NVPs. CONCLUSION: Progress in resolving the controversy surrounding NVP policy requires stakeholders to be frame-reflective and engage in a meaningful dialogue of risk trade-offs, as well as both intended and unintended consequences of proposed policies.

Beliefs and Self-reported Practices of Health Care Professionals Regarding Electronic Nicotine Delivery Systems: A Mixed-Methods Systematic Review and Synthesis.

AIMS: This review explores the (1) beliefs and attitudes of health care professionals (HCPs) toward electronic nicotine delivery systems (ENDS) including use as a smoking cessation aid and/or harm reduction, safety and regulation, and (2) the extent and content of patient-HCP communication about ENDS. METHODS: PubMed, Embase, CINAHL, and PsycINFO were searched to identify articles published since 2003. The Mixed Methods Appraisal Tool and Strengthening the Reporting of Observational Studies in Epidemiology checklists were used to assess the quality of studies. Thematic synthesis was used to analyze qualitative data. RESULTS: A total of 45 articles (32 quantitative, 12 qualitative, and 1 mixed) were included. There was wide variation regarding beliefs about the efficacy of ENDS as a cessation aid. Although the majority of HCPs believes that ENDS are safer than combustible cigarettes, they also have concern about the short and long-term safety of ENDS, uptake by adolescents, and the potential for ENDS to act as a "gateway" to smoking cigarettes. Beliefs about ENDS are influenced by media stories and experiences provided by patients. Although most HCPs do not proactively recommend ENDS, they are more likely to support ENDS use among patients with smoking related comorbidities, heavy smokers with previous unsuccessful quit attempts, or patients who express interest in trying them. CONCLUSIONS: Overall, HCPs hold diverse views about the efficacy of ENDS and expressed wariness over their potential health effects. HCP endorsement of ENDS use seems to depend largely on patient health status, the presence of other competing risk factors and patient preferences. IMPLICATION: Although evidence on safety and efficacy of ENDS is emerging, HCPs should be honest with their clients, stating that the long-term safety is not yet established but what is known is that they appear to be a lower risk alternative to cigarettes. Our review highlights a need for further training and support for HCPs regarding ENDS use, which would enable them to guide their clients in making evidence-based decisions.

Policy Debates Regarding Nicotine Vaping Products in Australia: A Qualitative Analysis of Submissions to a Government Inquiry from Health and Medical Organisations.

Australia has maintained a highly restrictive regulatory framework for nicotine vaping products (NVPs) and the regulatory approach differs from most other high income countries. This paper employed a thematic analysis to assess policy consultation submissions made to a government inquiry regarding use and marketing of NVPs. We included in the analysis submissions (n = 40) made by Australian institutions that influence or contribute to health policy-making including government agencies, health bodies and charities (n = 23), and public health academics and healthcare professionals (n = 18). Submissions from commercial entities and consumers were excluded. The majority of submissions from representatives of government agencies, health bodies and charities recommended maintaining current restrictions on NVPs. Arguments against widening access to NVPs included the demand for long-term evidence on safety and efficacy of an unusually high standard. There was widespread support for restrictions on sales, advertising and promotion, with most submissions supporting similar controls as for tobacco products. In contrast, the majority of individual submissions from healthcare professionals and public health academics advocated for widening access to NVPs for smokers and emphasized the potential benefits of smokers switching to vaping and the policy incoherence of regulating less harmful nicotine products more strictly than tobacco cigarettes. Progress in resolving the policy debate concerning NVP regulation in Australia will require policy makers, clinicians and the public health community to engage in a meaningful dialogue which gives due consideration to both intended and unintended consequences of proposed policies.

Nicotine vaping product use, harm perception and policy support among pharmacy customers in Brisbane, Australia.

INTRODUCTION AND AIMS: Despite regulatory barriers for accessing nicotine liquid, use of nicotine vaping products (NVPs) has increased rapidly in Australia. Legal use of NVPs to aid smoking cessation requires a prescription, and pharmacies report receiving enquiries about the use of and access to NVPs. In this study, we assessed vaping product use, harm perception and policy support among community pharmacy customers. DESIGN AND METHODS: A cross-sectional survey was conducted among customers (n = 470) from a large community pharmacy chain in Brisbane, Australia. Multivariable logistic regression was used to examine perception of NVPs as less harmful than combustible cigarettes and regulatory recommendations in relation to demographics, smoking status and NVP use. RESULTS: Almost one-third of the sample (31%) had either tried NVPs in the past (16%) or were current vapers (15%), the majority of them being current smokers (67%) who are trying to quit (31%) or substitute smoking (41%). Vapers primarily depended on family/friends as a source of information (76%). Current smokers and vapers were more likely to perceive NVPs as less harmful than cigarettes than non-smokers and non-vapers. Perceiving NVPs as safer than cigarettes was correlated with a recommendation to regulate as a tobacco product. DISCUSSION AND CONCLUSIONS: There was widespread misperception about relative risk of nicotine-containing products, with 37% of respondents perceiving nicotine-containing NVPs to be as harmful as combustible cigarettes. Community pharmacies represent an ideal setting for educating smokers about smoking and vaping. Thus, pharmacy staff needs educational support to ensure that they are equipped to provide current evidence-based information to customers.

Electronic nicotine delivery systems (e-cigarettes) as a smoking cessation aid: A survey among pharmacy staff in Queensland, Australia.

OBJECTIVES: This study examined views of pharmacy staff regarding the safety of e-cigarettes compared to nicotine replacement therapies (NRTs) and conventional cigarettes, as well as views on their regulation in Australia. METHODS: We conducted a cross-sectional survey among pharmacy staff (64 pharmacists and 76 pharmacy assistants) from the greater Brisbane region, Queensland, Australia. The self-administered questionnaire included closed- and open-ended questions that explores pharmacy staff perception on harms of e-cigarettes versus NRT and traditional cigarettes, knowledge of current e-cigarette regulations, views on how they should be regulated and information needs regarding e-cigarettes. Pearson's chi-square test was employed for computing differences between variables. A content analysis of responses to open-ended questions was also performed. RESULTS: Over 90% of pharmacy staff regarded e-cigarettes without nicotine and NRTs as less harmful than regular tobacco cigarettes. This reduced to 72% for e-cigarettes containing nicotine, with 24% of respondents believing they are equally as harmful as conventional cigarettes. Moreover, few respondents were confident about the short and long term safety of e-cigarettes containing nicotine (36% and 15% respectively) whereas pharmacy staff were more comfortable with the safety of NRTs for short (88%) and long term (35%) use. The majority of respondents believed that e-cigarettes with nicotine should be regulated as a medicine, either requiring a prescription (24%) or sold only by pharmacies (22%), though many believed that they should be regulated in the same way as regular tobacco cigarettes (27%). Some pharmacy staff (39%) reported having been asked about e-cigarettes by customers and 75% believed that their customers would be interested in using e-cigarettes as a smoking cessation aid. CONCLUSIONS: There is a need to provide evidence-based and customised education for pharmacists regarding e-cigarettes to help them guide their clients.

Dosage form modification and oral drug delivery in older people.

Many people cannot swallow whole tablets and capsules. The cause ranges from difficulties overriding the natural instinct to chew solids/foodstuff before swallowing, to a complex disorder of swallowing function affecting the ability to manage all food and fluid intake. Older people can experience swallowing difficulties because of co-morbidities, age-related physiological changes, and polypharmacy. To make medicines easier to swallow, many people will modify the medication dosage form e.g. split or crush tablets, and open capsules. Some of the challenges associated with administering medicines to older people, and issues with dosage form modification will be reviewed. Novel dosage forms in development are promising and may help overcome some of the issues. However, until these are more readily available, effective interdisciplinary teams, and improving patient health literacy will help reduce the risk of medication misadventures in older people.

Sustained Simultaneous Delivery of Metronidazole and Doxycycline From Polycaprolactone Matrices Designed for Intravaginal Treatment of Pelvic Inflammatory Disease.

Poly(ɛ-caprolactone) (PCL) intravaginal matrices were produced for local delivery of a combination of antibacterials, by rapidly cooling a mixture of drug powders dispersed in PCL solution. Matrices loaded with different combinations of metronidazole (10%, 15%, and 20% w/w) and doxycycline (10% w/w) were evaluated in vitro for release behavior and antibacterial activity. Rapid "burst release" of 8%-15% of the doxycycline content and 31%-37% of the metronidazole content occurred within 24 h when matrices were immersed in simulated vaginal fluid at 37°C. The remaining drug was extracted gradually over 14 days to a maximum of 65%-73% for doxycycline and 62%-71% for metronidazole. High levels of antibacterial activity up to 89%-91% against Gardnerella vaginalis and 84%-92% against Neisseria gonorrhoeae were recorded in vitro for release media collected on day 14, compared to "nonformulated" metronidazole and doxycycline solutions. Based on the in vitro data, the minimum levels of doxycycline and metronidazole released from PCL matrices in the form of intravaginal rings into vaginal fluid in vivo were predicted to exceed the minimum inhibitory concentrations for N. gonorrhea (reported range 0.5-4.0 µg/mL) and G. vaginalis (reported range 2-12.8 µg/mL) respectively, which are 2 of the major causative agents for pelvic inflammatory disease.

Nicotine alkaloid levels, and nicotine to nornicotine conversion, in Australian Nicotiana species used as chewing tobacco.

A range of endemic Nicotiana species are chewed as a smokeless tobacco by several Aboriginal populations of Australia. In tobacco research, nicotine to nornicotine conversion is important because nornicotine lowers tobacco quality and is detrimental to health. A diverse group of cytochrome P450 genes with different transcriptional regulations are involved in this conversion. The primary aims of this study were to quantify the pyridine alkaloids and investigate nicotine to nornicotine conversion in laboratory-grown Australian Nicotiana spp. Nicotine, nornicotine, anatabine, anabasine, myosmine and cotinine were quantified in fresh leaves of 24 out of the 26 recognised Australian Nicotiana taxa. Conserved regions of CYP82E related genes were PCR amplified in all studied taxa. The conversion process in fresh leaves was compared with that in leaves that underwent a simulated curing process for species that we identified as being high converters (N. cavicola, N. goodspeedii, N. velutina) and low converters (N. benthamiana, N. excelsior, N. gossei). Agarose gel electrophoretic analysis of CYP82E related genes obtained from the PCR amplification of the cDNA in fresh versus leaves with simulated curing showed about a 3-fold increase in transcript accumulation levels in cured leaves of the high converter species, while the transcript accumulation in N. gossei and N. excelsior maintained a steady basal level and increased by a small amount in N. benthamiana. This suggests the presence of functional loci that are triggered by curing in only high converter species and indicates a potential risk for chewers of high converter species.