The recent Australian Burden of Disease Study shows that smoking is still the largest cause of death and disease in our patients. This is not surprising, since smoking rates have not fallen significantly over the last six years.
As GPs, we need to consider additional new strategies to help smokers quit, such as vaping.
Although not supported by Australian authorities, vaping is now becoming established internationally as a valid evidence-based tobacco harm reduction strategy, endorsed for example by the UK Royal College of Physicians, the British Medical Association and the New Zealand Medical Association.
Just a couple of weeks ago, the New Zealand Ministry of Health launched a new website called Vaping Facts. The website provides accurate information on vaping and encourages smokers to make the switch.
Personal vaporisers (e-cigarettes) are now the most popular quitting aid in the US, UK, Canada and many other countries. Vaping can also be considered for the many Australian smokers who have been unable to quit with conventional treatments.
WHAT IS VAPING?
Vaping involves heating a liquid which may or may not contain nicotine, into an aerosol which the user inhales. Vaping simulates smoking by providing nicotine and mimicking the hand-to-mouth ritual and the sensory and social aspects of smoking.
To be clear, vaping is not harmless and those who don’t smoke shouldn’t vape. But it is much less harmful than smoking.
According to the UK Royal College of Physicians, the risk of vaping long-term is at least 95% less than that of smoking. It is the products of combustion of tobacco that kill smokers and vaping involves no combustion, tobacco or smoke. Nicotine has only relatively minor adverse health effects in the doses used in vaping.
The latest research suggests that vaping is more effective than nicotine replacement therapy (NRT). A large, well-conducted randomised controlled trial in the UK found that smokers allocated to vaping were nearly twice as likely to quit as those using NRT (OR 1.83 at 12 months). Four out of five of those who quit smoking were still vaping at 12 months.
A recent study of 19,000 smokers in England confirmed that vaping also works in real-world settings. Smokers who used e-cigarettes had three times the quit rate of those using prescribed NRT (OR 1.95 vs 1.34).
IS VAPING LEGAL IN AUSTRALIA?
Under the TGA Personal Importation Scheme, it is legal for your patients to import and use nicotine liquid if you provide a nicotine prescription. The scheme allows the importation of three months’ supply at any given time for personal use with a maximum of 15 months’ supply imported in any 12-month period.
It is legal for doctors to issue nicotine prescriptions when clinically indicated, for example for adult smokers who have been unable to quit with conventional therapies and who want to switch to a less harmful nicotine product.
Good practice involves taking a history and discussing all the available treatment options, including their potential benefits and harms. No special permission or forms are required to write a nicotine prescription.
HOW TO PRESCRIBE NICOTINE E-LIQUID
Nicotine e-liquid consists of nicotine dissolved in propylene glycol (PG) and vegetable glycerine (VG) with added flavouring. Most users start with a nicotine concentration of 6mg to 18mg/ml, although more dependent smokers may need 24mg/ml. Typical use is 2ml to 5ml per day, although some vapers use a lot more.
Suitable devices for beginners are prefilled pod models which use a replaceable pod or cartridge of e-liquid and simple pen-style models which have a refillable tank filled by the user.
How to write a prescription for nicotine e-liquid is explained in the box on this page. More detailed instructions can be found on the www.athra.org.au website.
As with any other smoking pharmacotherapy, the best results are likely when vaping is used with counselling and support as part of a comprehensive management plan.
Smokers should aim to cease vaping use once they feel ready to do so without relapsing to smoking. This may take some smokers longer than others.
However, some smokers are not able to give up nicotine or the smoking ritual. In these cases, long-term vaping appears to be much safer than smoking.
Long-term dual use should be discouraged, but emerging evidence suggests it is also safer than smoking.
Visit the Australian Tobacco Harm Reduction Association (ATHRA) website and use your AHPRA number to login to the Health Professionals section
Mendelsohn C, Wodak A. Vaping. Ten frequently asked questions. Respiratory MedicineToday 2018
Mendelsohn CP. Electronic cigarettes. A guide for discussion with patients. Respiratory MedicineToday 2016
Conjoint Associate Professor Colin Mendelsohn (UNSW) is chairman of the Australian Tobacco Harm Reduction Association
The Australian Tobacco Harm Reduction Association (ATHRA) is a registered health promotion charity established to reduce the harm from tobacco smoking in Australia. ATHRA’s aim is to provide smokers and health professionals with evidence-based information on safer alternatives to smoking. ATHRA does not accept funding from tobacco or e-cigarette companies.