With new regulations on vaping taking effect last month, the RACGP launched its guide for supporting smoking and vaping cessation.

Here are the key things you need to know.

Strengthened evidence on nicotine vapes for smoking cessation

An updated January 2024 Cochrane Review found high certainty evidence that quit rates are significantly higher with nicotine E-cigarettes or vapes, compared with nicotine replacement therapy (NRT).

The RACGP expert advisory group on smoking cessation reanalysed the Cochrane review’s evidence with the help of an external group, and subsequently changed its rating of the certainty of the evidence from ‘low’ to ‘moderate.’ The RACGP attributed the discrepancy between its rating and the Cochrane’s rating to “a different assessment of the risk of bias.”

“The evidence that nicotine vaping products can be effective has grown stronger over time with more studies being published, particularly comparing nicotine vapes with nicotine replacement therapy and showing that nicotine vapes can be modestly more effective. And the certainty of that evidence has become stronger as more studies have been published,” says Professor Nick Zwar, Chair of the RACGP Smoking Cessation Expert Advisory Group.

Dr Colin Mendelson worked in tobacco treatment for more than 40 years, helping smokers quit, and although recently retired, he continues to advocate for vaping and tobacco harm reduction.

“I disagree with the rating of the efficacy evidence as moderate. The Cochrane Review rates it as high, and it is widely accepted as the gold standard,” he says.

While there are no approved vapes, the TGA has a list of those that have self-declared they comply with quality standards, noting it will conduct routine assessments to monitor compliance.

People may require higher doses than what’s available over the counter

Nicotine e-liquid up to and including 20mg/mL can be sold in pharmacies without a prescription to adults 18 and over. Higher concentrations require a prescription.

“There will definitely be patients who will do better with a higher strength to control their nicotine withdrawal symptoms and be more likely to succeed if they’re treated with higher strength products,” Professor Zwar says, caveating that while there isn’t conclusive evidence yet, it’s likely to be the case.

Dr Mendelsohn notes that “higher nicotine concentrations (typically 20-50mg/mL) are needed for compact, closed systems that have small batteries.”

“These devices generate smaller volumes of vapour and are preferred as they deliver fewer toxicants and are safer,” he says.

The new guide includes a table with suggested starting doses.

“If I use a smoker as an example, someone smokes within half an hour of waking and they’re smoking more than 10 cigarettes a day, they’re likely to need higher than 20 mg/mL,” Professor Zwar says, noting that because there is so much variability in how much nicotine people inhale when they smoke, time to first cigarette tends to be a better indicator of nicotine dependence than the number of cigarettes someone smokes.

Access is problematic

Some states are not allowing pharmacies to dispense vapes

Tasmania and Western Australia have said that under their state laws, pharmacies cannot dispense Schedule 3 vaping products.

So for people in Western Australia and Tasmania, the only way they’ll be able to get therapeutic nicotine vapes is by first getting a nicotine prescription from a doctor or nurse practitioner.

Even in states without bans, very few pharmacies are selling vapes without a script, Dr Mendelsohn explains, citing a national survey of 305 pharmacies in the first two weeks of October that found 99% didn’t have low-nicotine vapes (≤20mg/mL) on hand for walk-in customers. Moreover, because pharmacies aren’t allowed to advertise that they stock nicotine vapes, it’s even more challenging for adults to access them.

Likewise, online pharmacies require a prescription – and in NSW and the ACT, customers can’t purchase online at all because pharmacists are required to physically hand the product to them.

Additionally, people under 18 cannot access nicotine vapes over the counter anywhere in the country, Professor Zwar says.

“And in fact, in quite a few jurisdictions, even if it’s got a prescription, the pharmacist can’t dispense it. So that’s quite an issue for under 18s,” he says. “Access will not be easy.”

The only available flavours now are tobacco, mint and menthol.

New guidance on vaping cessation

The RACGP guideline also includes a section on supporting patients to quit vaping.

The guideline recommends asking patients if they vape or use e-cigarettes, and/or smoke, starting from age > 10 as long as you can ensure confidentiality for young people – including how frequently – and recording it, noting that “implementing recording systems that document tobacco use almost doubles the rate at which clinicians intervene with patients who smoke, resulting in higher rates of cessation.”

Professor Zwar says there’s not a lot of scientific evidence to inform quitting vaping, with very few studies on pharmacological strategies.

“So we need to really apply what’s been shown to help with tobacco, in the absence of specific research about nicotine vapes,” he says, for example encouraging people to get support from family and friends and to use services like Quitline.

Gradually reducing the nicotine concentration and frequency of use can be helpful.

“There’s a little bit of evidence for nicotine replacement therapy as a way of coming off nicotine vapes. And there’s a couple of studies on varenicline and one study on cytisine,” Professor Zwar says.

Behavioural strategies may also help, Dr Mendelsohn says. This might include distracting themselves with a walk or deep breathing when they start to experience a craving, or avoiding situations that trigger vaping, such as drinking or hanging out with others who will be vaping, especially in the first two to three weeks. Delaying cravings can also help, he says. “If you can delay the thought of vaping for 10 minutes, for example, until a certain time or after completion of a task, the craving will almost invariably be gone.”

Professor Zwar says that monitoring and support are also key.

“It’s important to try and follow up people and offer that support. And I think to make it clear that as a medical practitioner, the aim is to help people to become nicotine free, not to prescribe these products in the long term,” Professor Zwar says. “Now how long it might take for someone to become nicotine free will vary. And we don’t want people who’ve managed to stop smoking using nicotine vapes to relapse to tobacco use. So that’s an important consideration.”

However, Dr Mendelsohn argues that the main priority is to help people become –and stay – smoke-free, and that nicotine vapes can prevent relapse to combustible tobacco.

“Vaping carries only a small fraction of the risk of smoking and many people rely on it for long-term harm reduction. Former smokers should try to stop vaping if they can, but many people need to use nicotine long-term to reduce the risk of relapsing to smoking,” Dr Mendelsohn says.

For more information:

Supporting vaping and smoking cessation: a guide for health professionals

TGA vaping hub