Vaping can help disadvantaged Australians quit smoking. What now for clinical practice? 

Vaping has shown promise as an effective quit smoking aid in the general population, but prior to this clinical trial vaping’s role in helping those experiencing socio-economic hardship to quit was unknown.

Tobacco smoking is a leading cause of preventable morbidity and mortality in Australia with over 24,000 Australian’s dying per year from attributable tobacco related disease (equating to 66 deaths per day). Daily smoking rates for those aged 14 and over are currently 8.3%, having dropped from 11% in 2019. Smoking rates are not uniform across the Australia population and people experiencing higher levels of socioeconomic disadvantage are three times more likely to smoke daily (13.4%) compared to those experiencing the least disadvantage (4.1%). New and improved quit aids are needed to compliment population level tobacco control strategies and further reduce smoking rates. Cochrane Systematic Review evidence suggests that vaping is an effective smoking cessation aid for the general population, however prior to this clinical trial, the potential role of vaping in facilitating quitting among people from low-socioeconomic status (low-SES), or for those experiencing social disadvantage, was unknown.

Limitations of previous clinical trials evaluating vaping for smoking cessation have been:

1. minimal choice of device selection, typically providing one device;
2. lack of flavour selection, and if flavour supplied typically tobacco e-liquid only; and
3. use of freebase e-liquids now superseded by pod devices containing nicotine salts with superior pharmacokinetic profile (ie, swift administration of higher concentrations of nicotine in a smoother and more palatable manner to relief cravings).

Quitting through vaping

Our clinical trial, is one of the first globally to evaluate the relatively newer nicotine “pod” devices which use nicotine e-liquid salts. In the trial participants were randomly allocated to either 8-week supply of:

1. two vaping devices (tank and pod) alongside three e-liquid flavours (tobacco, mint and fruit flavour); or
2. nicotine replacement therapy (choice of gum or lozenge; 4mg).

Each group also received a 5-week text message quit support program alongside allocated treatment. All participants were recruited from the Sydney and greater metropolitan area and to be eligible had to be: a daily smoker, aged 18 years or older, willing to quit and receiving a government pension or allowance (proxy measure to define low-SES/social disadvantage).

The clinical trial analysed adverse event data and smoking cessation outcomes for 1045 participants at various timepoints with a primary outcome of verified six-months continuous abstinence verified by CO monitor at 7-month follow-up. Participants in the vaping group were three times more likely to achieve continuous abstinence (28.4%) compared to NRT group (9.6%). All sub-group analyses for sex, age, recent diagnosis or treatment for mental illness found comparable quit rates with vaping superior to NRT in all analyses. Adverse events for those that reported treatment use were less frequent in the vaping group compared to NRT group. There were no significant differences in self-reported respiratory outcomes by treatment group. For participants completing their final 7-month follow-up, 31% in the NRT group reported continue allocated product use (at least on a weekly basis or more often) compared to 56% in the vaping group. For those meeting the primary outcome, 34% in the NRT group continued allocated product use compared to 58% in the vaping group. Whilst the current trial provided higher nicotine strength e-liquids and multiple flavours it was not powered to establish differential effects of individual devices or e-liquid flavours (tobacco vs other flavours).

Limitations and challenges ahead

Nicotine vapes can help people quit smoking, but they are no magic cure and most people who make a quit attempt will relapse to smoking — highlighting the challenges in smoking cessation. Nicotine vapes to quit smoking are more likely to be used longer-term, compared to NRT. For people who smoke, switching to vaping (and stopping smoking completely) is much less harmful. However, given we know little about the risks of long-term vaping it is prudent that people aim to stop vaping eventually ie, as soon as they feel safe that they will not relapse to smoking.

Australia’s current precautionary approach to pharmacological intervention has vaping as a “conditional” recommendation for intervention that may be explored as a “reasonable” approach to smoking cessation only after first-line pharmacotherapies (NRT and varenicline) have failed. Pharmacy supply of vapes is limited with many major pharmacy chains reluctant to stock vapes. Only approximately 3000 authorised prescribers out of a potential 39,000 Australian doctors are currently prescribing vapes. Some concerns and barriers regarding vaping have been raised by doctors and pharmacists including:

1. insurance and indemnity;
2. no licensed or regulated therapeutic product;
3. safety of long-term use; and
4. doubts regarding effectiveness.

Whilst Australia’s stringent requirement for quality standards is critical for patient safety most vapers are using illicit disposable vapes (ie, recent national surveying found 87% of vapers acquired vape without prescription). General practitioners (GPs) and pharmacists are a key source of advice and support for smokers, and this quit support is shown to increase quitting rates. However, whilst an illicit vape market flourishes with lower cost vapes readily accessible to consumers, it is likely the Australian pharmacy vaping model will have limited impacts on quit rates unless further education, advice, strategies and support are provided to GPs and pharmacists. Without this, the true design features and potential of our underutilised/untapped pharmacist model for smokers to quit may not be reached (ie, facilitating increased access to high-quality vapes which meet strict safety and quality standards set by the TGA, and pharmacists providing brief expertise and advice to patients on vaping and smoking cessation.)

For now, $350 million as part of the National Disruption Group will be spent to crack down on both the illicit vape and cigarette market with strict enforcement efforts trying to curb illicit supply. While we wait to see the results from this crackdown, another new smoker light-ups a cigarette, and another 66 Australians will die per day prematurely from smoking-related disease.

Dr Ryan Courtney is an Associate Professor, National Heart Foundation Future Leader Fellow and Program Lead of the Tobacco Research Group based at the University of New South Wales, National Drug and Alcohol Research Centre.

Dr Hayden McRobbie is a Professor of Population Health, based at Queen Mary University of London, Wolfson Institute of Population Health.

No declaration of interests to declare. The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article and have disclosed no relevant affiliations beyond their academic appointment. This research was funded by a Project Grant 1127390 from the Australian National Health and Medical Research Council.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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