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New provisional guidance from the RACGP on the use of e-cigarettes to help Australians quit smoking provides a balanced approach for GPs, according to tobacco control experts.
E-cigarettes have been widely promoted as a smoking cessation aid to help people who have struggled and failed to quit smoking with first line treatment of pharmacotherapies and counselling. The putative benefits of e-cigarettes are in fact modest and interpretation of the evidence is far from unanimous (here, here and here). Against this, the uptake of vaping by young people who have never smoked has reached concerning levels in many countries, including the United States, the United Kingdom, New Zealand and Australia.
E-cigarettes are not safe, there is no doubt about this. In December 2023, the World Health Organization (WHO) recognised the harms at a population level from widespread use far exceed the potential benefit. These harms include nicotine addiction, poisoning, seizures, acute cardiovascular and respiratory effects and burns (here and here). The long term health effects of regular use on the body are not yet known. People who have never smoked are around three times as likely to take up smoking if they use e-cigarettes compared to if they do not. Tellingly, to date, no tobacco or e-cigarette company has submitted a product to the Therapeutic Goods Administration (TGA) for consideration as a therapeutic device, yet tobacco companies have heavily invested in marketing and product design development that maximises appeal to a younger demographic.
The vaping reforms
In late 2023, Australia’s Health Minister the Hon Mark Butler MP announced a series of policy reforms aimed at reducing e-cigarette use by young people who do not smoke. These include, from 1 January 2024, a ban on the importation of single use disposable vapes which have flooded Australia. From March, further measures will come into place including:
- stopping the personal importation of vapes;
- a ban on the importation of all non-therapeutic vapes;
- a requirement for therapeutic vape importers and manufacturers to notify the TGA of their product’s compliance with the relevant product standards; and
- requiring importers to obtain a licence and permit from the Office of Drug Control before the products are imported.
These measures will further strengthen and streamline the prescription access model for e-cigarettes. New product standards expected to come into effect later in the year will limit nicotine strength to 20 mg/mL (2%), in line with European Union, UK and Canadian regulations; regulate allowable flavours to tobacco, menthol and mint; and require pharmaceutical-like packaging. Prescribing will also be easier, with any medical or nurse practitioner able to do so.
The Government is expected to shortly introduce legislation to prevent domestic manufacture, advertisement, supply and commercial possession of non-therapeutic and disposable single-use vapes. Once adopted, this legislation will put a firm date on the end of vape shops in our communities. In a nutshell, the reforms seek to curb illegal activity while, importantly, facilitating a treatment pathway for people addicted to nicotine.
The industry response
The reforms proposed by Minister Butler have passed the “scream test” with flying colours – if tobacco industry front groups are “screaming” about the negative impact of reforms on their business via their usual tactics, then the policy is likely to be successful in preventing uptake (here, here and here). Despite the fact that general practitioners (GPs) have welcomed the announcement, some retail industry bodies claim the changes will overwhelm the medical system, as people who use e-cigarettes will flood GP offices seeking a prescription, and that the reforms will stoke illicit trade. Those who risk losing profit have combined these two claims – along with a good dose of astro turfing – with the result that one of the strongest narratives against the reforms is a fear that people who use e-cigarettes will not be able to obtain prescriptions from “doctors who are apathetic or unwilling to provide assistance” and, therefore, will be forced to turn to the illicit market to obtain their e-cigarettes.
These claims incorrectly assume that every person who currently uses e-cigarettes will continue to vape. It also assumes that every person will suddenly demand a prescription from a GP. These ideas fail to recognise what we know well: in the same way most people who smoke want to quit, we know that among young Australian adults, over 40% want to quit vaping and quit attempts are increasing. Additionally, most young people who use e-cigarettes are not vaping daily and report most frequently vaping in social situations. Just as we know that the most common smoking cessation method is to quit unassisted, also known as “cold turkey”, so too we will expect to see most quit vaping attempts to be unassisted.
As to the illicit market claims, the industry argument is that retailers should now be legally allowed to sell nicotine e-cigarettes. The e-cigarette industry and irresponsible retailers quite simply cannot be trusted. Not only have some retailers fuelled the current illicit market by knowingly and illegally selling e-cigarettes to children, but they have also driven a narrative that misleadingly positions the reforms as a ban.
Implications for clinicians
The Australian Government’s reforms are supported by most national health, scientific and consumer bodies because they comprehensively address the availability and attractiveness of vaping to young Australians. For those people who do seek cessation support, medical and nurse practitioners have a vital role to play in ensuring they are managing nicotine addiction with a view to cessation.
When a patient is given medical advice to quit, along with combination pharmacotherapy and behavioural support, this increases nicotine cessation rates. The recent provisional guidance from the Royal Australian College of General Practitioners (RACGP) on the use of e-cigarettes for cessation has upgraded the evidence for e-cigarettes in cessation from low to moderate certainty. However, since e-cigarettes remain an unapproved therapeutic medicine with unclear long term health impacts, the decision to use e-cigarettes to manage nicotine addiction must therefore be made based on an individual’s personal circumstances and medical history. These combined factors make the prescription access framework the most appropriate for managing e-cigarette access.
One of the major parts of the reform package recognises the need to streamline the e-cigarette prescribing process. The previous requirement for prescribers to apply for and become an authorised prescriber was time-consuming and complex. Recognising the need to remove this obstacle, the authorised prescriber scheme is no longer a requirement, and the prescription of e-cigarettes can be managed through Special Access Scheme C. Under this scheme a medical or nurse practitioner can use the online notification system to immediately access the unapproved product without waiting for special approval.
Until the evidence matures, we believe the RACGP guidance document provides a balanced and appropriate approach to assisting practitioners to prescribe e-cigarettes. We welcome these reforms, which are consistent with the advice of the WHO as they aim to restrict e-cigarette use to the only population that might benefit; that is, people who are struggling to quit smoking (or vaping) by usual means. Health care professionals need to be aware of the industry-driven narratives that seek to undermine the effectiveness of the reforms. Medical and nurse practitioners have a vital role to play in supporting nicotine cessation and the RACGP Provisional Guidance provides them with support to help patients with proven effective methods to quit.
Professor Tanya Buchanan is CEO of Cancer Council Australia and Honorary Professor of Practice in the School of Health and Society at the University of Wollongong.
Associate Professor Henry Marshall is a Thoracic Physician at the Prince Charles Hospital and University of Queensland Thoracic Research Centre.
Associate Professor Becky Freeman is with the School of Public Health at the University of Sydney.
Ms Anita Dessaix is Director of Cancer Prevention and Advocacy at Cancer Council NSW.
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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Great article! Thank you.