What does the Royal Australian College of General Practitioners (RACGP) say about smoking cessation options? 

RACGP provides a comprehensive guideline for doctors regarding smoking cessation. The relevant section can be accessed here. In essence, RACGP recommends as first-line the existing nicotine replacement therapies (patches/gum/inhalers), as well as pharmacotherapy (such as Champix or bupropion). There is also a strong role for counselling. Nicotine vaping is listed as a second-line smoking cessation method.The RACGP says vaping nicotine ‘may be a reasonable intervention’ in certain groups:

“For people who have tried to achieve smoking cessation with approved pharmacotherapies but failed, but who are still motivated to quit smoking and have brought up e-cigarette usage with their healthcare practitioner, nicotine containing e-cigarettes may be a reasonable intervention to recommend.”

As a GP with RACGP fellowship, I use these official guidelines as they are intended – recommendations not mandates. It is ultimately up to each clinician to decide how to best implement any guideline, based on the specific requirements of their patient. There is an interplay of official guidelines, and specific patient complexity. In brief, my approach is this: I acknowledge that every patient has their own ideas, concerns and expectations. Heavy smokers in particular are more likely to have complex medical issues including mental health, substance use and chronic physical health issues. They are also more likely to have had previous negative experiences from healthcare professionals, including feeling judged and not heard. I have found the most effective method is to engage the patient in respectful dialogue, and make it easier for them to access a prescription for therapeutic nicotine products. I take a ‘long view’, which is to have longer term followup including lung cancer screening and cardiovascular disease management via my SmokerHealth telehealth platform. However, the first step is to keep them smoke-free. I have a deep understanding of their needs and complexities, based on 4 years experience with this cohort. I am aware that some adults choose to vape instead of smoke, for a multitude of reasons (including but not limited to: improved mental health; pain management; diverting away from other drug use; ADHD; cognitive improvements; stress relief/relaxation). We are in an evolving landscape of transitioning from a consumer good (cigarettes) to a prescription-only alternative (prescription vapes). This is not a simple transition, and there are significant issues of access that prevent current smokers gaining access to a healthier alternative. I err on the side of providing a script for vaping first, then continuing the patient relationship with longer term followup. This keeps them away from the blackmarket (which many vapers would otherwise turn to), with the quality assurance of pharmacy-grade vapes.

How safe and effective is liquid nicotine for vaping?

There is mixed evidence on its effectiveness as an aid to quit smoking. There is no long-term evidence on the safety of nicotine vaping, or the potential long-term impacts of its use. Animal studies have shown that liquid nicotine may be harmful to the foetus, although these results have not been replicated in human studies. Potential side effects of nicotine (whether in cigarettes or vaping) include high blood pressure, heart arrythymias and cardiovascular events. On the other hand, some studies suggest that liquid nicotine is up to 95% safer than tobacco, with almost none of the inhaled toxins and carcinogens of tobacco.

It is essential that liquid nicotine is obtained from a reliable supplier, with TGO-110 (Australian safety standard) accreditation. Store in a childproof, lockable cupboard. Liquid nicotine can be toxic and even fatal if ingested in high concentrations. Battery care is essential, to ensure leakage or explosions do not occur. Always follow the package directions for use.

Vaping in under 18s, with or without nicotine, is unsafe. There are many valid concerns that underage vaping may be an ‘on ramp’ to other tobacco or substance use. Further, the effect of nicotine on the developing brain is unknown.

Under no circumstances should ‘black market’ vapes be used. Nicotine levels are unregulated, toxicology analysis is very limited, and the batteries and electricals can be of very poor quality with explosion risks. Although no-one can say with 100% certainty that Australian TGO-110 standard nicotine is safe, the safety risks are vastly reduced if legally accessed nicotine products are used instead of black market nicotine.

What does the World Health Organization say about nicotine vaping?

The World Health Organization provides a balanced assessment of the role of nicotine vaping. Click here for the full report. Essentially, although the lack of long-term safety data is highlighted as a major issue, WHO does offer support for nicotine vaping in current smokers who are unable to stop smoking:

“If the great majority of tobacco smokers who are unable or unwilling to quit would switch without delay to using an alternative source of nicotine with lower health risks, and eventually stop using it, this would represent a significant contemporary public health achievement.”

“Electronic nicotine devices are unlikely to be harmless, (but) the magnitude of these risks is likely to be smaller than from tobacco smoke.”
— World Health Organization 2016, WHO Framework Convention on Tobacco Control