Introduction by Croakey: Nicotine vaping products can now be prescribed by doctors and advertised by pharmacists under recent regulatory changes.
Smoking cessation experts are concerned that the potentially addictive chemical cocktails could have the unintended consequences of channelling people away from safe and effective pharmacotherapies to give up smoking.
In the article below, Quit Victoria Director Dr Sarah White and University of Melbourne Honorary Principal Fellow Associate Professor Cathy Segan call for a refocus on the most effective ways to quit smoking and question how vapes will fit in.
Sarah White and Cathy Segan write:
Liquid nicotine was rescheduled from a Schedule 7 poison to a Schedule 4 prescription-only medicine on October 1. This means that liquid nicotine or nicotine vaping products (NVPs) are now available from Australian pharmacies on prescription from a doctor.
It is generally unlawful to advertise prescription medicines to the public; however, a legal permission has been granted which allows pharmacies to advertise NVPs under specified conditions. The promotion of NVPs in pharmacies may prompt people who smoke to consider vaping and to seek advice from health professionals. This creates an opportunity for people who smoke to get best practice advice on how to quit smoking.
But it raises some questions. What is the most effective way to quit smoking? And how does nicotine vaping fit in?
According to national guidelines, first-line, evidence-based treatment for smoking cessation is multi-session behavioural counselling (Quitline is recommended) combined – if clinically appropriate – with pharmacotherapies approved by the Therapeutic Goods Administration (TGA). These include varenicline (brand name Champix), bupropion (brand name Zyban) and nicotine replacement therapies (NRT) such as nicotine patch, gum, lozenge, mouth spray and inhalator.
For people showing signs of nicotine dependence (such as smoking within half an hour of waking or smoking more than 10 cigarettes per day), combining long-acting nicotine patch with one of the other faster acting oral NRT forms (known as combination therapy) is recommended.
The TGA has not yet approved any NVPs for smoking cessation – that is, it has not assessed any NVPs as being safe, high quality and effective. This means doctors must prescribe an “unapproved” medicine if they choose to prescribe an NVP for smoking cessation.
In recently updated national guidelines NVPs plus behavioural counselling remains a second-line treatment option for smoking cessation in people where first-line treatment (TGA approved pharmacotherapies plus behavioural counselling) have been unsuccessful.
NVPs should be considered a short-term approach for quit attempts. People using NVPs to quit smoking should be encouraged to transition completely to NVPs as soon as possible, as smoking and vaping (‘dual use’) appears to have increased risks of health harms compared to smoking alone.
Once a person has successfully quit smoking using an NVP, they should be encouraged to quit the NVP given the lack of safety data for long-term use. Repeated inhalation of a chemical cocktail is not risk-free, with cases of e-cigarette or vaping product use-associated lung injury (EVALI) reported in Australia.
Evidence suggesting that people who use NVPs to quit smoking might have difficulty in subsequently quitting vaping is of great concern.
The Quitline is already receiving calls from people seeking help to quit vaping and, more worryingly, from people who are trying to support their children to quit vaping. Quitline offers free multi-session behavioural counselling Australia-wide and can provide support to people using NVPs to stop smoking as well as support to people seeking help to quit vaping.
Behavioural counselling the starting point
While pharmacotherapies help address the physiological aspect of nicotine addiction, behavioural counselling is needed to help people manage their situational and emotional triggers to smoke (or vape).
Counselling can also work directly on increasing people’s confidence and motivation to stop smoking. It offers an opportunity for tailored psychoeducation about stopping smoking, such as how to use NRT correctly, and the benefits of quitting, such as improved mental health.
Quitline callback services are effective in increasing smoking cessation. Highly trained professional counsellors offer calls over a period of about a month to help people make a quit attempt, manage nicotine withdrawal and adjust to a smoke and vape-free life.
Heavy demands on healthcare professionals mean they rarely have the time or skills to provide multi-session behavioural counselling. Referral to Quitline is therefore recommended as part of health professional brief advice: Ask Do you smoke? Advise about help to quit, and Help by referring to Quitline and prescribing or referring for pharmacotherapy.
A person referred by a health professional to a Quitline is 13 times more likely to engage in treatment, compared to someone advised to call themselves.
The referral to behavioural counselling is important because it significantly increases smoking cessation rates beyond that achieved with brief advice plus pharmacotherapy. Only a small proportion of people currently trying to quit smoking use Quitline plus TGA-approved pharmacotherapy.
If there is a silver lining from the decision to reschedule liquid nicotine, it is the increased interest in supporting smoking cessation. We could increase the smoking cessation rate – particularly among priority populations, such as people with mental illness – if all health professionals were to proactively promote smoking cessation and facilitate their patients to use treatments that increase their chances of quitting successfully.
However, it would be devastating if the rescheduling of liquid nicotine had the unintended consequence of channelling people away from safe and effective pharmacotherapies to an unapproved product with high addiction potential.
Health professionals should consider adopting a policy of requiring patients to try TGA-approved pharmacotherapy plus Quitline before they will consider NVP plus Quitline to maximise smoking cessation rates.
Dr Sarah White is Director Quit Victoria. Cathy Segan is Honorary Principal Fellow of Population Health, The University of Melbourne.
See Croakey’s archive of stories on tobacco control.