Vaping changes have been made but there is still no clear pathway ahead for GP, pharmacist or consumer.
By Eric Martin
As of 1 June 2024, it became illegal for any business other than a pharmacy to sell vapes or vaping products in Australia, irrespective if the vape contained nicotine or not.
The move has been hailed by GP and specialists’ groups as a step in the right direction, however it has put GPs in an even more pivotal role in smoking cessation.
Dr Ramyan Raman, the Chair of RACGP WA, said that from a clinician’s perspective, while the vaping restrictions were supported, one of the most surprising aspects was the decision to redesignate vapes as a pharmacy supplied product.
“GPs have been on the frontline of smoking cessation for a long time in Australia, it’s part and parcel of preventative health. We know that patients will need to have a conversation with their pharmacist about their options whenever they purchase vaping products, and the system will need monitoring to ensure there is genuine compliance at the point of purchase,” Dr Raman said.
“We are especially interested in what that means for the prescription process and GPs. We have a responsibility to support this primarily because vaping can cause quite serious respiratory damage, even if we are still not particularly clear about the full long-term impact of vaping.”
The National Centre for Epidemiology and Population Health compiled a report for the Australian Department of Health that was foundational in the department’s approach to the issue and the subsequent ministerial decision.
They reported that the prevalence of dependence symptoms ranged from 23-46% among exclusive e-cigarette users in 15 studies. Among exclusive e-cigarette users, 46.1% reported use 30 minutes after waking, 46.2% reported strong cravings, 46.2% reported the need to use and 22.8% reported withdrawal symptoms when abstaining.
“There is conclusive evidence that e-cigarettes cause acute lung injury, largely linked to e-liquids containing THC and vitamin E acetate, although around one in eight cases in the largest study to date were from reported use of nicotine-only products. Their environmental impacts include waste, fires and indoor airborne particulate matter, which, in turn, are likely to have adverse health impacts, the extent of which cannot be determined,” the report said.
Overall, it concluded that nicotine was highly addictive and there was clear evidence of ‘widespread use and addiction, particularly among youth,’ around the world.
One of the key factors touted by the ‘vape-to-quit’ campaign has been the relative success of New Zealand in using the electronic devices to lower traditional tobacco consumption. The much-cited 2022 study by Burrowes et al. found that vaping showed good potential as a medium for quitting.
“Based on our data the use of e-cigarettes in a “vape to quit” strategy is attractive to smokers, based on the high uptake of their selected use as a smoking cessation aid (75%),” Professor Burrowes’ team concluded. “In total, 16% of those in the follow up “vape to quit” cohort were both smokefree and vape free.”
However, Dr Raman noted that because there were pros and cons with each of the options available for cessation, it depended on the actual patient, their specific needs, and the GP’s expertise in selecting the most tolerable product in those circumstances – starting with nicotine replacement, using gum or lozenges, then followed by medicines such as Champix.
“When those medications were initially released, there was a lot of interest and uptake in terms of how they would work. For example, Champix was very popular with patients and at that time, it was determined to be the first and best treatment,” she said.
“But importantly, that discussion involved a counselling process with the patient. There was a consultation explaining what the side effects were, examining where they were in their motivational change cycle, and looking at their past medical history and current medications to ensure there were not going to be any adverse interactions.
“Everything has side effects, and the original system was not perfect, but at the same time, with GPs now required to issue prescriptions for a nicotine-replacement device, we are potentially being asked to favour an option that is definitely not first-line in terms of smoking cessation.
“There are a lot of misconceptions in the community about the effectiveness of vaping as a nicotine replacement therapy, but that’s not the case at all – it’s not first line or even second or third line, for that matter.”
Australian research conducted by the department found that there was insufficient evidence regarding the exacerbations of respiratory disease or changes in respiratory symptoms, lung function and other respiratory measures, to justify recommending vapes.
“There is limited or insufficient evidence that use of ENDS (electronic nicotine delivery systems) in non-smokers leads to acute reductions in lung function and other respiratory measures. Among smokers, there is moderate evidence that use of ENDS increases heart rate, systolic blood pressure, diastolic blood pressure and arterial stiffness acutely after use,” the report said.
“There is strong evidence that e-cigarettes increase the uptake of combustible smoking in non-smokers, particularly youth, and limited evidence that freebase nicotine e-cigarettes are efficacious in the clinical setting as an aid to smoking cessation. There is limited evidence that ex-smokers who use e-cigarettes have around double the likelihood of relapse to resuming smoking than ex-smokers who do not use e-cigarettes.”
“As such, we don’t want these things to make their way into the hands of young patients – we need that close monitoring and while there’s still questions that remain,” Dr Raman said.
“And that’s not to undermine the role of the pharmacist in any way at all, but rather highlight the need for clarification around that process. How is that conversation going to be had? And what is that monitoring and compliance process?
“We don’t want pharmacies to become like the new corner store, and they don’t want that either, going by the comments that they have made. It is a real concern for pharmacists as well.”
However, one of the biggest challenges facing GPs is potentially locating a pharmacist willing to stock vaping products as nicotine replacement services, especially after the amendment to the legislation pushed by the Greens and Nationals, allowing people 18 years or over with no prescription to purchase – effective as of 1 October 2024.
Medical Forum spoke with the WA Pharmacy Guild last month, when changes were announced and the guild’s policy and media officer, Mr Alan Hill, said that the decision to stock vaping products would be up to individual pharmacists.
“As was the case prior to that date, nicotine vapes are available from community pharmacies. However, only to patients who have a valid prescription. However, individual pharmacies have the discretion on stocking and supplying vaping products, early feedback from pharmacies is that post 1 October, many may or may not,” Mr Hill said.
“While it is too early to effectively measure any increase in demand at a sector-wide level, patients providing a valid prescription should be aware of the possibility that their preferred community pharmacy will have to order in the stock, which may take 24-48 hours.
“The WA Branch is yet to be advised of how this legislation will be implemented in community pharmacies. However, currently, there is no guidance or protocol for pharmacists regarding their requirements for patient consultation to establish a clinical need for a nicotine containing vape, or the regulatory compliance of these instances.
“Vaping products have not been approved by the Therapeutic Goods Administration (TGA) and no nicotine-containing vape is listed on the Australian Register of Therapeutic Goods.”
Similarly, as far as Dr Raman was aware, there had been no guidance from the government or the health department in terms of what devices, mechanisms or processes was going to be recommended by GPs.
A pharmacist, who stocked vaporising products, told Medical Forum that the product they stocked was not compatible with any of the pre-existing vaporiser products that patients already owned.
“I’m a practising GP. We would know if something came through for the patients in our clinic that specified this is what we need to give them,” Dr Raman said.
“We are now in a position where there’s a lot of information out there for patients, readily available on multiple platforms, but the reliability of this information can be questionable – especially on social media platforms. Just in my population of patients, there’s a lot of myths about the use of nicotine containing e-cigarettes.”
Whatever the outcome of the ongoing political and medical discussion around vaping, the article in the Medical Journal of Australia in December by Dr Samantha Howe from Melbourne’s School of Population and Global Health holds true:
“The COVID pandemic saw each jurisdiction charting a different course to manage the pandemic. Some policies and jurisdictions were more successful than others. Sharing the lessons of what worked and did not work, and why, is an important part of transferring policy success that will be a key part of preparing for current and future public health challenges.”