In the August issue of Retail Pharmacy magazine, we take a deeper dive into vaping, considering the topic from the perspective of healthcare and industry professionals, and addressing the role of pharmacists within this complex space. The purpose is to equip pharmacists with knowledge and insight into the importance of smoking cessation, the potential for nicotine vaping products (NVPs) as a second-line treatment and how NVP companies are operating within this space.
We need to strike a balance between prevention and treatment when it comes to smoking cessation and nicotine dependence, says Associate Professor Johnson George from the Centre for Medicine Use and Safety at Monash Institute of Pharmaceutical Sciences.
This balance involves having various tools on hand to help people quit smoking and/or vaping, such as nicotine vaping products (NVPs) and other nicotine replacement therapy (NRT) options while minimising and/or preventing unnecessary exposure to these products, which Associate Professor George says should be viewed as medications to be used strictly under medical or healthcare professional supervision.
However, when it comes to NVPs specifically, as a harm minimisation strategy, he underscores the importance of ensuring people have exhausted all other evidence-based NRT options first, before being prescribed NVPs to aid smoking cessation efforts.
“The government has made it very clear that if you’re in definite need of these vaping products to help quit smoking after you’ve exhausted all other options in terms of evidence-based treatments and behavioural counselling, then you can go to the GP and get a prescription,” Associate Professor George said.
“Then at least you know you’re getting a regulated product that is dispensed by the pharmacist just like any other medication and that you’re under medical supervision and you’re getting support from other health professionals and pharmacists in terms of your medicine use and follow up, etc.
“So this applies to vaping as a harm minimisation strategy. But the important point here is, people should try other more evidence-based treatments first … under healthcare supervision.”
He continued: “Under the supervision of a GP or pharmacist, we know what they’ve done before – what they’ve tried … and once they’ve exhausted all their other options and the only thing that’s left are NVPs, in that case, under medical supervision, they get a script, they go to the pharmacy and get the particular NVP, and then they use that as a harm minimisation strategy under regular medical supervision.”
The concern with the infiltration of the unregulated vaping industry in the community, he adds, is the rising number of people who vape, especially younger Australians, which is where the latest government reforms have come in.
Health and Aged Care Minister Mark Butler announced in May that following public consultation led by the Therapeutic Goods Administration in December 2022, the government planned stronger regulation and enforcement of all e-cigarettes, including controls on their importation, contents, and packaging.
“The government will work with states and territories to stamp out the growing black market in illegal vaping,” he stated.
This includes measures to:
- Stop the import of non-prescription vapes.
- Increase the minimum quality standards for vapes, including by restricting flavours, colours and other ingredients.
- Require pharmaceutical-like packaging.
- Reduce the allowed nicotine concentrations and volumes.
- Ban all single-use, disposable vapes.
Mr Butler says research has shown that many teenagers take up the vaping habit because of peer pressure or increased availability of these products.
“Or they may be thinking that this is harmless because that’s the way this particular group of products were introduced into the market – as a harm minimisation strategy,” he said.
Associate Professor George added: “When it comes to younger Australians, efforts should be centred around re-education: [understanding that] inhaling anything other than oxygen isn’t good for your lungs.
“Studies have shown there’s a condition called EVALI [e-cigarette and vaping associated lung injury] … It’s been shown people are more prone to infections [through this habit] and also, it will have an impact on their lung capacity, lung function, etc, in the longer term.”
Concerningly, when it comes to the unregulated vaping market and particularly products from overseas, the labelling on many of these unregulated products may say they are nicotine free “but what we know is that many people are addicted”, Associate Professor George says.
“So, they get addicted because there’s something in those products that make them addicted to [them] and I wouldn’t be surprised if that’s nicotine, because studies have shown that many of them contain nicotine, even though the labels claim [they are] nicotine free,” he said.
Given the government plans, Associated Professor George says pharmacists will have an important role to play in support for those addicted to NVPs who suddenly find themselves unable to freely access the products.
“I would manage vaping-related addiction the same way as managing nicotine dependence,” he said, adding that people “should be encouraged to seek support from pharmacies and then, if they need something that requires a prescription, go through the GP – use experts rather than buying things off the shelf in the supermarket.”
Expanding on the pharmacy role, he says this can begin with pharmacists recommending OTC products when supporting customers around smoking cessation and nicotine dependence.
However, he adds, those who are strongly addicted may need higher doses of NRT or a combination product – “a patch, and then as needed, or if there are strong cravings, then you’d use maybe a [nicotine] chewing gum, or a lozenge, or a mouth spray that is shown to be highly effective”.
“If they have any withdrawal symptoms or cravings, then they definitely need support, and that could be exactly as what we currently offer through pharmacies: a combination of pharmacotherapy with behavioural counselling,” Associate Professor George said. “So, Quitline support is important, or a pharmacist can provide smoking cessation counselling on top of the NRT product.
A second-line quitting aid
In line with Associate Professor George’s comments, a 2022 article published in the Australian Journal of General Practice by Colin Paul Mendelsohn and Carolyn Beaumont states that “vaping is a second-line quitting aid for adult smokers who are unable to quit with approved treatments”.
Explaining that vaping “involves heating a liquid nicotine solution into an aerosol, which is inhaled and exhaled as visible mist” and that vaping “delivers nicotine and mimics the hand-to-mouth action of smoking”, it’s “only appropriate for adult smokers who are unable or unwilling to quit smoking tobacco with first-line treatments”.2
“For some smokers, it is a short short-term quitting aid. For others it serves as a longer-term, less harmful substitute for smoking (tobacco harm reduction),” the authors write, adding that the “long-term risk of vaping has not yet been established”.2
In terms of whether vaping is an effective quitting aid and referring to the 2021 meta-analysis of randomised controlled trials (RCTs) by the Cochrane group, the article states that while more studies are needed “there is a growing body of evidence that vaping can help smokers quit”.2
“Meta-analyses of RCTs by the Cochrane group and a review commissioned by the RACGP concluded that vaping nicotine was 53-69 per cent more effective than nicotine replacement therapy. The certainty of the evidence was moderate and low respectively, and more studies are needed to confirm the exact effect size.”2
One of the roles of pharmacists in this smoking cessation space is to provide counselling and advice to customers, including around the appropriate use of NVPs for smoking cessation.
“Patients should be instructed on correct use, side effects, when to quit smoking and vaping, and safety issues,” write Dr Mendelsohn and Dr Beaumont.2 “New users should be offered behavioural support and followed up within the first month to review progress. After quitting smoking, it’s important to advise patients to cease vaping as soon as they feel comfortable that they will not go back to smoking.” 2
Dr Mendelsohn and Dr Beaumont conclude: “Vaping nicotine is another evidence-based quitting method for the GP’s toolbox. It is regarded in Australia as a second-line treatment for adult smokers who are unable or unwilling to quit with conventional treatments.” 2
This is an excerpt of the full feature published in the August issue of Retail Pharmacy magazine. To read the feature in full, visit: retailpharmacymagazine.com.au/magazine/retail-pharmacy-august-2023