Guidance on the use of vapes for smoking cessation or the management of nicotine dependence

Clinical guidelines for prescribers

Prescribers should be familiar with the clinical advice provided in the Royal Australian College of General Practitioners (RACGP). This clinical advice is currently being updated to include new guidance on prescribing vapes (including for persons under 18) and supporting vaping cessation. 

The current RACGP Guidelines can be accessed here:  Supporting smoking cessation: A guide for health professionals.

The RACGP Guidelines stipulate that vapes (referred to as nicotine vaping products in the document) are not a first-line treatment for smoking cessation. The strongest evidence base for efficacy and safety relates to existing registered pharmacological therapies combined with behavioural support. The Guidelines also state that there is a lack of well conducted randomised controlled trials comparing vapes with approved pharmacotherapies, such as bupropion and varenicline.

The TGA has registered many other products such as patches, gum, lozenges, mouth spray and inhalators as quitting aids that are safe to use and are demonstrated to increase likelihood of quitting smoking.

For persons who have unsuccessfully tried to stop smoking with approved pharmacotherapies, but continue to be motivated to stop smoking, therapeutic vapes may be a reasonable intervention. However, this needs to be preceded by an evidence-based, informed shared decision-making process.

Clinical efficacy evidence

Evidence of the potential efficacy of vapes for smoking cessation is currently mixed, with more reliable, large-scale studies required. References are provided in the current version of our Guidance for Therapeutic Goods (Standard for Nicotine Vaping Products) (TGO 110) Order 2021 and related matters), which is currently being updated.

A recently updated Cochrane review (November 2022) compared the effects of vapes containing nicotine with other ways of delivering nicotine, such as nicotine replacement therapies (NRTs) like patches and chewing gum, e-cigarettes without nicotine, and behavioural support only/no support. The review included 78 studies (22,052 participants), including 40 randomised controlled trials, and studies were designed to report abstinence from smoking cigarettes at six months. Of the included studies, ten (all but one contributing to the authors’ main comparisons) were rated at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk.

In relation to the quit rates:

• there was high certainty that quit rates were higher in people randomized to nicotine vaping product (NVP) than in those randomized to nicotine replacement therapy (NRT) (risk ratio RR 1.63, 95% CI 1.30 to 2.04; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 using NVP.
• there was moderate-certainty evidence that quit rates were higher in people randomized to vapes containing nicotine compared to vapes not containing nicotine (RR 1.94, 95% CI 1.21 to 3.13; 5 studies, 1447 participants). In absolute terms, this would represent an additional seven quitters per 100 using vapes containing nicotine.
• compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; 7 studies, 3126 participants). In absolute terms, this would represent an additional two quitters per 100. However, this finding was of very low certainty, due to issues with imprecision and risk of bias.

The Cochrane Collaboration is an international non-profit organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions. A Cochrane Review is a systematic review of research in health care and health policy.

A  meta-analysis from the Australian National University^[1] (September 2021), also demonstrated a small benefit in smoking cessation for freebase vapes containing nicotine compared to registered NRT, in the clinical context and based on low certainty evidence. Significantly greater quit rates for participants randomised to freebase vapes containing nicotine were found compared to no intervention or usual care; evidence was also of low certainty.

Practical information on vapes for smoking cessation or the management of nicotine dependence

The following practical information and resources about vapes are provided for prescribers and consumers in light of the mixed efficacy evidence.

Health practitioner resources in Australia

The following links are to resources for health practitioners in Australia.

New South Wales

• Information for health professionals - Tobacco and smoking (nsw.gov.au) - is a site developed for health professionals on the hidden impact of vapes. 

Queensland

• Clinical information | Quit HQ (initiatives.qld.gov.au) - contains clinical information for health professionals to assist with helping patients quit smoking and vaping.

Healthdirect (Australian Government)

• E-cigarettes (vaping) | healthdirect – information about vaping as well as links for medical professionals to trusted information partners.

Health practitioner resources from the United Kingdom and New Zealand

The following links are to resources for health practitioners from the United Kingdom (UK) and New Zealand (NZ).

It is important when reading these materials to be aware that, unlike in Australia, vapes containing nicotine are available in the UK and NZ as consumer products (not medicines) without a prescription. Nevertheless, vapes containing nicotine are regularly used by health practitioners in the UK and NZ for smoking cessation programs.

United Kingdom resources

• E-cigarettes: a guide for healthcare professionals is a course developed by the National Centre for Smoking Cessation and Training (UK) to assist health and social care practitioners to support people wanting to use vapes containing nicotine to stop smoking.
• Information for specialist stop-smoking services that are considering providing e-cigarette starter packs: recommendations from the Trial of e-cigarettes (sic) (TEC) is a National Centre for Smoking Cessation and Training (UK) briefing summarising the findings from the Trial of E-Cigarettes (TES) research that was carried out in stop smoking services in London, Leicester and East Sussex. It includes recommendations for stop smoking services on providing starter packs.
• Using e-cigarettes to stop smoking is a National Health Service (UK) briefing on the use of e-cigarettes (vapes) to stop smoking.
• Combination nicotine replacement therapy (NRT) is a National Centre for Smoking Cessation and Training (UK) briefing on the efficacy of a combination NRT (e.g. patch plus a faster acting form such as gum, inhalator etc.) relative to a single NRT product.

New Zealand

• Vaping Facts includes several resources for new users (smokers).
• Vaping to Quit Smoking includes information for patients on other means to support their quest to stop smoking, whether vaping is an appropriate treatment and, if so, what product might be appropriate.
• Quitstrong advises smokers on the different supports to stop smoking, including behavioural support and pharmacological therapies.
• Nicotine management includes advice on how to quit smoking and be ‘vape-free’.

Further information

For further information about prescribing vapes, see vapes: information for prescribers.