GP prescriber-route rarely used for nicotine vapes

Jolyon Attwooll

28/03/2023 4:57:35 PM

The impact of e-cigarettes is already being felt in general practice, but reforms may see more patients presenting for help with accessing – and quitting – the addictive products.

Young person vaping.
New research suggests while nearly half of all Australians aged 15–30 have tried vaping, very few have accessed the products through authorised prescribers.

When the law changed in October 2021 to make nicotine vaping products (NVPs) prescription-only, Dr Hester Wilson expected an impact in the consulting room.
Having become an authorised prescriber Dr Wilson, who is the Chair of RACGP Specific Interests Addiction Medicine, waited for requests from patients to arrive.
She is still waiting.
‘When the last TGA [Therapeutic Goods Administration] move came, I thought “well, we’re going to be seeing people, this is going to be something that we need to be aware of”, and I became an authorised prescriber because I thought it was something that I would need,’ Dr Wilson told newsGP.
‘I’m not seeing anybody. Literally no one.
‘You’re supposed to get it as a smoking cessation tool through a prescriber, through a GP, but the fact is that isn’t happening, because people are just getting their vapes illegally.’
It is a story that plays out in publicly available figures too. By January 2023, more than 15 months into the shift in approach, the TGA had approved just 1635 Authorised Prescriber applications for unapproved nicotine vaping products nationwide.
Meanwhile the surge in the number of people vaping – particularly among younger generations – features almost daily in the media. This week, the Australian and New Zealand Journal of Public Health published research which suggests that almost half young people aged from 15–30 have tried vaping, with 14% of the 1006 people surveyed categorising themselves as ‘current users’.
Of those, only a ‘very small’ number of respondents (7%) obtained their e-cigarettes via prescription, with most relying on vape and tobacco shops, online suppliers, or friends.
Last week, the TGA published the results of almost 4000 public submissions on potential changes to border controls, minimum standards, and clarifying the status of vapes as therapeutic goods.
It flagged ‘a large number … from the general public appeared to be campaign responses that advocated changing the current regulatory framework in which NVPs are regulated as prescription medicines’, which it said is outside of the scope of the consultation.
It also noted health professional bodies and public health associations ‘overwhelmingly supported tightening border controls’, and acknowledged strong support for imposing warning statements on vaping products.
At the same time, Federal Health and Aged Care Minister Mark Butler has also signalled the Government’s intention to clamp down on the illegal importation of products and address widespread concerns about marketing aimed at younger people, including children.
Dr Wilson agrees the status quo cannot be allowed to continue.
‘The situation that we’re currently in at the moment is an absolute failure in terms of protecting our young people,’ she said.
‘Philosophically, I hate the idea that we have a generation of young people who are being sold this product that has no value, and are losing control, because they’re becoming dependent on it.
‘One of the things that’s clear is that it is very rapidly dependence forming.
‘And people who vape tend to vape more than they would smoke, so they’re getting big doses of nicotine, and we don’t know what the long-term risks of vaping are.’
While her role as an authorised prescriber for non-approved vaping products has not been used, Dr Wilson reports a rising number of consultations for patients seeking to address nicotine addiction through vaping.
‘I do think it is an issue that we are going to increasingly see in the general practice setting,’ she said.
‘At the moment, what I’m seeing is adults who want to stop vaping.
‘I’m also seeing parents who are really concerned about their kids, their middle teen and older adolescents still living at home, and the fact that they’re vaping.
‘They vape and they are getting up during the night to vape. It’s highly, highly dependence forming.
‘I’m seeing a few young people who are going “I’ve got to stop this. How do I stop this?”
‘The evidence is emerging around what’s the best way to assist people to change that.’
Professor Nick Zwar, Chair of the RACGP’s smoking cessation guidelines’ Expert Advisory Group, says that while such presentations remain limited at the moment, they are likely to rise given the rapid increase in vaping uptake in Australia.
While most of the changes advocated by the college have been captured in the TGA proposals, the push for a TGA-approved product for smoking cessation purposes is not among the suggested reforms – and that is an omission noted by Professor Zwar.
‘An authorised, properly approved product would help greatly, because practitioners have much more confidence in what they’re prescribing, that it meets the quality and safety standards,’ he said.
However, he believes the prescriber model still has the potential to work and allow GPs to be at the centre of prescribing products that meet the Therapeutic Goods Order (TGO) 110 standard, and help with smoking cessation.
Dr Colin Mendelsohn, who in the past has also helped compile the RACGP’s smoking cessations guidelines, has long advocated for the potential of nicotine vaping to help long-term smokers.
He said that prohibition will not reduce the black market.
‘Instead, the TGA’s proposed reforms will be a disaster for public health as more adult smokers and ex-smokers are forced onto the dangerous black market, feeding its power and putting young people at risk,’ he said.
However, Professor Zwar believes the likely course has now been clearly signalled by Minister Butler – and believes that if the proposals have an impact, then GPs are likely to find their authorised prescriber status much more in demand.
‘There will be a lot of people who, you would think, would then be considering the prescription route as an alternative, and that might greatly increase the number being coming in to see GPs,’ he said.
‘I don’t know that we’re very prepared for that if that was to happen.
‘If the prescription model is going to work, it does need practitioners to be willing to look into it, to try to understand and make an informed choice about whether they want to be involved.
‘Then it’s about actually understanding how to use the products, and that’s where the guidelines can help.’
A guide for health professionals on supporting smoking cessation is available on the RACGP website.
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Dr Robert William Micallef   29/03/2023 6:41:40 AM

The solution is banning vapes altogether nicotine containing or not. Why would any GP want to get involved with prescribing these harmful products? Putting them on prescription merely legitimises them.

Dr Bethany Reynolds   29/03/2023 10:32:23 AM

Many start before 18, so if they’re getting them before, why would they change to go see a GP / pharmacy? Many are also not interested in quitting, so don’t want to get a lecture.
I know risk reduction is important, but why should cigarettes or vapes be legal in the first place..?

Getafix   29/03/2023 1:11:04 PM

The question should be - are they less harmful than smoked tobacco. Head in sand does not make health problems go away.

Dr David Andrew Helliwell   29/03/2023 2:37:52 PM

Interestingly young people's access to vapes is a problem both in the UK and Australia. In the UK they are 'under regulated' and can be bought over the counter at outlets that sell tobacco. In Australia officially they require an authorised doctor's prescription making them 'over regulated' and difficult for nicotine dependant folk to jump through the hoops to switch from tobacco. The resultant black market is, of course, subject to 'no regulation' and allows access to anyone. A sensible solution might be to make vapes and vape liquid Schedule 3 (pharmacy only) medication for 18+ years. This will allow regulation, access and point of sale counselling about both their use and provide health advice on quitting completely.