The vaping conundrum

Governments do rather like making decisions that may affect us and our patients without asking.
 
If you don’t know already, as of 1 October 2021, people have no longer been able to import liquid nicotine for vaping via e-cigarettes into Australia.
 
Now, to legally obtain liquid nicotine they need a prescription from us, their GP.
 
Of course, there are concerns about vaping. I get it – we don’t know the long-term risks and I’d love all my patients to be nicotine and tobacco free. But jeez, these laws put us as prescribers in a tricky place.
 
As it stands, we’re being asked to prescribe an ‘unapproved’ product, for which ‘safety, efficacy and quality has not been established’.
 
We don’t want people starting e-cigarettes di novo and we don’t want a generation of young people dependent on this product; as health practitioners, we want our patients to stop smoking, as we know the outstanding benefits of this.
 
For what it’s worth, I don’t want to get into an argument about the pros and cons of e-cigarettes.
 
Some of our colleagues are very supportive and others strongly object to the idea that people have access to this substance. I also know that by writing this article I will get hate mail.
 
And I’ve got to say I really dislike the idea of companies profiting from the addictive properties of a substance that keeps people using it. This is not free choice.
 
But it is also true that for some people – highly dependent smokers – e-cigarettes have a harm minimisation role.
 
So, I’ve taken a fatalistic approach to the changes. The Federal Government have put them through, there’s no point whinging.
 
Instead, I still see this as an opportunity to assist a group of people who have so much to gain from stopping smoking, to get the support they need to do this.
 
Which brings me to Sam*, who came to see me for help to get off cannabis, tobacco, and e-cigarettes.
 
Sam’s plan is to stop everything completely, but this is difficult for her. She has severe anxiety and social phobia, and while she knows that stopping everything will help in the long run, it’s hard work for her to change.
 
For Sam, cannabis was the most pressing issue as it made her feel paranoid and a-motivated.
 
We worked on that first and she is now three months post last cannabis use. This is a brilliant achievement for Sam. Problem is, stopping the cannabis led to increase in tobacco use. To decrease this, Sam increased e-cigarette use.
 
At this point Sam was smoking 3–4 cigarettes a day and inhaling this small number of cigarettes deeply, which suggests she was getting maximum nicotine out of the few cigarettes she smoked.
 
Sam was also concerned about the high level of e-cigarette nicotine use, particularly as she feels it interfered with her sleep, which is not great at the best of times.
 
We talked about pharmacological options. A BMJ paper in 2019 suggested that varenicline might have a role for helping people to stop dual use of tobacco and e-cigarettes, while another found that nicotine replacement therapy (NRT) and vaping can assist smoking cessation.
 
Sam decided to try a 25 mg/16-hour NRT patch to see if this could change the level of tobacco and e-cigarette use and hopefully not affect her sleep.
 
I also suggested counselling to help address her anxiety and social phobias. She was reluctant to undertake this, saying ‘I’ve tried that before and it didn’t help’ but with some encouragement on my part decided to give it another go.
 
This time around she said the counselling helped, saying ‘the counsellor explained a lot and has helped me learn skills to manage my anxiety’ and she was able to stop all tobacco and drop the liquid nicotine use by two-thirds.
 
Her next step is to stop e-cigarettes completely. Sam has been obtaining nicotine liquid ‘under the counter’ since the changes to the law.
 
To my mind, an e-cigarette prescription is short-term on the road to Sam ceasing all nicotine containing products and I wonder what other medications we might use to help her to do this. If we use NRT or varenicline to help her stop e-cigarette use, this will be off-label prescribing and therefore not available on PBS. So, there are lots of unknowns and considerations for her and I to discuss.
 
I also don’t know if NRT and/or varenicline could help her cease e-cigarettes. Likewise, I don’t know if Sam will stop e-cigarettes completely.
 
What I do know is that I’m committed to assisting Sam to have the best outcome possible and we’ll work on this together in coming months.
 
That may include prescribing liquid nicotine for her e-cigarettes as part of a comprehensive assessment and plan that takes into account the unique situation and risk profile for Sam.
 
She deserves that degree of support and treatment.
 
More information is available via the TGA and RACGP clinical guidelines.
 
*Sam’s name has been changed to protect her privacy.
 
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