GPs willing to prescribe e-cigarettes to aid the quitting process

Professor Nick Zwar told the Select Committee on Tobacco Harm Reduction that GPs will upskill to prescribe nicotine-containing e-cigarettes to help patients who smoke as another form of replacement therapy.
 
‘Because they want to help their patients. There are patients that GPs see who have struggled for many years with trying to quit smoking and not being able to,’ he said.
 
‘[A]n opportunity to assist them is something that doctors would like.’
 
At present, only a handful of GPs are able to prescribe nicotine-containing e-cigarettes, but that number is expected to soar if the Government shifts to a proposed prescription-only model.
 
Speaking at the 19 November hearing, Professor Zwar – who chaired the RACGP Smoking cessation guidelines advisory group – said prescribing nicotine vaping ‘shouldn’t be open-ended’ and should occur through discussions on aiming to taper and withdraw from nicotine use.
 
‘We don’t know about long-term harms, and even the short-term harms are not that well described, because there haven’t been a huge number of studies,’ he said. ‘Some of these harms, of course, may take quite a time.
 
‘The time between initiating tobacco use and developing lung cancer might be 25 or 30 years, developing COPD is often 20-plus years.
 
‘We won’t know for some time about the extent of the risk, hence a precautionary approach makes a lot of sense.’
 
The inquiry is examining how nicotine-containing vaping products should be regulated, as well as the international evidence base for their use.
 
Professor Zwar said education support for GPs and other prescribers would be necessary to be able to outline risks and benefits.
 
‘[M]edico-legal risk is always present in medical encounters. This is somewhat different,’ he said.
 
‘We do not know as much about what we’ll actually be prescribing, because … it hasn’t been through a full assessment as a medicine. It’s notable that none of the vaping manufacturers around the world, as far as I’m aware, have put forward their products to be tested as medicines.
 
‘[I]it would be better if a nicotine-containing e-cigarette had been assessed as a medicine and had a full assessment for its efficacy and safety and what it actually delivered in terms of not only nicotine, but what other molecules are delivered into the lung of the user’s body by the device.
 
‘[I]t would be another form of nicotine replacement therapy [NRT].’
 
While nicotine vaping has become a consumer product in countries like the US and New Zealand, Australia – which has run a decades-long public health push against traditional cigarettes – has to date maintained more scepticism.
 
Professor Zwar drew an analogy with opioids.
 
‘[Opioid-substitution] therapy has been available for many years but we don’t have methadone available as a consumer product,’ he said.
 
‘No-one would countenance that, I think, and yet we’re talking about an addictive chemical here, in nicotine, and thinking about making it more available to consumers in a way that is quite difficult to regulate.’

Vaping is in the spotlight as Australia grapples with how to regulate the products.
 
Professor John Wilson, President of the Royal Australasian College of Physicians, told the inquiry he has ‘great pessimism’ that vaping is the answer to tobacco use.
 
‘e-Cigarettes do need to be controlled, regulated and appropriately prescribed,’ he said.
 
‘If the contention is that this is a treatment for addiction, in that case put it in that basket and say, “Okay, it’s a treatment for addiction. Let’s register it that way and treat it that way”,’ he said.
 
The committee also heard from a number of public health and smoking cessation experts, who warned against opening the door to vaping as a consumer product.
 
Emeritus Professor Mike Daube, a leading figure in tobacco control research, told the committee he would be ‘more than happy to see far more people going to their GPs’ specifically for advice on smoking cessation.
 
‘We know that brief advice – and we’ve known this for donkey’s years – from a GP about quitting smoking is a really important factor, so if the [Therapeutic Goods Administration] process encourages vapers or anybody else to go to their GP for advice on smoking cessation, then that’s going to be immensely beneficial,’ he said.
 
Senator Matt Canavan, who has opposed the Government’s regulatory push on vaping, asked the experts what would happen to the hundreds of thousands of people who currently use vaping products if Australia shifted to a prescription model. 
 
‘It seems that they’ll probably go back to smoking [regular cigarettes], won’t they?’ he said.
 
In response, another leading expert, Professor Simon Chapman, said many would quit, and some would go back to smoking.
 
‘[M]any of them are going back to smoking all the time now, and that’s with personal import schemes still in place,’ he said. ‘The idea that you can import it and therefore you’re off smoking for keeps, I’m afraid, is a huge myth.
 
‘Many people who vape aren’t even trying to quit; they just want to vape and smoke.’
 
Senator Canavan then put it to Professor Chapman that moving to the prescription model would ‘cause more harm to health’ if vaping is less harmful than cigarettes. 
 
Professor Chapman disagreed.
 
‘Your assumption is that by continuing with the present model or expanding access a lot of people will quit. The evidence for that is far from clear,’ he said.
 
Later, Professor Chapman said existing NRT is not very effective.
 
‘It may surprise you to hear me say that, but for many years I’ve been sceptical about NRT being an effective drug as well,’ he said. ‘The point is that going to see a doctor to quit smoking will often be an occasion of the doctor engaging in conversation with and being supportive of the person trying to quit.
 
‘A lot of the effort in quitting smoking is not the magic bullet you’re taking but the belief that you’re going through a process that’s going to lead to something at the end.
 
‘Two-thirds to three-quarters of people who quit smoking do so without any therapeutic agent whatsoever.’
 
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