P1.2.5 Electronic cigarettes (e-cigarettes)
E-cigarettes are battery-powered devices that may deliver nicotine in a vapour without tobacco or smoke. Nicotine e-cigarettes can relieve cravings and symptoms of nicotine withdrawal as well as simulating the behavioural and sensory aspects of smoking.
Concerns about e-cigarettes include limited evidence for short-term efficacy and short-and long-term safety, particularly in patients with current chronic disease. Rather than cessation, concurrent use with smoking may continue. A 2022 NHMRC CEO Statement on electronic cigarettes was informed by a systematic review of global evidence by Banks et al (Banks 2022) [evidence level I]. The statement was based on evidence reviews commissioned by the NHMRC on the topics of e-cigarette use and smoking behaviour (uptake and cessation), the effects of e-cigarette advertising, promotion and sponsorship, and e-cigarette use and health outcomes. Relevant evidence statements from the publication are:
- E-cigarettes can be harmful. All e-cigarette users are exposed to chemicals and toxins that have the potential to cause adverse health effects.
- E-cigarette-related poisonings have substantially increased over the past 5 years. E-cigarette related calls to Australian Poisons Information Centres have more than doubled between 2020 and 2021.
- There are no health benefits of using e-cigarettes if you do not currently smoke tobacco cigarettes.
- Short-term e-cigarette use may benefit smokers if they are able to quit smoking and have been previously unsuccessful with other smoking cessation aids.
- There are other proven safe and effective options available to help smokers quit.
In November 2022 the Cochrane Library published an update of its review on electronic cigarettes for smoking cessation (Hartmann-Boyce 2022). The review included 78 studies of which 17 were new to the update. The comparison of nicotine e-cigarettes versus NRT was of studies comparing smoking cessation at six months or more and measures of harm at one week or longer of e-cigarette use. There were six studies in the analysis including one study in a pregnant population. The total number of participants was 2378. The risk ratio was 1.63 (95% CI: 1.30 to 2.04) favouring nicotine e-cigarettes over NRT. Using the Grade criteria, the authors rated the certainty of evidence as high meaning that further studies would be unlikely to change the effect estimate in a way that would alter its clinical interpretation. A key factor in the rating of the evidence was the rating of risk of bias in the included studies. The review authors rated the risk of bias as low in five of the six studies, including the largest study (Hayek et al 2019) which exerted the greatest influence on the risk estimate.
There are limited studies of nicotine e-cigarettes in populations of people with COPD. An observational study of more than 4,500 current or former smokers aged 45 to 80 years (at least 10 pack years) has found that starting around 2010, there has been a rapid rise in the prevalence of e-cigarette use among older adults with or at risk for COPD (Bowler 2017). Patients with mild, moderate, and severe COPD were just as likely to try and continue to use e-cigarettes as those without COPD. E-cigarette users had a heavier conventional cigarette smoking history and worse respiratory health, were less likely to reduce or quit conventional cigarette smoking, had higher nicotine dependence, and were more likely to report chronic bronchitis and exacerbations. As stated in the e cigarettes position paper from the Forum of Respiratory Societies, since electronic cigarettes generate less tar and carcinogens than combustible cigarettes, use of electronic cigarettes may cause less disease related to these components. However, the health risks of electronic cigarettes have not been adequately studied and evidence on the safety and efficacy of e-cigarettes is still emerging (Hartmann-Boyce 2016). Until long-term safety and efficacy is established, e-cigarettes cannot be recommended as a harm minimisation strategy among smokers with, or at risk of COPD.
In some cases, doctors may choose to prescribe nicotine e-cigarettes as a means of supporting smoking cessation. TGA approved pharmacotherapy combined with behavioural support should be offered as first line therapy. Nicotine e-cigarettes are an unapproved product, meaning that unlike other forms of nicotine replacement therapy, they have not been assessed by the TGA for safety, quality and efficacy. From 1 October 2021, the Australian government introduced restrictions aimed at reducing access to the use of nicotine e-cigarettes among adolescents and young adults while making them available for supporting smoking cessation. The arrangements include requiring a valid prescription in order to get access to nicotine vaping products whether dispensed in Australia or imported from overseas. A focussed update of the RACGP Smoking Cessation guidelines was undertaken to provide guidance about the rescheduling of nicotine e-liquids. Therapeutic Goods (Standard for Nicotine Vaping Products) (TGO 110) Order 2021 (TGO 110) came into effect on 1 October 2021. TGO110 sets minimum standards for nicotine vaping products supplied in Australia.
Refer to the following to access these guidelines: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation/pharmacotherapy-for-smoking-cessation
Therapeutic Goods Administration provides information: https://www.tga.gov.au/resource/nicotine-vaping-products-and-vaping-devices
Lung Foundation Australia has a position statement about electronic cigarettes:
https://lungfoundation.com.au/health-professionals/clinical-information/smoking-cessation/
The rapid uptake of nicotine vaping in young people, including people who have never smoked, has prompted the federal health minister to propose further restrictions on access to nicotine vaping products. If passed, the legislation will:
- ban the importation of vaping products (including devices, e-liquids and pods, whether they contain nicotine or not), except by pharmacies who will be permitted to dispense them under a prescription
- introduce minimum quality standards for vaping products, including restricting flavours, colours and other ingredients
- require all vaping products to have pharmaceutical-like packaging
- reduce permissible nicotine concentrations and volumes
- ban all single-use disposable vaping devices
- allow all GPs to write prescriptions for vaping products without applying to become an “authorised prescriber” of NVPs.