P1.2.5 Electronic cigarettes (e-cigarettes)

E-cigarettes are battery-powered devices that may deliver nicotine in a vapour without tobacco or smoke. Before these products can be recommended for consumers, further research must be conducted on their safety and efficacy for smoking cessation. E-cigarettes can relieve cravings and symptoms of nicotine withdrawal as well as simulating the behavioural and sensory aspects of smoking. A small number of randomised controlled trials have suggested that e-cigarettes could have a role in cessation and harm reduction. A study in New Zealand found they had similar effects on six-month cessation rates to nicotine patch among smokers wanting to quit (7.3% for e-cigarettes compared to 5.8% for patch) and rates were higher than for the participants randomised to non-nicotine containing e-cigarettes (3.6%). With such a large variety of e-cigarette products on the market and little data on their nicotine delivery, it is not known if their results can be generalised and further research is needed before recommendations for their use can be confidently made (Bullen 2013, Caponnetto 2013). Concerns about e-cigarettes include a lack of 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 third of the participants allocated to e-cigarettes in a clinical trial reported continued product use at 6 months, suggesting that they might have become long-term e-cigarette users (Bullen 2013). There are also concerns that e-cigarettes may potentially act as a gateway to smoking (Pepper 2014).

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. There is currently a lack of evidence of effectiveness and safety of nicotine e-cigarettes. 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 further 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 to import nicotine e-cigarettes and liquids containing nicotine. 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.

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: