Guidance for the use of nicotine vaping products for smoking cessation

This page contains practical guidance to assist prescribers with the prescribing of nicotine vaping products. This guidance can be used regardless of whether the prescription is to be dispensed by an Australian pharmacy or from an overseas retailer through the Personal Importation Scheme.

Clinical guidelines for prescribers

Prescribers should be familiar with the clinical advice provided in the Royal Australian College of General Practitioners (RACGP) Supporting smoking cessation: A guide for health professionals (RACGP Guidelines). The RACGP Guidelines stipulate that nicotine vaping products are not a first-line treatment for smoking cessation. The strongest evidence base for efficacy and safety is for currently approved pharmacological therapies combined with behavioural support. They also state that there is a lack of well conducted randomised controlled trials comparing nicotine vaping products with approved pharmacoptherapies, such as bupropion and varenicline.

For people who have unsuccessfully tried to stop smoking with approved pharmacotherapies, but are still motivated to stop smoking, nicotine vaping products may be a reasonable intervention. However, this needs to be preceded by an evidence-based, informed shared decision-making process.

Clinical efficacy evidence

Evidence of the potential efficacy of nicotine vaping products for smoking cessation is currently mixed, with more reliable, large-scale studies required (references are provided in our Guidance for Therapeutic Goods (Standard for Nicotine Vaping Products) (TGO 110) Order 2021 and related matters).

A very recently-updated Cochrane review (November 2022) compared the effects of nicotine vaping products with other ways of delivering nicotine, such as nicotine replacement therapies (NRTs) like patches and chewing gum, e-cigarettes without nicotine, and behavioural support only/no support. The review included 78 studies (22,052 participants), including 40 randomised controlled trials, and studies had to report abstinence from smoking cigarettes at six months. Of the included studies, ten (all but one contributing to the authors’ main comparisons) were rated at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk.

In relation to the quit rates:

• There was high certainty that quit rates were higher in people randomized to NVP than in those randomized to nicotine replacement therapy (NRT) (risk ratio RR 1.63, 95% CI 1.30 to 2.04; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 using NVP.
• There was moderate-certainty evidence that quit rates were higher in people randomized to nicotine vaping products than to non-nicotine vaping products (RR 1.94, 95% CI 1.21 to 3.13; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 using NVP.
• Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; 7 studies, 3126 participants). In absolute terms, this represents an additional two quitters per 100. However, this finding was of very low certainty, due to issues with imprecision and risk of bias.

The Cochrane Collaboration is an international non-profit organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions. A Cochrane Review is a systematic review of research in health care and health policy.

A recent (August 2021) meta-analysis from the University of Queensland^[1] provided similar results. The study found that participants randomised to receive nicotine vaping products were 49% more likely to remain abstinent from smoking than those who received other NRTs (risk ratio RR = 1.49, 9 trials with 6080 participants). Those randomised to receive nicotine vaping products were 109% more likely to remain abstinent from smoking than those in control conditions where no nicotine was supplied (risk ratio RR = 2.08, 7 trials with 5674 participants). However, it concluded that more high quality studies are required to ascertain the effect of nicotine vaping products on smoking cessation due to risk of bias in the included studies.

Another recent (September 2021) meta-analysis from the Australian National University^[2] also demonstrated a small benefit in smoking cessation for freebase nicotine vaping products compared to approved NRT, in the clinical context and based on low certainty evidence. Significantly greater quit rates for participants randomised to freebase nicotine vaping product were found compared to no intervention or usual care; evidence was also of low certainty.

Practical information on nicotine vaping products

The following practical information and resources about nicotine vaping products are provided for prescribers and consumers in light of the mixed efficacy evidence.

• Nicotine Vaping Product Analysis: Evidence from the University of Wollongong
• Nicotine vaping products: University of Wollongong flowchart

Health practitioner resources from the United Kingdom and New Zealand

The following links are to resources for health practitioners from the United Kingdom (UK) and New Zealand (NZ).

It is important when reading these materials to be aware that, unlike in Australia, nicotine vaping products are available in the UK and NZ as consumer products (not medicines) without a prescription. The focus in those jurisdictions is on harm reduction. Nevertheless, nicotine vaping products are regularly used by health practitioners in the UK and NZ for smoking cessation programs.

United Kingdom resources

• E-cigarettes: a guide for healthcare professionals is a course developed by the National Centre for Smoking Cessation and Training (UK) to assist health and social care practitioners to support people wanting to use nicotine vaping products to stop smoking.
• Electronic cigarettes: A briefing for stop smoking services is a National Centre for Smoking Cessation and Training (UK) briefing to assist smokers wanting to use electronic cigarettes to help them stop smoking. Released in 2016, it provides evidence as well as practical information on the use of nicotine e-cigarettes for smoking cessation.
• Information for specialist stop-smoking services that are considering providing e-cigarette starter packs: recommendations from the Trial of Ecigarettes (sic) (TEC) is a National Centre for Smoking Cessation and Training (UK) briefing summarising the findings from the Trial of E-Cigarettes (TES) research that was carried out in stop smoking services in London, Leicester and East Sussex. It includes recommendations for stop smoking services on providing starter packs.
• Using e-cigarettes to stop smoking is a National Health Service (UK) briefing on the use of e-cigarettes to stop smoking.
• Combination nicotine replacement therapy (NRT) is a National Centre for Smoking Cessation and Training (UK) briefing on the efficacy of a combination NRT (e.g. patch plus a faster acting form such as gum, inhalator etc.) relative to a single NRT product.

New Zealand

• Vaping Facts includes several resources for new users (smokers).
• Vaping to Quit Smoking includes information for patients on other means to support their quest to stop smoking, whether vaping is an appropriate treatment and, if so, what product might be appropriate.
• Vaping vs other ways of quitting advises smokers on the different supports to stop smoking, including behavioural support and pharmacological therapies.
• Nicotine management and What vape liquid should I get? are two articles on nicotine management that include advice on nicotine free base versus nicotine salt products, including relative concentrations, and how to be ‘vape-free’.

Frequently Asked Questions

See the 'Prescribing nicotine vaping products' section of the Nicotine vaping products: Frequently Asked Questions for further information.