In the absence of specific guidance from the Therapeutic Goods Administration (TGA), experts have offered advice to general practitioners (GPs) regarding the prescription of nicotine e-liquids for smokers attempting to quit tobacco cigarettes. This comes after implementing the TGA’s Standard for Nicotine Vaping Products (TGO 110), effective 1 October 2021.
Current Regulatory Framework
Although TGO 110 regulates nicotine-containing liquids (e-liquids), it does not address e-cigarettes themselves, which remain unapproved by the TGA as smoking cessation devices. Under the new regulation, e-cigarette users in Australia can legally access nicotine e-liquids only with a prescription from an authorized prescriber or through a special access scheme facilitated by a registered Australian pharmacist.
The authors—Dr. Miranda Ween, Associate Professor Alexander Larcombe, and Dr. David Chapman—point out that the TGO 110 does not provide specific guidance to GPs on how to manage prescriptions for e-cigarettes. However, the Royal Australian College of General Practitioners (RACGP) guidelines recommend promoting approved nicotine replacement therapies (NRTs) and proven pharmaceutical therapies, alongside behavioral support, before considering e-cigarettes as a treatment option.
Guidance for Prescribing Nicotine E-Liquids
The authors offer several key points for GPs to consider when prescribing nicotine e-liquids:
1. Concentration of Nicotine
There is limited evidence on the ideal nicotine concentration to help smokers transition to complete nicotine abstinence. However, e-liquids with a concentration of 18 mg/mL have been shown to reduce cravings to a similar extent as traditional tobacco cigarettes. These e-liquids have also been found to provide small additional benefits in smoking cessation compared to NRTs. The EU maximum concentration of 20 mg/mL may serve as a reasonable starting point for prescription.
2. Behavioral Support
Nicotine cessation is a complex process that requires ongoing structured behavioral support. GPs should consider prescribing nicotine-containing e-liquids for short periods as part of a comprehensive abstinence plan, with regular monitoring of progress and potential health effects. Long-term use of e-cigarettes may present health risks, so careful management is essential.
3. Flavors
Due to the unknown long-term health effects of e-cigarettes, unflavored e-liquids should be prioritized for prescription. It is important to educate patients that no flavoring chemicals are approved for inhalation, and some have been shown to pose health risks. GPs should emphasize that complete smoking cessation, not long-term e-cigarette use, should be the ultimate goal.
4. Nicotine Absorption
Research indicates that flavored e-liquids can significantly increase plasma nicotine levels, potentially leading to more frequent use of e-cigarettes or the use of higher nicotine concentrations to achieve the desired effects. This increased nicotine absorption raises concerns about prolonged e-cigarette use. GPs should exercise caution when prescribing flavored e-liquids to ensure they do not inadvertently encourage excessive or extended use of e-cigarettes.
Conclusion
While nicotine e-liquids may offer some benefits for smoking cessation, they should be prescribed with caution and only as part of a broader plan that includes behavioral support and monitoring. The risks associated with long-term e-cigarette use must be considered, and GPs are encouraged to prioritize unflavored e-liquids while carefully managing the dosage and duration of nicotine therapy. The primary goal should remain complete nicotine abstinence, not reliance on e-cigarettes.
