Vaping (E-cigarettes)

Key Messages

• Increasing prevalence in Australia, especially young adults
• Rapidly evolving market:
  • Shift to disposable devices
  • Higher nicotine concentrations (nicotine salts)
• Legislation evolving across states and Commonwealth
• Lack of evidence ≠ safety
  • Insufficient long-term safety data
• Very limited evidence for:
  • Preventing uptake
  • Supporting cessation

Definition / Background

• E-cigarettes = devices that:
  • Heat liquid → aerosol → inhaled (“vaping”)
• Also called:
  • ENDS / ENNDS / vape pens
• Not included:
  • Heat-not-burn tobacco (rare + effectively illegal in Australia)

Epidemiology (Australia)

• Daily use (≥14 yrs): ~1.1% (2019)
• “Ever use”: ~11.3% (less clinically useful)
• Increasing daily use:
  • 0.9% → 2.4% (2018–2022)
• Higher use in:
  • Young adults (18–24 yrs)
  • Smokers/ex-smokers
• Common behaviours:
  • Sharing devices (esp. young people)
  • Use without prescription (despite legal requirement)

Composition & Exposure Risks

• E-liquids:
  • Contain multiple chemicals
  • Constantly changing composition
• NHMRC review:
  • ~69% chemicals → known harmful effects
  • ~89% → unknown inhalation toxicity
• May contain nicotine even if labelled “nicotine-free”
• Indoor vaping → ↑ airborne particulate matter

Health Effects

A. Acute Effects

• Throat irritation
• Cough
• Dizziness
• Headache
• Nausea

B. Serious Acute Risks

• Nicotine poisoning
• Seizures
• EVALI (rare but severe lung injury)

C. Long-term

• Uncertain (limited evidence)
• Not proven safe

Nicotine & Dependence

• Can cause nicotine addiction
• Dependence:
  • Less than cigarettes
  • More than NRT
• Adolescents:
  • Risk to developing brain

Association with Smoking

• Increased likelihood of smoking uptake:
  • OR ~3.19 (observational data)
• Possible explanations:
  • Causal vs shared risk behaviours (e.g. impulsivity)
• Concern for:
  • Gateway effect

Reasons for Use

• Curiosity (most common)
• Perceived lower harm
• Smoking reduction / cessation
• Social media influence & marketing
• Flavours targeting youth

Behavioural Advice

Children (11–17 yrs)

• Advise:
  • Do not start vaping

Adults – vape only

• Advise:
  • Quit vaping

Adults – vape + smoke

• Prioritise:
  1. Quit smoking
  2. Then cease vaping

Vaping cessation

Behavioural interventions

• Brief GP advice
• Quitline / digital programs (text-based strongest evidence)
• Trigger management + relapse prevention
• Motivational interviewing

Pharmacotherapy

• No pharmacotherapy is formally recommended as first-line for vaping cessation in current Australian guidance (RACGP/NHMRC-informed).
• Behavioural support remains first-line.
• However, emerging RCT evidence supports selective use, particularly:
  • Varenicline – RCTs (including youth & adults): ~2× higher abstinence vs placebo
  • Cytisine / cytisinicline – RCT: ~32% vs 15% abstinence – Promising but early

Role in Smoking Cessation

• Not a first-line treatment.
• Evidence for efficacy is limited and inconsistent.
• Safer, evidence-based alternatives exist (e.g. NRT, varenicline).
• Must be used under medical advice, especially in minors.

Setting a Quit Plan (Smoking → Vaping → Nicotine-Free)

• Set clear quit date
• Stop smoking completely (no dual use)
• Use vaping only as a temporary bridge if needed
• Taper and stop vaping within 3–6 months
• Ensure structured follow-up and relapse prevention

Step	Component	What to Do	Key Details / Clinical Notes
1	Assess readiness	Assess motivation & dependence	– Use readiness scale (0–10) – Identify triggers (stress, alcohol, routines) – Review prior quit attempts
2	Set Quit Smoking Date (QSD)	Choose a firm quit date	– Within 1–2 weeks – Avoid high-stress periods – Make it specific (exact date)
3	Pre-QSD preparation	Prepare environment & supports	– Remove cigarettes, lighters – Plan coping strategies (gum, water, distraction) – Identify high-risk situations
4	Start pharmacotherapy	Initiate evidence-based meds	– Varenicline → start 1 week before QSD – Nicotine Replacement Therapy → start on QSD
5	Quit smoking (QSD)	Stop cigarettes completely	– No dual use – Reinforce total switch
6	Introduce vaping (if used)	Use as harm-reduction tool	– Only if needed after failed first-line – Use regulated product (pharmacy/TGA compliant) – Frame as temporary
7	Stabilisation phase	Maintain abstinence from cigarettes	– Weeks 0–4 – Focus on avoiding relapse – Monitor nicotine intake
8	Plan to stop vaping	Set expectation early	– “Short-term bridge only” – Agree on taper plan
9	Taper vaping	Gradual reduction	– Weeks 4–12 – Reduce nicotine strength (e.g. 20 → 10 → 5 mg/mL) – Reduce frequency (sessions/day)
10	Cease vaping	Stop completely	– Target 3–6 months – Consider NRT for withdrawal support
11	Follow-up	Structured review	– 1 week: withdrawal – 2–4 weeks: reinforce – 8–12 weeks: taper – 3–6 months: cessation
12	Relapse prevention	Manage slips & triggers	– Normalise lapses – Identify triggers – Encourage rapid return to plan

Legal Reforms (Effective 1 July 2024)

https://www.health.gov.au/sites/default/files/2024-09/vaping-fact-sheet-for-prescribers.pdf

• All vapes (nicotine or non-nicotine) can only be sold in pharmacies.
• Purpose: quitting smoking or managing nicotine dependence.
• Non-pharmacy retailers (e.g. tobacconists, vape shops, convenience stores) cannot legally sell vapes.
• Sale of single-use disposable vapes is not permitted, even in pharmacies.

▪ From 1 October 2024

• All ages: Need a prescription for nicotine concentration >20 mg/mL.
• Adults (≥18): Can buy vapes nicotine ≤20 mg/mL without prescription, but only after pharmacist consultation.
• Pharmacists must:
  • Confirm age (ID)
  • Discuss dosage and quitting alternatives
  • May refuse sale (not obligated)
• Only 1-month supply allowed per month.

▪ Additional Restrictions

• Under 18s: Need prescription.
• Nicotine >20 mg/mL: Requires prescription at any age.
• Flavours restricted: Mint, menthol, tobacco only.
• Plain packaging required (like pharmaceuticals).

Rough equivalence (clinical approximation only):

Smoking	Vaping (rough equivalent use)
1 pack/day	~1 mL/day of 20 mg/mL (nicotine salt)
10 cig/day	~0.5 mL/day of 20 mg/mL
Light smoker	3–6 mg/mL liquids

in Queensland:

• Vapes cannot be:
  • used in smoke-free indoor/outdoor areas
  • sold to children under 18
  • advertised/promoted/displayed at retail outlets
  • sold via vending machine
  • supplied by pharmacy without required pharmacist consultation/prescription rules.

🔹 Enforcement and Penalties

• Focus on suppliers, not individual users.
• Personal possession (including by minors) not penalised.
• Illegal supply can be reported to the TGA.
• Illicit tobacco sales should be reported via the ATO.