E-cigarettes, commonly referred to as vapes, have proliferated over the past decade, often being promoted as a safer alternative to smoking traditional cigarettes. However, the explosion in their use, especially among young people, and regulatory loopholes have raised significant public health concerns. This blog will delve into what the current evidence says about vaping, its health risks, recent legislative changes in Australia, and the implications for health professionals.

Understanding E-cigarettes

E-cigarettes are battery-operated devices that heat a liquid to create an aerosol, which users inhale. The liquid typically contains nicotine, and/or flavourings, and other chemicals. While marketed under various names such as vapes, e-cigs, mods, and vape pens, they all function similarly by delivering nicotine and other substances to the respiratory system.

Public Health Risks of Vaping

1. Vaping results in exposure to harmful substances:

      E-cigarettes may not contain the tar found in traditional cigarettes, but they do emit several potentially harmful substances which are inhaled. Ingredients in vape liquids can include:

      • Formaldehyde: Used in industrial glues and as a preservative.
      • Acetone: Commonly found in nail polish remover.
      • Acrolein: Used in herbicides.
      • Heavy Metals: Such as nickel, tin, and lead.

      2. There are many potential health effects:

      Vaping can cause immediate health issues, such as:

      • Mouth and airway irritation.
      • Persistent coughing.
      • Nausea and vomiting.
      • Poisoning and seizures due to high nicotine intake.
      • Burns or injuries from device malfunctions.
      • Potential DNA damage from chemicals in aerosols.

      The long-term health impacts of vaping remain uncertain, but there’s concern over increased risks of lung disease, cardiovascular disease, and cancer.

      3. Impact on Youth:

      Nicotine exposure is particularly dangerous for young people as it can affect brain development, leading to issues with attention, learning, and mood alterations (Australian Department of Health, 2024). Studies show that young people who vape are also more likely to start smoking cigarettes in the future (National Health and Medical Research Council, 2022).

      Vaping and Smoking Cessation

      The use of nicotine vaping products (NVPs) as smoking cessation aids is a nuanced subject with mixed evidence. A comprehensive review by the Australian National University (2021) found that nicotine e-cigarettes offered a small benefit over traditional nicotine replacement therapy (NRT) based on limited high-quality studies. Similarly, the updated Cochrane Review (2022) indicated a higher success rate for smoking cessation using NVPs compared to NRT, although biases and methodological variations in studies necessitate caution.

      Revised guidelines from the Royal Australian College of General Practitioners (RACGP) in 2023 moved the certainty of evidence from low to moderate. These guidelines recommend NVPs for smoking cessation only when first-line treatments have failed, and always alongside behavioural support. Patients must be informed about the unknown long-term health effects, the lack of uniformity in devices, and the need for regular monitoring to mitigate risks effectively.

      Legislative Changes in Australia

      Effective from July 1, 2024, Australia has introduced stringent laws to regulate the sale and distribution of e-cigarettes to curb the health risks associated with vaping, especially among youth.

      1. Prescription-only Model:

        Vapes will only be available in pharmacies with a prescription to help individuals quit smoking or manage nicotine dependence. This move aims to limit access particularly to young people. From October 1, 2024, therapeutic vapes with a nicotine concentration of 20mg/mL or less will be available in pharmacies to patients 18 years or over without a prescription, provided the pharmacist deems it clinically appropriate and meets several other conditions. People under the age of 18 will continue to require a prescription.

        2. Limits on Nicotine Concentration:

        The nicotine content in vapes sold without a prescription will be limited to 20mg/mL, and only flavours such as mint, menthol, and tobacco will be permitted, with the aim of making these less attractive to youth who previously had access to flavours such as bubblegum.

        3. Advertising Restrictions:

        Strict regulations have been placed on the advertising of vaping products, limiting it to medical practitioners, pharmacists, and relevant stakeholders. Advertising is further restricted to ensure compliance with the Therapeutic Goods Administration (TGA) standards.

        4. Compliance and Safety Standards:

        Therapeutic vapes must adhere to quality standards set by the TGA, ensuring safer use through regulated ingredients and appropriate labelling.

        Implications for Health Professionals

        Health professionals have a critical role in addressing the vaping epidemic and supporting patients in quitting both smoking and vaping.

        1. Patient Education:

          Patients, especially youth, need to be informed about the risks associated with vaping. Health professionals should emphasise that while vaping may seem safer than smoking, it is not risk-free and there is mounting evidence of the harms of vaping.

          2. Smoking and Vaping Cessation Support:

          Patients seeking to quit vaping can be supported using strategies similar to those for smoking cessation, including behavioural support, counselling, and evidence-based pharmacotherapies such as nicotine replacement therapy and varenicline.

          3. Regulation Compliance:

          Pharmacists and prescribers must ensure they are up to date with the latest regulations regarding the dispensing of therapeutic vapes. Only TGA-approved pathways such as the Authorised Prescriber (AP) scheme, Special Access Scheme B (SAS B), and Special Access Scheme C (SAS C) should be used.

          Pharmacists should be aware of the following regulations when sourcing and dispensing vapes:

          • State and Territory Regulations: Each state and territory may have additional regulations, including the need for a retail licence, advertising restrictions, and supply to persons under 18 years of age.
          • Authorised Dispensing: Only vapes included in the TGA’s list of notified vapes can be dispensed. Pharmacists must validate prescriptions prior to dispensing and meet the criteria outlined by the TGA.
          • Compounding and Component Substances: Only finished products can be dispensed. Compounding vapes requires TGA consent and adherence to TGO 110 standards.
          • Sourcing Requirements: Pharmacies must source therapeutic vapes that conform to TGO 110 standards from Australian sponsors, wholesalers, or licensed overseas suppliers.

          Nicotine poisoning presents significant risks, particularly to children; thus, pharmacists must communicate symptoms and emergency procedures effectively. For detailed guidelines and resources, refer to the comprehensive documentation provided by the TGA and relevant authorities. (https://www.tga.gov.au/resources/resource/guidance/vapes-information-pharmacists).

          4. Monitoring and Follow-Up:

          Regular follow-up with patients is essential to monitor progress, manage any adverse reactions, and support sustained cessation efforts.

          The evidence on vaping underscores significant health risks, particularly for young people, and highlights the uncertain long-term effects. While e-cigarettes may help some smokers quit, they are not a first-line therapy for smoking cessation due to limited supporting evidence and potential safety concerns.

          Health professionals must stay informed about the latest legislative changes and ensure they provide comprehensive support to patients who seek to cease vaping. Public education about the risks and proactive regulation will be key to mitigating the potential health crisis posed by vaping.

          References

          Australian Government Department of Health and Aged Care (2024) About vaping and e-cigarettes

          https://www.health.gov.au/topics/smoking-vaping-and-tobacco/about-vaping

          Ministers Department of Health and Aged Care (2023) Next steps on vaping reforms

          https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/next-steps-on-vaping-reforms

          RACGP (2023) Supporting smoking cessation: A guide for health professionals Guidance updates on smoking and vaping cessation support related to changes to Australia’s vaping regulation, RACGP

          https://www.racgp.org.au/getmedia/2f8ffac1-8751-41aa-906f-f0ec7feca048/RACGP-NVP-and-Vaping-Cessation-Consultation-provisional-draft-Dec2023.pdf.aspx?%20fbclid=IwAR3Fd9EOtm4U0NeXAzZvaOhybBjYY6mnrNeHGfIngFOmix0wc6h7W6BhzYw%20https://www.mja.com.au/journal/2023/218/6/electronic-cigarettes-and-health-outcomes-umbrella-and-systematic-review-global

          Therapeutic Goods Administration. (2024). Vapes: information for pharmacists https://www.tga.gov.au/resources/resource/guidance/vapes-information-pharmacists

          National Health and Medical Research Council (NHMRC). (2022). CEO statement on electronic cigarettes.

          https://www.nhmrc.gov.au/health-advice/all-topics/electronic-cigarettes/ceo-statement

          Yazidjoglou A, Ford L, Baenziger O, Brown S, Martin M, Zulfiqar T, Joshy G, Beckwith K, Banks E. Efficacy of e-cigarettes as aids to cessation of combustible tobacco smoking: updated evidence review. Final report prepared for the Australian Government Department of Health: online version, September 2021. URL: http://hdl.handle.net/1885/247864