E-cigarettes and vaporisers

Purpose

The RANZCP has developed this position statement to outline its support for the use of NVPs as a harm minimisation measure for those dependent on nicotine through the use of cigarettes and other tobacco containing products.

Key messages

• Tobacco use remains the leading cause of morbidity and mortality for people living with mental illness. 
• Tobacco harm reduction is an essential component of any framework that aims to improve health outcomes for people who smoke tobacco, who require access to a broad range of harm reduction and smoking cessation tools, including pharmacological and behavioural interventions. 

• Nicotine vaping products are associated with specific risks in children, adolescents and young people distinct from adult populations. It is important that regulatory approaches strike a balance between promoting accessibility for smokers, and limiting access and risk for young people and non-tobacco smokers. 

• Nicotine vaping products are a safer alternative to tobacco smoking and offer a harm minimisation tool when first line pharmacotherapies and/or behavioural interventions have been unsuccessful.

• Nicotine vaping products have specific risks associated with both the nicotine vaping unit and nicotine vaping liquid which individuals and prescribers need to be aware of. They should never be prescribed for those not dependent on nicotine via cigarettes or other tobacco containing products, nor be shared with children or adolescents. 

• The evidence regarding nicotine vaping products’ effectiveness as a smoking cessation strategy, potential long-term harms from vaping, and their role in introducing young people to nicotine dependence and smoking is evolving and should inform future service provision.

Background

The RANZCP recognises nicotine dependence as a chronic relapsing and remitting illness for which some people will require sustained or repeated interventions to reduce the morbidity and mortality from tobacco use. Addictions, including nicotine dependence, are associated with significant morbidities and mortality across both physical and mental health dimensions; as such, they are a core concern for psychiatrists.[1] 

Smoking is the leading cause of the health gap between those with or without a mental health condition.[2] People living with mental illness suffer disproportionately from the harm of tobacco smoking and are less likely to succeed during a smoking cessation attempt.[3] In 2019, people with mental health conditions were over twice as likely to smoke daily as people who had not been diagnosed or treated for mental health conditions.[4] Those who reported high or very high levels of psychological distress were also over twice as likely to report daily smoking as those who reported low psychological distress.[4] 

Current policies have a narrow focus on abstinence, which risks exacerbating health disparities between those with and without a mental health condition. People living with mental illness have disproportionately higher rates of smoking prevalence, related to higher levels of nicotine dependence and historically lower rates of being offered evidence-based therapies for this dependence. 

The RANZCP supports a multi-pronged approach to reducing tobacco-related harm encompassing a wide range of clinical interventions and public policy initiatives, based on an appropriate balance between smoking cessation and tobacco harm reduction approaches. Tobacco harm reduction is an essential component of any policy framework that aims to improve health outcomes for people who smoke and is endorsed in Australia's National Tobacco Strategy 2022-2030 Strategy and New Zealand’s Smokefree Aotearoa 2025 Action Plan.[5-6] 

The RANZCP supports the use of NVPs as a harm minimisation measure, to support those smoking cigarettes or using other tobacco products to make changes or cease in their use of tobacco. This should be enacted through legalisation and regulation of e-cigarettes and vaporisers proportionate to their associated risks. The beginnings of this are evidenced in Australia, where NVPs require a prescription from a medical practitioner for purchase or importation, and New Zealand, where vendors of NVPs must register with the Ministry of Health.[7-8] This is consistent with a precautionary approach which encourages ‘the replacement of dangerous substances and activities with less dangerous substances or technologies where suitable alternatives are available’.[9] 

The Role of the Psychiatrist

Addressing smoking behaviour is important for psychiatrists and is currently not a common practice.[10] Given the strong association between nicotine dependence, with its associated comorbidities, and mental ill health, psychiatrists have a role in supporting individuals in providing interventions that can support those seeking to address their tobacco and nicotine dependence use via the therapeutic use of NVPs. 

The psychiatrist’s role is also central to the sound governance of services, providing review, direction and support where required, and promoting safe and rigorous practice.

Harm reduction

The RANZCP recognises that NVPs reduce the harms associated with smoking tobacco and using other tobacco containing products. Evidence suggests that long-term use of e-cigarettes is significantly less risky to an individual’s health than smoking regular cigarettes.[11-14] It has been estimated that long-term use of NVPs is up to 95% less risky to an individual’s health than smoking regular cigarettes.[15-18] This evidence is also reflected in existing guidelines.[19] As e-cigarettes are a relatively new invention, there are no long-term studies on the nature and magnitude of the effects of long-term vapour inhalation on people’s health and current research is conflicting.[11] 

Smoking cessation

In the past decade the volume and quality of evidence on NVPs as a smoking cessation aid has vastly increased. This is reflected in the updated Cochrane Review on Electronic Cigarettes for Smoking Cessation, which found NVPs to be superior to nicotine replacement products and vaping products without nicotine.[20] 

The RANZCP recognises the limitations in the current research on NVPs. The Cochrane review does acknowledge the limitations of the evidence base, with a comparatively small number of included studies being randomised control trials (RCTs) and an uncertain effect size. As more RCTs and other studies have been conducted however, the GRADE certainty of this evidence has risen. Further research into the role of these products alone, in combination with behavioural change approaches, other pharmacological agents, or novel approaches in order to reduce tobacco use in Australia and New Zealand, is required.  There is a particular need for such research in people with a variety of mental health challenges.

The RANZCP notes the use of NVPs by smoking cessation services in the UK, where market data has shown a reduction in tobacco sales as NVP sales have increased. There has been an increase in demand for NVPs as a smoking cessation aid by consumers as a perceived safer alternative.[11]

Harms 

The potential long-term harms of using NVPs for decades are thus far unknown. Although the level of risk is likely to be far less than from smoking, there should nevertheless be vigilance to any emerging evidence on e-cigarettes and vaporisers being linked to long-term health problems. Risks to children, adolescents and young people need to be considered in formulation of regulatory and legislative approaches. The RANZCP outlines potential harms below. 

Smoking initiation

International work suggests the use of e-cigarettes and vaporisers may be associated with the development of nicotine dependence and subsequent tobacco smoking initiation in young people.[21-25] Nicotine use has an adverse effect on the developing adolescent brain. The RANZCP only supports the prescription of NVPs to those already dependent on nicotine through the use of cigarettes or other tobacco products. Much of the current evidence is cross-sectional rather than longitudinal data however, so cannot definitively establish whether e-cigarette use preceded tobacco smoking initiation.[26] Where longitudinal data does exist, they do not distinguish between occasional or experimental tobacco use and established smoking. As a result, e-cigarettes may not necessarily lead to the uptake of tobacco smoking among non-smokers. From a public health perspective, smoking rates continue to fall among young people in countries that have widespread access to NVPs, with increased usage of e-cigarettes among young people coinciding with continuing declines in youth tobacco smoking rates.[27-29]

Nevertheless, the potential that increased access to NVPs may jeopardise continued progress in reducing smoking initiation in young people, holding back the ultimate goal of a future free of tobacco induced harms in Australia and New Zealand, is of concern.

Vaping products can be used with e-liquid flavours that are made to appeal a younger demographic of people who have never smoked. Individuals who use vaping products may be using them to experiment or for taste/entertainment and poses a unique risk to young people [30]. The RANZCP supports changes to legislation that limits access to commercial flavours outside of therapeutic use. However, recreational use of vaping products ought to be distinguished from legitimate use of NVPs for the purposes of smoking cessation. 

The RANZCP recognises the need for balance in the regulation of e-cigarettes and vaporisers to reduce the incidence of new nicotine users through this route while still encouraging the harm reduction gains of smokers switching to these devices. This should include stronger restrictions on all types of discounting, promotion, advertising and sponsorship relating to e-cigarettes and vaporisers, including prohibitions against advertisements which target children and adolescents. 

Nicotine vaping liquid

Nicotine vaping liquid generally contains propylene glycol, a safe substance, a variable amount of nicotine, and optional colours and flavourings. The RANZCP supports mandates that all ingredients be listed on NVP packaging, including nicotine concentration. 

Nicotine can be toxic when absorbed at excessive levels through the skin, eyes, respiratory or gastrointestinal tract. The RANZCP discourages at-home dilution of high concentration nicotine vaping liquid and encourages prescribing or use at doses which do not require this to reduce the risk of toxic transdermal absorption. There is no safe level of transdermal contact with nicotine vaping liquid in children. The RANZCP also supports mandates on child proof packaging of nicotine vaping liquids to prevent accidental poisoning with appropriate warning labelling. 

Some specific flavours of nicotine have been associated with specific harms, such as EVALI. The long-term effect of inhalation of heated colourants and flavourings is responsible for much of the uncertainty of long-term safety of NVPs. Unflavoured, uncoloured products are considered the safest option. Only products specifically designed to be used in nicotine vaping devices should be used.

Nicotine vaping units

NVP devices are composed of plastic and metal components, a heating element and battery. Poorly or cheaply constructed devices may leach unsafe compounds or have batteries which may explode. The RANZCP suggests purchasing devices via Australian pharmacies or if importing, doing so from countries with similar safety standards to Australia and New Zealand.[31]

EVALI

E-cigarette or vaping-associated lung injury (EVALI) is a severe and potentially fatal respiratory illness. While EVALI has been reported with nicotine-only vaping liquids, it is more commonly associated with vaping liquids containing tetrahydrocannabinol (THC), vitamin E acetate and oil containing additives. 

Regulation

The RANZCP supports a legislative and enforcement framework where NVPs are controlled proportionate to their risks while still allowing for individuals to have appropriate access to these products at a reasonable cost. It is important that regulations strike an appropriate balance between competing public health priorities such as the need to encourage uptake of NVPs among users of tobacco products while mitigating the potential risks and ensuring that uptake among non-smokers and youth is minimised. The tobacco industry should not be involved in shaping regulations given the unavoidable conflict of interest.

The RANZCP also suggests a review of any legislation after five or 10 years to ensure that regulations reflect up-to-date research on the harm and benefits of these products.

Recommendations

The RANZCP recognises the potential harm reduction benefits presented by NVPs for people living with mental illness and the utility in regulations that allow access to safer versions of these products to those looking to make changes to their tobacco use. The RANZCP therefore recommends:

• Nicotine vaping products become a common tool in the arsenal of all psychiatrists as a harm minimisation tool when caring for those with mental illness who are dependent on nicotine via tobacco use. 
• Nicotine vaping products safety standards should continue in line with current TGA (Australia) and Vaping Regulatory Authority (Aotearoa New Zealand) requirements to reduce short- and long-term harms associated with these products.
• Nicotine vaping products should not be prescribed to or used by people not dependent on nicotine via tobacco use. 
• Nicotine vaping products should not be advertised to young people and adults being prescribed should be counselled to not make nicotine vaping units available to children and adolescents. 
• Nicotine vaping products are subject to further research in order to determine:
  • the long-term health effects of vaping
  • the effectiveness of e-cigarettes and vaporisers as a cessation tool
  • the demographic patterns of use including rates of initiation by young people.

Additional Resources

• Australian Government Department of Health and Aged Care. Australian National Tobacco Strategy 2022-2030. May 2023.
• Equally Well. Equally Well Consensus Statement. December 2018. 
• Royal Australian College of General Practitioners (RACGP). Supporting smoking cessation: A guide for health professionals. October 2021. 
• Royal Australian New Zealand College of Psychiatrists. Mental Health Clinician Guidance for Managing People’s Smoking Cessation. June 2022.
• Therapeutic Goods Administration (TGA). Vaping Hub. 2023

References

[1] Equally Well. Equally Well Consensus Statement. December 2018. Available Online - https://www.equallywell.org.au/wp-content/uploads/2018/12/Equally-Well-National-Consensus-Booklet-47537.pdf.

[2] Sharma R et al. Should we encourage smokers with severe mental illness to switch to electronic cigarettes? Australian & New Zealand Journal of Psychiatry. Australian and New Zealand Journal of Psychiatry. 2017 Jul;51(7):663-664. doi: 10.1177/0004867417697823.

[3] Cather C et al. Achieving Smoking Cessation in Individuals with Schizophrenia: Special Considerations. CNS Drugs. 2017;31(6):471–81.

[4] Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019 - Drug statistics series no. 32. 2020. Available Online - https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019. 

[5] Commonwealth of Australia as represented by the Department of Health and Aged Care. National Tobacco Strategy 2023–2030. Report No.: 12710. [Internet]. Canberra: Commonwealth of Australia; 2023. Available from: https://www.health.gov.au/sites/default/files/2023-05/national-tobacco-strategy-2023-2030.pdf 

[6] Manatū Hauora (Ministry of Health). Smokefree Aotearoa 2025 Action Plan. December 2021. Available Online - https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/smokefree-aotearoa-2025-action-plan. 

[7] Australian Government Department of Health and Aged Care (Therapeutic Goods Administration). Therapeutic Goods (Standard for Nicotine Vaping Products) (TGO 110) Order 2021. May 2021. Available Online - https://www.legislation.gov.au/Details/F2021L00595.

[8] Parliamentary Counsel Office. Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Bill. December 2022. Available Online - https://legislation.govt.nz/bill/government/2022/0143/latest/versions.aspx.

[9] Martuzzi M &Tickner JA. The precautionary principle: protecting public health, the environment and the future of our children. World Health Organization. 2004.

[10] Gelenberg AJ, de Leon J, Evins AE, et al. Smoking Cessation in Patients With Psychiatric Disorders. Prim Care Companion J Clin Psychiatry 2008; 10: 52–58.

[11] Greenhalgh EM, Scollo MM & Winstanley MH. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria. 2023. Available Online - www.TobaccoInAustralia.org.au. 

[12] Prochaska JJ & Benowitz NL. Current advances in research in treatment and recovery: Nicotine addiction. Science Advances. 2019 Oct 16;5(10). Available Online -https://pubmed.ncbi.nlm.nih.gov/31663029/. 

[13] Marques P, Piqueras L & Sanz MJ. An updated overview of e-cigarette impact on human health. Respiratory Research 2021;22(151) Available Online - https://doi.org/10.1186/s12931-021-01737-5. 

[14] Levy DT et al. Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobacco Control. 2018;27:18–25. Available Online - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801653/. 

[15] Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction.2016. Available Online - https://www.rcplondon.ac.uk/file/3563/download 

[16] Office for Health Improvement and Disparities. Nicotine vaping in England: an evidence update including health risks and perceptions. 2022. Available Online - https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1107701/Nicotine-vaping-in-England-2022-report.pdf 

[17] McNeill A, Brose LS, Calder R, Hitchman SC, Hajek P, McRobbie H (2015) E-cigarettes: an evidence update. A report commissioned by Public Health England. London: Public Health England.
 
[18] Nutt DJ, Phillips LD, Balfour D, Curran HV, Dockrell M, Foulds J, Fagerstrom K, Letlape K, Milton A, Polosa R, Ramsey J, Sweanor D (2014) Estimating the harms of nicotine-containing products using the MCDA approach. European Addiction Research 20: 218–25.

[19] National Institute for Health and Care Excellence (NICE). Tobacco: preventing uptake, promoting quitting and treating dependence: Evidence review for long-term health effects of e-cigarettes NICE guideline. November 2021. Available Online - https://www.nice.org.uk/guidance/ng209/evidence/m-longterm-health-effects-of-ecigarettes-pdf-392068002710. 

[20] Hartmann-Boyce J et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews. 2022;11(CD010216). Available Online - https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub6/full 

[21] Chen R et al. Effectiveness of e-cigarettes as aids for smoking cessation: evidence from the PATH Study cohort 2017–2019. Tobacco Control. February 2022. Available Online - https://tobaccocontrol.bmj.com/content/early/2022/01/11/tobaccocontrol-2021-056901. 

[22] Bauld L et al. Young People’s Use of E-Cigarettes across the United Kingdom: Findings from Five Surveys 2015–2017. International Journal of Environmental Research and Public Health 2017;14(9): 973. Available Online - https://pubmed.ncbi.nlm.nih.gov/28850065/. 

[23] Peters M. E-cigarettes – the case for caution. 2017. Medical Journal of Australia. Available at - https://insightplus.mja.com.au/2017/10/e-cigarettes-the-case-for-caution/. 

[24] Primack BA et al. Initiation of Traditional Cigarette Smoking after Electronic Cigarette Use Among Tobacco-Naïve US Young Adults. American Journal of Medicine. 2018;131(4):443.

[25] Soneji S et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults - A Systematic Review and Meta-analysis. JAMA Paediatrics. 2017. Available Online - https://pubmed.ncbi.nlm.nih.gov/28654986/. 

[26] Chan G et al. A systematic review of randomized controlled trials and network meta-analysis of e-cigarettes for smoking cessation. Addiction Behaviour. Aug 2021;119:106912. Available Online -https://pubmed.ncbi.nlm.nih.gov/33798919.

[27] Yazidjoglou A et al. Efficacy of e-cigarettes as aids to cessation of combustible tobacco smoking: updated evidence review. September 2021. Available Online - http://hdl.handle.net/1885/247864.

[28] Etter JF. Gateway effects and electronic cigarettes. Addiction. 2018 Oct;113(10):1776-1783. Available Online https://pubmed.ncbi.nlm.nih.gov/28786147/. 

[29] Warner KE. How to Think – Not Feel – about Tobacco Harm Reduction. Nicotine & Tobacco Research. 2019 Sep ;21(10):1299-1309. Available Online -https://pubmed.ncbi.nlm.nih.gov/29718475/. 

[30] Notley C, Gentry S, Cox S, Dockrell M, Havill M, Attwood AS, et al. Youth use of e‐liquid flavours—a systematic review exploring patterns of use of e‐liquid flavours and associations with continued vaping, tobacco smoking uptake or cessation. Addiction 2022;117:1258–72. https://doi.org/10.1111/add.15723.

[31] Kerr DMI et al. Acute effects of electronic and tobacco cigarettes on vascular and respiratory function in healthy volunteers: a cross-over study. J Hypertens. 2019 Jan;37(1):154-166. 

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.