A heated debate


Researchers call for practice guidelines on nicotine vaping products to be developed for pharmacy staff, but Chief Medical Officer urges caution in light of seventh US death

Use of nicotine vaping products has increased rapidly in Australia, however many pharmacy staff feel uninformed and unsure of how to handle patient enquiries, say researchers from the University Queensland’s schools of pharmacy and public health.

In Australia it is illegal to use nicotine in vaping products unless used for a therapeutic purpose such as quitting smoking, in which it is classified as a Schedule 4 medicine—requiring the user to hold a valid medical prescription.

The TGA has indicated that it is possible for a nicotine-containing vaping product to be approved as an aid to quit smoking, but so far no product has yet progressed through the regulatory system.

Therefore Australians can only access nicotine for vaping purposes through personal importation, the Special Access Scheme, the Authorised Prescriber Scheme or through extemporaneous compounding, say the researchers.

They surveyed 470 adult pharmacy customers who visited four pharmacies in Brisbane in March 2015, with their findings published recently in Drug and Alcohol Review.

Over half of respondents were either current smokers (31.5%) or ex-smokers (22.1%).

Among current smokers, the majority (76%) indicated having tried to quit smoking at least once, with the most common methods being ‘cold turkey’ (91%), nicotine replacement therapies (64%) and nicotine vaping products (51%).

Almost a third of all respondents had tried nicotine vaping products in the past (15.9%) or were current users (14.8%).

The most commonly mentioned reasons for use of nicotine vaping products were ‘as a substitute for smoking tobacco’ (41.4%), ‘it is safer than smoking tobacco’ (40%), ‘to quit smoking’ (31%), and ‘to cut down the number of cigarettes I smoke’ (26.2%).

Over half of all respondents (56%) agreed or strongly agreed that short-term use (less than six months) of nicotine vaping products is safe.

However respondents were more wary of long-term of lifetime use of these products – more disagreed (62%) than agreed (18%) with the statement that lifetime use of nicotine vaping products is safe.

Current vapers perceived the products as less harmful than combustible cigarettes, irrespective of whether they contained nicotine (93%) or were nicotine-free (97%).

In contrast, nearly half of non-users perceived nicotine-containing vaping products to be equally as harmful as smoking.

Comprehensive research by the National Academies of Sciences, Engineering, and Medicine (NASEM) published in January 2018 found conclusive evidence that in addition to nicotine, most e-cigarette products contain and emit numerous potentially toxic substances.

Additionally NASEM found substantial evidence that e-cigarette aerosol contains metals.

But evidence also showed that except for nicotine, under typical conditions of use, exposure to potentially toxic substances from e-cigarettes is significantly lower compared with combustible tobacco cigarettes.

Conclusive evidence also showed that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens.

However there are also emerging potential risks of the products.

As of 11 September 2019, the Centers for Disease Control and Prevention (CDC) in the US has reported 380 confirmed cases of lung illness across the country linked to e-cigarette use.

All reported cases have a history of e-cigarette product use or vaping, with most patients reporting a history of using e-cigarette products containing THC.

Many also reported use of both THC and nicotine, while some reported use of only nicotine.

All patients have a reported history of e-cigarette product use, with the suspected cause being chemical exposure.

Six deaths have been confirmed related to e-cigarette use, with reports of a seventh case this week.

In light of these cases, Australia’s Chief Medical Officer and all State and Territory Chief Health Officers have urged a precautionary approach to the marketing and use of e-cigarettes, and recommended that e-cigarette users with unexplained respiratory symptoms seek medical advice.

International evidence is emerging of a possible link between the use of e-cigarettes and lung disease, they say.

Australian health organisations such as the Australian Medical Association (AMA) have also taken a conservative approach, speaking out against regulation of vaping products citing potential risks.

“The AMA strongly supports the response from all Australian governments to emerging international evidence of a possible link between the use of e-cigarettes and lung disease,” the organisation said in a statement on Wednesday.

The governors of California and New York recently announced emergency plans to ban sales of the flavoured vaping devices.

CDC warns adults who do not currently use tobacco products should not start using e-cigarette products, and those who use e-cigarettes or vaping products should not buy these or any related products “off the street”.

However it adds that adults who used e-cigarettes containing nicotine to quit cigarette smoking should not return to smoking cigarettes.

The Queensland researchers believe pharmacists need to be provided with education, training and relevant resources so they can provide unbiased and evidence-based advice for customers.

“Community pharmacies are an ideal setting for educating smokers about less harmful alternatives such as nicotine vaping products,” they say, varying from the AMA stance that e-cigarettes should not be promoted.

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