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Source: APNA Primary Times Summer 2021 (Volume 21, Issue 2)
Tobacco smoking is a major risk factor for almost all types of cardiovascular disease and has been shown to at least double the risk of heart attack and heart failure.1 The good news is that 1 year after quitting smoking the increased risk of cardiovascular events and mortality halves, and after about 15 to 20 years the rate is similar to that of someone who has never smoked.2,3,4
In recent years, we have seen the Australian market flooded with e-cigarettes, positioned by tobacco companies as a safer alternative to smoking. However, the short-term health effects of e-cigarettes are not fully understood and there is not enough data to determine the long-term effects. We do know that vaping nicotine can increase blood pressure, heart rate and arterial stiffness. So potentially it could increase the risk of developing cardiovascular disease and or compromise lung function.5 There is also evidence that vaping increases the risk of adolescents initiating smoking and increases the risk of people who have formerly smoked to relapse.6 The evidence for the efficacy of nicotine e-cigarettes for smoking cessation is to this point limited.
Earlier this year, the Australian Government made regulatory changes to the Poisons Standard through the Therapeutic Goods Administration (TGA) to allow people to use nicotine e-cigarettes and e-liquids (referred to by the TGA as ‘nicotine vaping products’) with a prescription from their doctor. This is to balance the need to protect adolescents and young adults from taking up nicotine vaping (and potentially smoking), while granting access to adults who want to use these products to quit.
These regulatory changes came into effect on 1 October 2021, and general practices may see an increase in patients enquiring about nicotine vaping products.
This provides an excellent opportunity for primary care nurses to inform patients about the smokingcessation treatments available and to provide education about first-line, evidence-based interventions. The following points are important to keep in mind.
First-line treatment for smoking cessation consists of behavioural intervention combined, if clinically appropriate, with pharmacotherapies approved by the TGA (varenicline, bupropion and nicotine-replacement therapies).7
The TGA has not approved any nicotine vaping products. This means they have not been assessed by the TGA for safety, quality and efficacy. Nicotine vaping products are not recommended as a first-line treatment option for smoking cessation in newly released guidelines from the Royal Australian College of General Practitioners (RACGP).7
As unapproved medicines, nicotine vaping products can be prescribed by medical practitioners through the Authorised Prescriber Scheme, the Special Access Scheme, or the Personal Importation Scheme. The Special Access Scheme can also be utilised by other prescribing health-care professionals, such as nurse practitioners. With a valid prescription, people can buy nicotine vaping products from Australian pharmacies or from overseas online retailers under the Personal Importation Scheme.
The RACGP guidelines note that as unapproved products, it is ‘valid and reasonable for medical practitioners to choose not to prescribe them’.7 Press releases issued on 29 September 2021 from both the RACGP and Australian Medical Association emphasised that doctors should not feel pressured to prescribe nicotine vaping products if they feel uncomfortable.
Primary care nurses play an important role in identifying patients who smoke and helping them to quit by providing brief advice using the ‘Ask, Advise, Help’ model7 :
The Heart Foundation and Quit have recently published a joint position statement on smoking and vaping cessation endorsed by APNA. Key recommendations for health professionals are discussed in more detail here:
1. E Banks, G Joshy, RJ Korda et al., ‘Tobacco smoking and risk of 36 cardiovascular disease subtypes: fatal and nonfatal outcomes in a large prospective Australian study’, BMC Med, 2019, 17(1):128, doi:10.1186/s12916-019-1351-4.
2. AC Novello, ‘Surgeon General’s report on the health benefits of smoking cessation’, Public Health Rep, 1990, 105(6):545–548.
3. AA Ahmed, K Patel, MA Nyaku et al., ‘Risk of heart failure and death after prolonged smoking cessation: role of amount and duration of prior smoking’, Circ Heart Fail, 2015, 8(4):694–701, doi:10.1161/ circheartfailure.114.001885.
4. M Shields and K Wilkins, ‘Smoking, smoking cessation and heart disease risk: a 16-year follow-up study’, Health Rep, 2013, 24(2):12–22.
5. M Chaumont, B de Becker, W Zaher et al., ‘Differential effects of e-cigarette on microvascular endothelial function, arterial stiffness and oxidative stress: a randomized crossover trial’, Sci Rep, 2018, 8(1):10378, doi:10.1038/s41598-018- 28723-0.
6. ON Baenziger, L Ford, A Yazidjoglou, G Joshy and E Banks, ‘E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and metaanalysis’, BMJ Open, 2021, 11(3):e045603, doi:10.1136/bmjopen-2020-045603.
7. The Royal Australian College of General Practitioners (RACGP), Supporting smoking cessation: a guide for health professionals, RACGP, Melbourne, 2019.
8. JI Vidrine, S Shete, Y Cao et al., ‘AskAdvise-Connect: a new approach to smoking treatment delivery in health care settings’, JAMA Intern Med, 2013, 173(6):458–464. doi:10.1001/ jamainternmed.2013.3751