NVP's In Practice

Titrating down ahead of abstinence

There is no clear evidence that underpins which strategy should be used for lowering nicotine ahead of a quit attempt, or if such titration is likely to increase the probability of successful abstinence. Clinicians should consider whether a move to NRT ahead of abstinence may be more conducive.

Possible methods for titrating nicotine in NVPs include:

1. Using a lower concentration of nicotine and limiting the overall daily dosage of nicotine. Patients will have to ensure they do not take additional compensatory puffs; or
2. Using full dosage and limiting the amount of nicotine prescribed. Patients will have to consciously moderate the number of puffs they take per day.

Do note that users can extract more nicotine from the aerosol by inhaling deeply and holding breath.

Abstinence and relapse prevention

Nicotine abstinence is only possible when patients are ready to achieve it. In practice, it may be impossible for clinicians to determine in advance if a patient is ready. When any single attempt at abstinence is made, clinicians should assume that it will result in relapse.

Accordingly, provision should be made that patients that successfully achieved smoking cessation with an NVP should have access to the same to prevent relapse to cigarettes.

Clinical considerations – open systems

A significant number of Australian smokers use vaping products. Of these, an unknown proportion use open systems for smoking cessation. From October 1st, GPs will start to receive patients currently using open systems requesting a prescription of nicotine liquids.

The benefits of prescribing e-liquid refills to patients who do not wish to use a closed system may outweigh the risks of relapse to smoking.

GPs should consider the following:

• Prescribing e-liquid only if the patient has stopped smoking entirely or has committed to doing so within a defined timeframe.
• Taking usage history for appropriate prescribing and understanding of usage.
  • E-liquid nicotine concentration and type (freebase or salt nicotine);
  • Daily nicotine dosage, i.e., e-liquid concentration and amount consumed/day: and
  • The device name and power output. User-selected power settings used (if variable).
• Ensuring written informed consent reflects that patients understand that:
  • They are electing to use open systems as a continuation of existing use;
  • Open systems have risks related to user choices or device performance;
  • TGO 110 does not cover e-liquids imported from overseas, and there are no internationally agreed standards for ingredients or quality of e-liquids; and
  • Devices are unregulated in Australia.

Understanding and assessing NVPs

NVPs are a heterogenous category of products, meaning that there are hundred of thousands of permutations of e-liquid and device that a user can use, and nicotine delivery varies considerably between devices and liquid | device combinations.

Closed | open systems

In general, NVPs can be classified as :

• Open systems, in which a user adds nicotine-containing e-liquid to a refillable “tank”; and
• Closed systems, in which a pre-filled cartridge or “pod” is used until empty, when it is replaced.

While open systems allow discretion to meet the user’s own personal usage preferences, from a risk perspective:

• Closed system NVPs can be well characterised in terms of nicotine delivery and their toxicant emission profile, since the liquid | device combination is known;
• Since open systems operate across a range of power settings and can be used with multiple liquids, neither the toxicant emission profile nor the nicotine delivery cannot reliably be known;
• Some open system device/liquid combinations have been found to deliver dangerously high levels of nicotine and can generate high levels of toxicants due to overheating or other design characteristics;
• Recent literature has found that lower concentrations of nicotine typically result in higher overall consumption of liquid thereby increasing overall exposure to excipients; and
• Further, closed systems remove many of the aspects of user discretion associated with open systems which are designed to allow user customisation. By removing these aspects, closed systems minimise the risks associated therewith, particularly for novice users. Until such time as products have been admitted to the ARTG, risk minimisation represents a pragmatic approach. This is especially true where the patient has comorbidities that may make using complex/high-maintenance open devices challenging.