Vaping nicotine – making the switch from smoking tobacco | By Dr Colin Mendelsohn
Dr Colin Mendelsohn works exclusively with smokers to help them quit. Colin uses evidence-based treatments including vaping nicotine when appropriate.
Colin has worked in tobacco treatment for 40 years as a doctor (general practitioner) and academic. He is on the committee that develops Australia’s national smoking guidelines and is the Founding Chairman of the Australian Tobacco Harm Reduction Association, a health promotion charity formed to raise awareness of safer alternatives to smoking. Colin is actively involved in teaching health professionals about smoking, writing articles in peer-reviewed journals, research and advocacy for tobacco harm reduction. He is the author of the recently published book Stop Smoking Start Vaping.
Users News interviewed Colin and got so much good stuff we couldn’t fit it all into one piece.
Part 1 (this article) is for people who want to start legally vaping nicotine but don’t know how.
Part 2 will be out soon and will be for people who want to understand more about the controversies around vaping. If you aren’t sure if vaping is a good idea, this article is for you. It talks about the evidence and the politics. It is full of myth busting.
UN: Why vape nicotine?
CM: Over 21,000 tobacco smokers die prematurely each year in Australia — it is the leading preventable cause of death. 2 out 3 smokers die prematurely and lose an average of 10 years of life.
Most smokers want to quit, but most fail repeatedly even with the best first-line treatments in Australia: varenicline (Champix), nicotine replacement therapy (patches, gum, lozenges, mouth spray, inhalator) and bupropion (Zyban).
Vaping nicotine is now the most popular quitting aid in Australia and is also the most effective. The UK National Institute for Health Research did an analysis of 171 randomised controlled studies of all medications used to stop smoking and they found that vaping nicotine was the most effective single treatment.
In Australia, vaping is a legitimate second-line quitting aid when other first-line therapies have failed.
UN: Why get prescribed nicotine instead of buying from the illicit market?
CM: The illicit market has thrived because the legal pathway is complex, difficult and expensive. Illicit vapes and nicotine e-juice are smuggled into Australia from China and are unregulated. We don’t know what is in them and we don’t have any information about quality or safety. Using them is risky.
Legal nicotine products are less risky because they must meet the TGO 110 standards set by the Therapeutic Goods Administration (TGA). This includes regulation of ingredients, labelling and packaging.
From 1 October 2021, consumers require a prescription for all purchases of nicotine vaping products, such as nicotine e-cigarettes, nicotine pods and liquid nicotine. This includes purchases from Australian pharmacies and from overseas. It remains illegal for other Australian retailers, such as tobacconists, 'vape' shops and convenience stores, to sell you nicotine vaping products, even if you have a prescription.
All nicotine vaping products sold by Australian pharmacies must satisfy the minimum standards. The standards do not apply to nicotine-free liquids. If you import nicotine vapes from overseas under the TGA Personal Importation Scheme, the TGA encourages you to check if the product has compliant labelling and packaging. Products purchased from New Zealand are regulated and generally comply with Australian standards. (Editor: More information about the TGO 110 standards can be found in the resource list at the bottom of this page).
UN: How can I get started with vaping nicotine? How can I get my doctor to prescribe me legal nicotine? What conversation will make it happen? Do I need a special doctor? What if I'm not dependent on tobacco/nicotine already and just want to have some fun vaping?
CM: The first thing is to do your homework about vaping.
Your local vape shop is a good place to start. They're usually staffed by former smokers who now vape. Vape shops are legal. They sell vape hardware and nicotine-free e-liquid, which you don't need a prescription for. You need to be over 18.
E-liquid (also known as ‘e-juice’) is what goes in a vape or e-cigarette. E-liquids may contain nicotine, as well as propylene glycol, vegetable glycerin or glycerol, flavorings and, in some cases, water.
There are also lots of good online resources and forums for vapers (Editor: Check out the resources at the bottom of this page). You could also speak to vaping friends.
Even though vaping nicotine is far less harmful than smoking, Australian authorities don’t support vaping, so most doctors won’t prescribe nicotine, and most don’t know how to.
Vaping is approved as a second-line quitting aid when other methods have failed, so they might want you to try another quitting method first, such as patches.
Any doctor can prescribe nicotine if you want to import it.
Confusingly, you need a script from a doctor who is an “Authorised Prescriber” to purchase nicotine from an Australian pharmacy.
There is a list of doctors willing to prescribe nicotine on the ATHRA website (Editor: Check out the resources at the bottom of this page). Also, some doctors are approved but aren’t on the list. (I am not on the list because I want to focus on training more doctors rather than writing scripts).
Vaping nicotine is only approved for smokers as a quitting aid or for preventing relapse. Doctors are not supposed to prescribe it if you say it is for recreational use.
UN: Do you recommend any particular vape?
CM: There is an overwhelming range of vapes available and it can be very confusing for beginners.
Choosing a vape depends on your preference for ease-of-use and maintenance, size, cost and a number of other factors.
The image below explains the various types of vapes:
Source: Stop Smoking Start Vaping
For beginners, the most popular models are pod vapes. Pod devices have a detachable pod which contains the e-liquid and a rechargeable battery. Some models have sealed, prefilled pods, so you just throw the pod away when it is empty and replace it with a new one. Others have refillable pods which you can refill easily from a bottle of e-liquid. Generally, you charge the battery daily.
Disposable vapes are also popular. These are sealed units. Put the device in your mouth, puff it like a cigarette and throw it away when it stops working. They come in a range of sizes and flavours.
There are more complex devices which have more features and some vapers progress to these later.
Doctors aren't allowed to say where to find the shops or the websites or where to buy the vapes or nicotine. But there are many reputable online shops based in NZ.
UN: How much does it cost to get a legal vape and nicotine? How does that compare to smoking costs?
CM: Vaping is 5%-25% of the cost of smoking, depending on the type of device you use. A pack-a-day smoker (20 cigarettes) spends about $12,500 per year. Vaping typically costs $500-$3,000 per year.
Pod vapes cost $30-$40. Prefilled replacement pods cost $7-$11 depending on the brand and each pod is equivalent to about a packet of cigarettes. Refillable pod vapes require nicotine e-liquid, which is about $30 for a 30mL bottle (1-2 weeks supply on average).
Disposables range from $15-$35 depending on the size (up to 5,500 puffs) and brand.
UN: If I get a script, who will fill it? Will any pharmacy do it? Or can I order what I want online from Australia or internationally?
CM: Most vapers order nicotine e-liquids online from New Zealand websites and there are many reputable suppliers. When you place your order, you simply upload the script from your doctor and it is returned with your order to prove the importation is legal.
You can also buy nicotine e-liquid from selected Australian physical or online pharmacies. The number of pharmacy suppliers is currently small but is rapidly increasing. Some pharmacies sell pod vapes (with prefilled nicotine), disposable vapes (with prefilled nicotine), and nicotine liquid (for refillable vapes), but they don’t sell the refillable vapes (though you can get them from vape shops).
UN: I hear a lot of people are starting to use vapourisers for cannabis herb... is it safe to vape tobacco herb too?
CM: It is much safer to vape cannabis than to smoke it. Vaping heats the herb without combustion and avoids most of the deadly chemicals caused from burning organic matter. Cannabis vapes and nicotine vapes are usually not interchangeable. (Editor: Check out Dr Liam’s guide to vaping cannabis resource below).
UN: I hear a lot of people say they like vaping but that it doesn’t replace the feel of a cigarette or a cannabis & tobacco joint... how can they get a similar feel? I’ve heard of a thing called snus... I also have a friend who loves using a nicotine vape in one hand and a cannabis vape in the other and inhaling on them both at the same time – is this something you recommend? (And is this something you’ve heard of before? ... Because he insists he’s the first person in the world to have this idea!)
CM: Smoking is very ritualized, and many people become attached to the habit of removing the cellophane, flicking open the box, lighting the cigarette etc. This behaviour is associated with the pleasure of smoking and is a conditioned response which diminishes over time after quitting.
Most established vapers say they enjoy vaping more than smoking. But it can take time to adjust.
Nicotine is an ‘alkaloid’. There are other alkaloids in smoke which some smokers miss when they switch to vaping. You can get these alkaloids from snus. Snus (or snuff) is a moist, tobacco product that comes in a small pouch. Snus is placed under the upper lip. Snus provides nicotine levels similar to smoking but also releases other alkaloids. Some vapers find the combination of vaping and snus more satisfying.
Snus can’t be sold legally in Australia but you can import 1.5kg without a prescription (you just need to declare it to customs). Customs will hold it and send you a letter and then you pay the import tax ($1.60 per 1 gram).
People often have to go on a journey to find the right vape and e-liquid. Some people prefer the flavor of heated tobacco products.
I’ve never heard of vaping cannabis and nicotine at the same time, but there is no reason why it should not work.
UN: What is your best advice on how to stop smoking tobacco / cigarettes?
CM: The Australian guidelines advise smokers to use first-line medication combined with counselling from a health professional. The first-line medications are:
• varenicline – which is not currently available because they recently found trace amounts of toxic nitrosamines in it
• nicotine replacement therapy (such as patches) and
• bupropion (another prescription tablet).
Though it is unapproved, vaping is the most effective single therapy, however the most effective overall therapy is varenicline plus a nicotine patch.
However, most smokers have tried these products unsuccessfully. The next option for them is to try vaping nicotine, preferably with some expert counselling.
UN: What is your best advice for someone who wants to stop vaping nicotine?
CM: There is very little evidence on the best way to stop vaping, but it is much easier to quit vaping than smoking. The usual advice is to gradually reduce the nicotine concentration and frequency of puffs. You can also use nicotine patches, gum or lozenges to supply nicotine while you wean off the smoking/vaping behaviour.
UN: Can you vape if you’re pregnant?
CM: Although it is not risk-free, vaping has a role as a substitute for pregnant women who are otherwise unable to quit smoking. A recent study of 1140 pregnant smokers found that vaping was nearly twice as effective as nicotine patches in helping pregnant women to quit smoking and was just as safe. In fact, babies of vaping mothers were less likely to be low birthweight than those using NRT. Low birthweight is associated with higher risk of neonatal death and poorer health outcomes in the child.
Vaping should not be used by pregnant women who do not smoke.
UN: Is it bad to vape around your kids?
CM: Unlike secondhand smoke, there is no evidence so far that secondhand vapour is harmful. However, it is best to avoid vaping around children to reduce any exposure and to avoid modelling a behaviour that may look like smoking.
UN: How can readers learn more about your work and this area?
CM: It is hard to get accurate information about vaping as Australian health authorities are opposed and media reports are generally unreliable. Most Australians are seriously misinformed about vaping, even doctors.
I have written a book about vaping called Stop Smoking Start Vaping, which dispels the myths about vaping and outlines the evidence in an easy-to-read style. It provides step-by-step advice on how to make the switch from smoking tobacco, and why vaping is controversial. It is available as a paperback and e-book. More information is available here.
I also have a list of FAQs on my website and regular blogs on current vaping issues. My published peer-reviewed articles are available here.
Links to other resources: