Letters
Substance‐related disorders Environmental health Pharmacology
Volume 217 - Issue 10

What doctors should consider before prescribing e‐liquids for e‐cigarettes

Authors:  Alexander Larcombe, David Chapman and Miranda Ween

Med J Aust 2022; 217 (10): 548-548. || doi: 10.5694/mja2.51765
Published online: 21 November 2022

In reply

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In reply: We thank Mendelsohn and Beaumont1 for their commitment to tobacco harm reduction and we agree that a personalised approach is likely to be most beneficial. However, nicotine prescriptions have been thrust upon Australian medical professionals with effectively no guidance, especially as to how a personalised approach should and could be implemented. Our approach takes into account current evidence to provide a foundation for prescribing e‐cigarettes until the necessary data become available.2 Our intent was to provide information for all clinicians, including general practitioners and pharmacists, especially for those with minimal experience implementing smoking cessation who may be approached to prescribe e‐cigarettes.

The authors’ statement that a “starting nicotine concentration of 18mg/mL is inappropriate for most new users”1 is not supported by published data. As we stated, there is little evidence for an “ideal” nicotine concentration in e‐liquids; however, 18mg/mL has been shown to reduce nicotine cravings and promote tobacco cessation.3 As mentioned, we strongly advocate for timely follow‐up support so nicotine dose can be appropriately adjusted as required for each user.2

Our concerns about nicotine toxicity are well founded. In addition to observed toxic effects to users,4 as little as 50mg of nicotine (10mL of a 5mg/mL e‐liquid) is sufficient to be fatal to a child.5 Thus, it is reasonable to suggest that higher nicotine concentration e‐liquids present greater risks of accidental poisonings.

We also stand by our statement that “unflavoured e‐liquids should be preferentially prescribed”. This does not necessarily mean flavours should not be used where needed, but their use should be discussed in an informed way so that vapers are aware that no e‐liquid flavours are approved for inhalation use and many pose health risks.

Finally, we do not advocate for a “blanket 3‐month prescription maximum” — this is a reasonable approach suggested by the Royal Australian College of General Practitioners,6 and there is literature supporting the efficacy of this time frame.7 Although we acknowledge some smokers will require longer, it is important, and achievable, to work towards nicotine abstinence. Without a plan and consistent feedback, the final goal of nicotine abstinence will not be achieved. Our approach is consistent with the known vital role for behavioural support for tobacco cessation.

 

Authors

  • Alexander Larcombe1,2
  • David Chapman3
  • Miranda Ween4
  • 1. Telethon Kids Institute, Perth, WA
  • 2. Curtin University, Perth, WA
  • 3. University of Technology, Sydney, Sydney, NSW
  • 4. University of Adelaide, Adelaide, SA

Correspondence: miranda.ween@adelaide.edu.au

Competing interests

All authors have received funding from funding bodies that are not associated with the tobacco, e‐cigarette, or smoking cessation industry.

References

Linked content

  • MJA Perspective: What doctors should consider before prescribing e‐liquids for e‐cigarettes

  • MJA Letter: What doctors should consider before prescribing e‐liquids for e‐cigarettes

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