Will Australia's tightened prescription system reduce nicotine vaping among young people?

Preventing uptake of e-cigarettes by youth is a central health policy objective; however, a balanced approach to e-cigarette regulation should also support the accessibility of e-cigarettes for adults seeking to quit smoking using e-cigarettes. Australia's 2011 e-cigarette prescription-only model has not prevented many youth and young adults from vaping, according to Hall's [1] recently published article. As Hall [1] points out, few people have obtained e-cigarettes via the medical prescription route under Australia's current ban on the sale of e-cigarettes on the open consumer market, therefore, many of the two million people who vaped in 2023 used illicit products. This was further corroborated by a recently published study by Borland et al. [2] that examined the proportion of Australian adults using prescription e-cigarettes to quit smoking. The authors reported that despite a modest increase between 2018 and 2022, only 16.5% of Australian adults who used an e-cigarette during a smoking cessation attempt received a prescription. Therefore, approximately four in five of adults who tried to quit smoking and used an e-cigarette to do so, obtained their products through illegal means. Globally, e-cigarettes have been the focus of a contentious debate regarding how they should be regulated, arising from the desire to protect youth and non-smoking young adults from vaping (and addicting a new generation to nicotine) while also considering how e-cigarettes—that contain substantially fewer toxicants than combustible cigarettes [3, 4]—can offer people who smoke a less harmful alternative. Countries and jurisdictions around the world have taken very different approaches, with some completely banning e-cigarettes with nicotine, some regulating them as tobacco products, some regulating them as distinct from tobacco products (e.g. as their own product category or as general consumer products), and others not having any regulatory framework at all [5]. The public health impact of e-cigarettes will depend on their substitutability for tobacco cigarettes. Some studies have found that e-cigarettes are good substitutes for cigarettes under specific price and marketplace conditions [6, 7]. Moreover, a recent Cochrane review concluded that there is high-certainty evidence that e-cigarettes increase quit rates compared to nicotine replacement therapy [8]. However, several real-world studies have shown that many people who smoke and initiate vaping also continue dual use [9]. Therefore, public health benefits from e-cigarette use will depend on whether those who smoke and vape actually quit smoking rather than continue with long-term dual use. We agree with Hall that restrictive forms of e-cigarette regulation may result in unintended consequences. First, under Australia's prescription scenario, many healthcare professionals (HPs) are not willing to provide prescriptions [10]. Many HPs appear to have significant concerns about the safety and efficacy of e-cigarettes for smoking cessation [10] and few recommend them to their patients [11, 12]. If a majority of physicians remain unwilling to provide e-cigarette prescriptions, allowing pharmacists to do so could increase access to e-cigarettes for therapeutic purposes [13]. Additionally, considering adding e-cigarettes to clinical practice smoking cessation guidelines may help encourage HPs to recommend them if an individual is committed to quitting smoking. Second, eliminating access to e-cigarettes may result in deterring people who would otherwise continue to smoke from considering and trying to switch to a less harmful alternative. Third, if individuals who smoke want to switch to vaping, they may seek out illicit vaping products. This appears to be the reality in many countries, including Australia, which was ranked ninth among countries in Chinese exports of e-cigarettes in 2023, despite their illegality [14]. Fourth, vaping may constitute a unique harm reduction opportunity for preventing relapse among those who have quit smoking, particularly if they are heavily dependent on nicotine [15-18]; however, more research is needed. Finally, people who have switched from smoking to vaping may be deterred from the inconvenience of repeatedly filling prescriptions if they continue long-term use (vape as a permanent alternative to cigarettes rather than using e-cigarettes as a short-term cessation aid). A balanced policy approach to e-cigarette regulation that supports the accessibility of e-cigarettes to adults who smoke, while also reducing their appeal, availability and affordability to people who do not smoke is complex. While the prescription-only model is one approach, there are other avenues that could be considered as suggested by the United Kingdom Royal College of Physicians [19] and by Hall [1], including e-cigarettes being sold as consumer products by licensed adult retailers under regulations requiring plain packaging, strict regulations on advertising and promotions and imposing strict age verification at the time of purchase. Shannon Gravely: Writing—original draft (lead). Geoffrey T. Fong: Writing—review and editing (equal). G.T.F. has served as an expert witness or consultant for governments defending their country's policies or regulations in litigation. S.G. and G.T.F are funded by the United States National Cancer Institute (P01 CA200512) and the Canadian Institutes of Health Research (FDN-148477). Additional support to G.T.F. is provided by a Senior Investigator Award from the Ontario Institute for Cancer Research. The authors do not have any relationships with the nicotine industry to disclose.

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