The Royal Australian College of General Practitioners (RACGP) has given a conditional recommendation for the use of e-cigarettes as a last resort in smoking cessation guidelines.

However the College stresses the move is not a major shift in policy or an endorsement of e-cigarettes as claimed by some pro-vaping groups.

Recommendation 15 of the guidelines includes the advice to GPs that: “for people who have tried to achieve smoking cessation with approved pharmacotherapies but failed, but who are still motivated to quit smoking and have brought up e-cigarette usage with their healthcare practitioner, nicotine containing e-cigarettes may be a reasonable intervention to recommend.”

Chair of the Expert Advisory Group behind the guidelines, Professor Nicholas Zwar, said the College was saying there could a place for vaping products in a smoking cessation program, but only if supported by an informed decision-making process with the patient on risks involved.

“There’s a range of caveats around that about we don’t know about long-term safety, as there isn’t the data. We don’t have a product that’s been through a Therapeutic Goods type assessment to know about its quality and safety. And there’s the risk of dual-use and long-term use,” Prof Zwar told the limbic.

“But the reality is there are some patients who just have not been able to quit using the tools that we have available at the moment. And I’m sure thoracic physicians face that challenge, as do GPs and other health professionals,” said Professor Zwar, a GP with a special interest in lung disease who is now Executive Dean of Bond University’s Faculty of Health Sciences and Medicine.

Important clarification. The @RACGP does not endorse vaping. Our guide’s conditional recommendation (link below) notes that it’s only a reasonable intervention in very limited circumstances & that the long-term health effects are unknown #FactCheck https://t.co/MNsZDg9nMZ pic.twitter.com/rzwBWukk8t

— RACGP President (@RACGPPresident) January 28, 2020

The RACGP position stands in contrast to opposition to the use of e-cigarettes by other Australian medical professional groups, such as Thoracic Society of Australia and New Zealand, who  have emphasised “the direct harms e-cigarettes pose to human health.”

TSANZ, Lung Foundation and the Cancer Council have pointed to mounting evidence that use of e-cigarettes, or vaping, has been linked to cell damage in the lungs, and an increase in smoking uptake by young people.

TSANZ president Professor Bruce Thompson said the RACGP was not endorsing vaping but making a pragmatic response to real world use of the products by patients.

“The RACGP response has recommended e-cigarettes are not a first-line option as they are not an approved cessation product,” he said.

Prof. Thompson noted that no tested and approved e-cigarette products are available (despite the European Medicines Association conducting ingredients tests on the market), and the long-term health effects of vaping are unknown although in some cases have been found to be lethal.

“We would further add, that smokers should be supported by behavioural change programs to further ensure the best chance of quitting.”

Professor Matthew Peters, head of respiratory medicine at Concord Hospital, Sydney, said the inclusion of e-cigarette advice within the guidelines could be interpreted as an endorsement of vaping by those with financial links to the industry.

“People can draw their own conclusions, but you need to understand the fundamental premise of this is to provide good guidance for GPs so they can best handle a specific clinical situation that may arise in their practice,” he said.

The RACGP’s President Dr Harry Nespolon said there was a need to reduce the cost of nicotine replacement therapy (NRT) due to the high rates of smoking within low socioeconomic groups. He said PBS prescribing rules should be changed to allow GPs to prescribe a second round of PBS-subsidised NRT within a 12-month period.

“Varenicline or combination NRT almost triples the odds of quitting and bupropion and NRT alone almost double the odds of quitting versus a placebo at six months. The evidence is also clear that combination NRT is most effective,” said Dr Nespolon.