Smoking cessation: the need for a new approach

Smoking as a chronic condition

While many people successfully quit smoking before causing severe damage to their health, for others smoking is a chronic disorder that may require multiple quit attempts over a long period before they achieve enduring abstinence. Research has demonstrated a representative pattern of smoking cessation that will be familiar to all health professionals:

• Around 50% of smokers quit successfully on their first serious attempt;
• For the rest, it takes on average, 30 attempts over 20 years before achieving abstinence; and
• After a failed quit attempt, it will take most smokers a year before they try again.

For long-term smokers, the typical outcome of a quit attempt is a relapse to smoking and, consequently, continued exposure to toxic smoke.

Morbidity and mortality typically start to compound after the age of 30. Dependent smokers who fail in their first serious quit attempt have a high risk of smoking in their 50s and beyond, having inflicted severe damage to their health and incurred a significant risk of early death.

On the other hand, successfully quitting smoking is beneficial to health at any age.

Cigarettes represent a uniquely challenging problem

Nicotine is reinforcing when administered by cigarettes, and the speed of its delivery in cigarettes facilitates unique and complex behavioural mechanisms. These mechanisms underlie nicotine reinforcement well beyond the drug’s actions as a primary reinforcer. Nicotine also acts as a moderator of associative learning and has unique effects on conditioned responses to cigarette-specific, social, and environmental stimuli.

For this reason, and due to cigarettes’ wide availability and entrenched cultural and mnemonic significance, cigarettes remain the default mode of nicotine consumption for most nicotine users. When quitters relapse, they relapse back to smoking, not NRT.

Understanding smoking cessation and NRT

NRT replaces the nicotine from cigarettes with a lower and more slowly administered dosage and aims to aid motivated quitters in managing the transition from smoking to abstinence more comfortably.

Nicotine replacement has long been known to be safe and effective in patients who adhere to treatment. Adherence, however, remains low and is much lower in real-world use than in clinical trials.

The success or failure of NRT or any other licensed cessation therapy is down to the patient’s sustained motivation to stop smoking and achieve permanent nicotine abstinence. Unfortunately, while motivational factors predict attempts to quit smoking, they are poor predictors of the maintenance of smoking cessation.

NVPs as a new smoking cessation tool

An alternative to smoking led by people who smoke

NVPs emerged as a user-innovated technology and are frequently used by smokers for smoking cessation. Innovations over the last half-decade mean that NVPs can now closely reproduce cigarettes’ pharmacological and behavioural properties. NVPs do this without producing the toxic constituents of smoke; NVP aerosols contain substantially fewer chemical constituents than cigarette smoke, and while toxic compounds have been found, they are at orders of magnitude less than in cigarettes.

The widespread adoption of NVPs in consumer markets worldwide, led by recent innovations in New Generation NVPs, such as Nicovape® Q, demonstrates their appeal to smokers.

Adapting a consumer-led technology to a clinical framework

The new framework governing access to NVPs seeks to address the public health concerns that NVPs may attract youth and non-smokers to nicotine addiction while implementing minimum standards for prescribed NVPs.

In a world-first, this framework makes the Australian medical community custodians of NVP technology and, consequently, confers on it the responsibility for maximising its potential for patients.

Clinicians must develop expertise in integrating NVPs into good clinical practice, leveraging the opportunity to address one of their patients’ most intractable problems.

Types of NVPs available under the Framework

NVPs comprise a wide array of different products. Under TGO 110, only two categories of NVP may be prescribed and dispensed:

Closed system (New Generation)

• Device and single-use cartridges containing e-liquid
• Mitigates avoidable risks
• Allows uniform dosage
• Appropriate for pharmacy

Recommended by RACGP

Open system

• Refillable devices where users add refill liquids
• Old technology, unlikely to qualify for ARTG registration
• High risk of contamination or potentially toxic or illegal substances consumed
• Thousands of devices and e-liquids of differing qualities

Not recommended by RACGP, except for experienced vapers

Disposable

• Non-rechargeable, single-use devices, discarded after use
• Typically low quality and often counterfeit
• Responsible for widespread youth access
• Environmentally unsustainable battery and plastic waste

Prohibited

New Generation closed-system NVPs have largely replaced the older open-system technology. Nevertheless, some patients still use open-system NVPs.

The RACGP suggests that open-system NVPs be prescribed to these patients only if needed and that Prescribers encourage patients to adopt a closed-system NVP where possible.

Prescribers should note that closed-system NVPs may be the only type available for prescribing in the longer term since closed-system NVPs can be sufficiently characterised for listing on the ARTG, whereas open-system NVPs cannot.

Understanding Nicotine Concentration and Dose Delivery from NVPs

Nicotine concentration is frequently used incorrectly as shorthand for “dose”. It is important that Prescribers understand how nicotine concentration interacts with other factors to determine the delivered dose.

Multiple factors determine the amount of nicotine an NVP delivers systemically:

• Device power
• The mass of liquid that the device turns into aerosol per given puff
• Nicotine concentration
• The amount of nicotine in the mass of aerosol per given puff
• User characteristics
• How often the patient puffs, how long they puff for, how deep they inhale

New approaches to smoking cessation may provide exceptional benefits

Significant research efforts have been made into how behavioural support, non-nicotine pharmacotherapies, combination therapies, and public health strategies can enable smokers to develop the willpower to become cigarette and nicotine-free.

However, successes in driving down smoking in Australia have increasingly come from decreases in youth initiation. Notwithstanding, 40% of Australian smokers make a quit attempt each year, and increasingly do so with the assistance of a health professional. Consequently, even with a modest increase in treatment efficacy, there will be a tremendous longer-term population-level upside as this effect compounds.