Australia’s prescription model of vaping needs to be replaced by regulated retail sales

E-cigarettes (vapes, for short) have been marketed as products to assist smokers to quit and as a safer alternative than cigarette smoking for those who are unable to quit.

In England, medical and public health authorities have promoted vapes as a smoking cessation aid and as a less harmful alternative to cigarette smoking. The government has allowed vapes to be sold in retail outlets and the NHS has promoted vaping for smoking cessation and tobacco harm reduction. These policies have had the strong support of the Royal College of Physicians, Cancer Research UK, and Public Health England.

In Australia, by contrast, public health authorities adopted a much more restrictive policy that has the primary goal of preventing adolescent uptake. In 2016, Australia banned the retail sale of vapes that contained nicotine and would only allow them to be sold as prescription medicines.

The primary aim was to prevent adolescent vaping from serving as a gateway to cigarette smoking because Australian policymakers were sceptical about claims that vaping was a successful smoking cessation aid. They assumed that eventually, smokers would be able to legally access e-cigarettes that contained nicotine if the TGA approved them as effective cessation aids.

How has Australia’s policy fared?

In brief, the prescription model and retail sales ban have failed to prevent the uptake of youth vaping. Few adults have used the legal prescription pathway to access vapes, instead mainly sourcing vapes from illicit suppliers and thereby adding vapes to the illicit market for tobacco products

Australia’s vape sales ban has not prevented what has been described as a “youth vaping epidemic”. The extent of the “epidemic” has been inflated by highlighting the prevalence of lifetime vaping by adolescents (35%) while downplaying the much lower prevalence of use in the past 30 days (10%) and in the last week (less than 6%). Talk of a “vaping epidemic” has created parental and public alarm, prompted headmasters to expel students for vaping and led to calls for even more punitive policies. It has also encouraged adolescents to believe that all their peers are vaping, potentially normalising vaping and generating a ‘fear of missing out’ among those who don’t vape.

Australia’s prescription system has not increased legal access to vapes. The TGA has not approved any vapes for smoking cessation and most of the 1.6 million Australians who used vapes did so without a prescription.  In 2021, regulatory reforms encouraged medical practitioners to prescribe vapes as unapproved therapeutic goods via a streamlined authorised prescriber pathway for patients who had failed to quit smoking using approved smoking cessation products (e.g. nicotine gum and patches and varenicline).

By 2023, less than 10% of the 1.8 million Australians who now use vapes had a prescription.

The factors that most likely contributed to the low rate of prescriptions were the continued easy access to illicit vapes and the reluctance of many medical practitioners to prescribe vapes

For example, the Australian Medical Association and the Royal Australian College of General Practitioners have strongly discouraged medical practitioners from prescribing vapes.

The majority of Australian vapers continued to illegally purchase vapes online and from retail tobacconists and “vape shops”. These outlets illegally sold vapes that contained nicotine, using the figleaf that they were selling nicotine-free vapes (which were legal in all states apart from Western Australia). Very few vapers were probably aware that obtaining a vape that contained nicotine without a prescription could be punished by a large fine (up to $45,000 in Western Australia) or imprisonment for up to two years in the ACT.

Illegal sales of vapes have been added to an existing illicit tobacco market

Australia’s very high tobacco taxes have produced cigarette pack prices of $40-$60 and stimulated many low-income smokers to purchase smuggled manufactured cigarettes and loose tobacco (chop chop) illicitly grown in Australia. Customs have seized large quantities of illicit tobacco cigarettes smuggled into Australia by organised crime syndicates and over 30 tobacco retail stores in Melbourne have been firebombed because their owners refused to sell illicit tobacco. The Australian Tax Office has estimated that several billions in tobacco excise have been lost to illicit sales.

In 2024 the Federal government made the personal importation of vapes illegal. It only allowed cigarette smokers to obtain vapes that complied with strict requirements (eg only tobacco or menthol/mint flavours, and restricted nicotine content) on a doctor’s prescription from pharmacists.  The legislation to enact this policy was rejected by the Senate and the bill was amended to allow pharmacists to supply adults with low-dose vape products (up to 2% nicotine). Prescriptions were required for products that deliver higher doses (up to a maximum of 5% nicotine) and for products used by 16-17-year-olds. This change was rejected by the Pharmacy Guild,  making it unclear how many adult smokers will be able to legally obtain vapes from pharmacies.

A false policy choice

Australian policymakers seem to have accepted the false framing presented by advocates of Australia’s restrictive vaping policy, namely that Australia must choose between (1) enforcing a prescription model and (2) allowing the unregulated sale and promotion of vapes to nonsmoking adolescents and young adults.

Australia could instead allow adult smokers to legally purchase vapes in ways that minimised youth uptake, as shown by recent US success in reducing youth vaping (and smoking) without banning the sale of vapes (Warner, 2024)

We could, for example, require plain packaging of TGA-approved vapes, ban their promotion (apart from at points of sale), restrict their sales to licensed retailers, such as tobacconists or vape shops and enforce age limits on purchases. These retail outlets would be required to comply with age restrictions on entry or risk losing their licenses. This rule could be enforced by mandating CCTV recording of all sales, as has been done in US states that have legalised the sale of cannabis products to persons over the age of 21 years. Licensing retail tobacco sellers is a long overdue reform that would also reduce the scale of illicit tobacco sales and ready access to cigarettes.

• if you do not smoke, do not vape;
• if you do smoke cigarettes, consider using vapes to quit smoking; and
• if you are unable to quit smoking by vaping, then switch completely to vaping to obtain nicotine in a far less harmful way than continuing to smoke.

Article in The Mandarin

Hall W. Australia’s prescription model of vaping needs to be replaced by regulated retail sales. The Mandarin 28 October 2024