Study population
Demographic characteristics of participants are reported in Table 1. It can be seen the sample comprised GP’s located in 5 states, the majority in metropolitan regions (n = 12). A balanced number of females and males were interviewed. GPs had been practicing on average for 19 years. Three GP’s worked in academia, two in addiction services and one in an Aboriginal health service.
Table 1
Demographic characteristics
| | Total N = 13 |
Gender | Female | n = 7 (54%) |
| Male | n = 6 (46%) |
Years of practice | 1–10 | n = 4 (31%) |
(min 4- max 46 years) | 11–20 | n = 4 (31%) |
| 21–30 | n = 3 (23%) |
| 30+ | n = 2 (15%) |
State | Victoria | n = 4 (31%) |
| Queensland | n = 4 (31%) |
| New South Wales | n = 3 (23%) |
| South Australia | n = 1(7.5%) |
| Western Australia | n = 1 (7.5%) |
Region | Metropolitan | n = 12 (92.5%) |
| Rural | n = 1 (7.5%) |
Participants reported they would use clinic software (n = 12) to record patients smoking status and all reported they asked their patients on their initial consults whether or not they were current or former smokers.
Five main themes were identified: GP’s attitudes toward e-cigarettes, concerns about safety of e-cigarettes, concerns of dual use and the gateway effect to other tobacco products, GP’s understanding of policy and finally, mixed levels of confidence and comfort prescribing and discussing e-cigarettes with patients.
Theme 1: GP’s attitudes on e-cigarettes
There were diverse views among the GP’s interviewed toward recommending e-cigarettes to patients and prescribing nicotine e-liquids. These mixed opinions arose from gaps in the participants knowledge about e-cigarettes as well as concerns they held about the availability and veracity of data on the safety and efficacy of e-cigarettes. Behind these diverse attitudes were concerns about the quality of evidence underpinning recommendations about the role of e-cigarettes as a smoking cessation therapy.
Some GP’s described how they were adamant they would not recommend e-cigarettes, such as GP’s #2 and #8 who stated:
“I won’t recommend them, I have not recommended them” (GP#2, M, 6 years of practice).
“[There is] no situation in which I would recommend an e-cigarette. I am not going to recommend it to anyone.” (GP#8, M, 40 years of practice)
However, others were willing to consider them if they had further evidence that they help patients quit smoking, with particular interest in groups of patients such as “older established smokers” (GP#13, F, 25 years of practice) that haven’t been successful quitting using other available treatments.
“As a last resort to my older patients who are quite desperate to quit and have failed using all other methods.” (GP#4, F, 7 years of practice)
“I don’t know if I would [recommend e-cigarettes] until more information and evidence comes out.” (GP#11, F, 17 years of practice)
Some GPs’ who had tried established treatments to help their patients cease smoking without success, were willing to recommend e-cigarettes as a “third line option” (GP#12, M, 19 years of practice) and as a “last resort” (GP#1, M, 46 years of practice) to patients that have “tried varenicline, bupropion, nicotine replacement therapies, counselling, behavioural support and hasn’t worked” (GP#7, M, 23 years of practice).
The attitudes held by GP’s reflected their knowledge and confidence in their understanding of e-cigarettes. GP’s stated they had “limited” (GP#4, F, 7 years of practice) to “adequate” (GP#3, F, 25 years of practice) knowledge about e-cigarettes, whilst others believed they had enough, “basic knowledge” (GP#2, M, 6 years of practice; GP#9, F, 4 years of practice; GP#10, F, 15 years of practice) to offer advice if patients asked. Some GP’s mentioned they haven’t had patients ask them about e-cigarettes to quit smoking and hence, didn’t know much about the topic.
“Probably not really [having enough knowledge]. In practice a lot of things are stimulated by having a patient ask us then if we’re good doctors we’d go and do some homework, so we can advise them. I’ve got a bit of understanding but I haven’t really, because I haven’t had anybody ask me about it.” (GP#1, M, 46 years of practice)
A few participants mentioned they remained uncertain about how to prescribe and decrease the nicotine e-liquid dosage after patients had started using e-cigarettes. They desired more information on how to do so.
“I just don’t think as a doctor we are really knowledgeable or trained in how to talk to people about milligrams of nicotine that is equivalent in their vaping liquid and how much they should be reducing that by over what period of time. There is just no information on that.” (GP#6, M, 11 years of practice)
“When it comes down to the individual doses, duration of being on a certain dose, before you step up or down. That part of it I don’t think I have as much knowledge.” (GP#9, F, 4 years of practice)
In order to enhance GP’s level of knowledge, GP’s wanted further materials and resources available to them. These included updated, easy to read guidelines on e-cigarettes from the Royal Australian College of General Practitioners (RACGP) and Therapeutics Good Australia (TGA). Some GP’s also mentioned they would like to receive training as long as it was not a long and time intensive training session. They would prefer the session be pre-recorded for them and be available online to view in their own time and when they felt the need to watch it as a reminder. A simple one-page summary or an infographic of the pro’s and con’s on e-cigarettes was also preferred as well as, a quick snapshot on the types of devices, flavours and strengths of nicotine e-liquid to help GP’s prescribe e-cigarettes to their patients.
Some GP’s mentioned they would like to see the “latest up to date evidence” (GP#4, F, 7 years of practice) on e-cigarettes as smoking cessation aids to help guide them in their current practice.
“I’d like to see more evidence that compares it to other smoking cessation aids, but I haven't seen any or heard of any good evidence yet.” (GP#3, F, 25 years of practice)
“Evidence for cessation of smoking [using e-cigarettes] over a three-month program with the following doses and frequency of use, something that looks a little bit scientific.” (GP#8, M, 40 years of practice)
GP’s gained information and knowledge on e-cigarettes through medical journals, social media platforms and guidelines from the RACGP. This information helped shape their attitudes toward the role of e-cigarettes as part of a smoking cessation strategy.
Theme 2: Safety sits above all in considering a role for e-cigarettes in smoking cessation
Many GP’s expressed optimism about the role that e-cigarettes could potentially have as smoking cessation treatments. Some GP’s described their belief that e-cigarettes were “much safer” (GP#6, M, 11 years of practice; GP#8, M, 40 years of practice) and “less harmful than regular cigarettes” (GP#9, F, 4 years of practice; GP#13, F, 25 years of practice).
“I think they are a good tool [e-cigarettes] providing we accept that there are unknowns to it, but I think it is a good tool [e-cigarettes] to get people to stop smoking. If it’s used appropriately as smoking cessation it is a powerful tool [e-cigarettes].” (GP#6, M, 11 years of practice)
“I think they [e-cigarettes] have a role that’s sort of second or third line after the other options which we kind of know the safety data on. My understanding is that they’re [e-cigarettes] more effective, or have been shown to be more effective than nicotine replacement therapies (NRTs).” (GP#9, F, 4 years of practice)
“The role that I see them [e-cigarettes] as, it’s automatically taking out a lot of really harmful carcinogens and it’s basically another form of NRTs that has the cultural, psychological, and behavioural link that gum, lozenges and patches don’t have. I think it’s a great option for smoking cessation.” (GP#5, F, 9 years of practice)
However, some GP’s expressed concerns about potential harmful effects e-cigarettes could have on the body and not knowing the long-term health effects they may produce in the future.
“Concerns about harms and not knowing if they [e-cigarettes] actually do help people stop smoking enough to be worth recommending them to use.” (GP#1, M, 46 years of practice)
“There’s potential harm still if there’s additives to the vape, like flavours and fragrances. There could still be other chemicals there that we just don’t know enough about.” (GP#3, F, 25 years of practice)
Theme 3: Concerns of dual use and gateway effect to other tobacco products
There was apprehension about the use of e-cigarettes for smoking cessation, “as it has the potential to become a window or a door to other products and a pathway to smoking” (GP#2, M, 6 years of practice). Making the devices more accessible and more visible was considered by some as providing a gateway to groups at risk of taking up smoking like young people.
“I think that’s a huge risk [dual use], and I think it’s already happening. You can see socially that people are more likely to interchange their use, depending on what’s available at the time.” (GP#4, F, 7 years of practice)
“It’s a gateway to an unnecessary addictive behaviour that isn’t going to do anyone any favours. Even if they [young people] just vape and do nothing else, that’s worse for them than if they didn’t vape, and that’s enough harm for me to feel very uncomfortable about what’s happening in the young people who are being recruited to vaping.” (GP#13, F, 25 years of practice)
GP’s expressed concerns on the various types of flavours available to young adolescents and the potential groups the tobacco industry is trying to target.
“It’s [e-cigarettes] easily accessible, young people would probably be thinking it’s kind of cool – different colours, different flavours.” (GP#4, F, 7 years of practice)
“The biggest thing is that I think it is being used to appeal to the adolescents and younger markets who aren’t smokers. It’s like cigarettes all over again. It’s an image thing. It’s because of the candy flavours.” (GP#6, M, 11 years of practice)
Theme 4: ‘A bit of a guess’ – GP’s understanding of policy was limited
Understanding of current policy about e-cigarettes in Australia was limited amongst participants. Some GP’s stated they knew “very little” (GP#6, M, 11 years of practice) or, their understanding of it was “not very good” (GP#1, M, 46 years of practice) or, they didn’t know the “specific ins and outs” (GP#4, F, 7 years of practice), or had very little idea of the current legislation.
“My understanding of the current policy is that it’s similar to smoking, there’s no smoking including vaping in cars with kids and then in public places and inside. In terms of e-cigarettes it’s illegal to supply it to a minor, illegal to have nicotine liquid without a prescription.” (GP#10, F, 15 years of practice)
A couple of GP’s had formed a ‘personal’ policy position, for example.
“I think the policy for me is, it’s not yet established in terms of what we are going to do with this phenomenon. It is misinforming, it is changing, there is differences in the opinions between the policy makers across the country, between states and territories. It has created some confusion for service providers including clinicians.” (GP#2, M, 6 years of practice)
“My policy is that there’s no evidence to recommend it’s use in smoking cessation.” (GP#11, F, 17 years of practice).
Only a few participants had prior knowledge of the current legislation.
“I understand it's meant to be only on a doctor’s prescription that can be compounded or imported. But there's not any TGA listed specific liquids or devices that are really available.” (GP#7, M, 23 years of practice)
“My understanding is that the products are not TGA approved, but there was a desire to regulate the industry, and so, prescriptions are required to legally purchase them or legally import them.” (GP#13, F, 25 years of practice)
A small number of GP’s expressed their concerns and frustrations on being gatekeepers to e-cigarettes. They “wished they didn’t have to do this” (GP#12, M, 19 years of practice) and tended to disagree with it. They didn’t see “why this needs to be a GP’s problem and that doctors don’t have a role here” (GP#6, M, 11 years of practice). One GP had seen “a lot of people [other GPs] voice discomfort at being put into a gatekeeper role” (GP#7, M, 23 years of practice).
Further discussions took place about illegal risks.
“I think the ownership of me prescribing it [e-cigarettes] and taking on that risk, is a massive negative. That’s a big barrier because why would anyone want to risk legally their career and their potential for legal ramifications 15 years from now because it’s an unknown quantity that has been mandated but, it can only come from me which is really frustrating?” (GP#5, F, 9 years of practice)
“I know that a lot of other GP’s were really wary about prescribing or endorsing e-cigarettes and didn’t feel like they were I suppose medico-legally protected if they did that. A lot of GP’s don’t feel very confident about them.” (GP#9, F, 4 years of practice)
One GP suggested having consent forms available for patients to sign and read before giving a prescription of e-cigarettes to cover any future legal ramifications.
Theme 5: Mixed levels of confidence and comfort prescribing and discussing e-cigarettes with patients
GP’s stated they felt “fairly confident” (GP#7, M, 23 years of practice; GP#9, F, 4 years of practice; GP#10, F, 15 years of practice; GP#12, M, 19 years of practice) or “moderately confident” (GP#3, F, 25 years of practice; GP#6, M, 11 years of practice) but others were “not confident” to answer patient questions about e-cigarettes (GP#1, M, 46 years of practice; GP#2, M, 6 years of practice; GP#11, F, 17 years of practice).
In regards to level of comfort to prescribe nicotine e-liquids, some GPs didn’t feel comfortable (GP#7, M, 23 years of practice; GP#11, F, 17 years of practice) to do so as they “haven’t had suitable patients” (GP#3, F, 25 years of practice; GP#6, M, 11 years of practice). Others didn’t feel comfortable due to lack of knowledge and the need for further information.
In order for GP’s to feel comfortable to recommend e-cigarettes for smoking cessation to patients they suggested having further training and information available to them when they needed it, particularly, a one-page summary of pertinent information.
Others wanted to see more information from the TGA on the types of devices in addition to information on recommended doses for nicotine e-liquids that GP’s should prescribe as they lacked knowledge in this area.
“From the TGA, it would be nice to see more about recommended doses, maybe even a guide to which pharmacies are stocking them and are registered if that’s a requirement.” (GP#9, F, 4 years of practice)
“Sometimes patients will try one vape but they don’t like that device. Some more specific guidance around well, if this device doesn’t work for you, why is that, maybe you need a higher concentration, or maybe this device doesn’t suit you, what device next?” (GP#10, F, 15 years of practice)