Starting and reviewing nicotine vaping products for tobacco smoking and nicotine dependence

Nicotine forms available in Australia for use in nicotine vaping products are freebase nicotine or nicotine salts.

Freebase nicotine is the original form of nicotine for vaping; it suits people who use nicotine vaping products in small inhalations because it can cause throat irritation at concentrations higher than 20 mg/mL.

Nicotine salts have been pH-balanced to reduce the risk of irritation; these newer products are suited to people who are highly nicotine dependent or those who cannot, or prefer not to, use small inhalations of nicotine vaping products regularly during the day and prefer to rely on larger intakes less frequently. These salts have a higher potential for nicotine dependence than freebase nicotine because the concentration of nicotine in each use may be higher.

For patients with low or moderate nicotine dependence (those who start smoking more than 30 minutes after waking), appropriate products are freebase nicotine of 6 to 12 mg/mL or nicotine salts of 20 to 30 mg/mLTherapeutic Goods Administration (TGA), 2021.

For highly nicotine-dependent patients (those who start smoking within 30 minutes of waking), appropriate concentrations are freebase nicotine of 18 to 20 mg/mL or nicotine salts of concentrations above 30 mg/mLTherapeutic Goods Administration (TGA), 2021.

If unsure of the appropriate dose, start at a low dose and increase if needed to the lowest effective dose.

Prescribers can specify a nicotine concentration, flavouring and brand if desired, and whether the device is prefilled or refillable. For patients without a preference, a prefilled unit, at a low nicotine concentration (eg 6 to 12 mg/mL) is recommendedTherapeutic Goods Administration (TGA), 2021. Counsel patients that the long-term safety of flavourings in nicotine vaping products is unknownMuthumalage, 2017.

Review patients using nicotine vaping products at least 3-monthly. Discuss reducing the nicotine concentration in the nicotine vaping product or switching to nicotine replacement therapy.