18.11 Cessation interventions to help people quit vaping

With the rapidly increasing use of e-cigarettes, particularly among young people, researchers are increasingly examining e-cigarette cessation behaviours. The addictive potential of nicotine vapes—including popular products that can deliver the equivalent nicotine of a pack of cigarettes¹—has led to urgent calls for evidence-based strategies to help people who vape to quit.^2,3 Prolonged exclusive use of e-cigarettes is becoming an increasingly common pattern of use,⁴ and e-cigarette users report symptoms of withdrawal when abstaining from vaping.⁵ Like people who smoke,⁶ many people who vape report wanting to quit. Research shows that many established e-cigarette users, including both adolescents and adults, have tried to cut back on vaping, have intentions to quit vaping in the future, or have tried to quit but were unsuccessful.^3,7-17

Some of the motivations for wanting to stop vaping are similar to those reported by people who smoke who want to quit, including health, financial, and social reasons,^10,14,18-24 as well as disliking the taste of the products.²² Young people have reported that issues accessing the products, including cost, restrictions, or inability to purchase, have motivated changes in vaping.^14,25 In the US, calls and texts to quitlines from e-cigarette users,²⁶ as well as internet searches for how to quit,²⁷ reportedly rose in the wake of the EVALI outbreak (a non-infectious respiratory illness linked to vaping—see Section 18.6). Several surveys have also found that respondents cite concern about risks of COVID-19 as a reason to stop vaping.^18,28 Higher levels of harm perceptions are associated with quit attempts among people who vape,^8,14 while interest in and attempts to quit vary across studies by dependence, frequency of use, and device type (e.g., disposable, cartridges/pods, or tank systems)^8,11,29-31 The most common method of trying to quit is going ‘cold turkey’, while other methods include cutting down frequency of use or nicotine concentrations, getting advice or support from someone (e.g., a doctor, counsellor, or parent), finding distractions, using the internet or a mobile phone app, and using nicotine replacement therapy (NRT).^{10,12-14,18,24,32}

18.11.1 Interventions for adults

Despite the identified need for evidence-based interventions, and even though surveys consistently show that many adults who vape want to quit,^7,29 to date there have been limited studies on the effectiveness of cessation aids for stopping vaping. Several recent reviews have highlighted a paucity of evidence on effective interventions for vaping cessation,^33-35 though one meta-analysis of studies testing educational content, digital tools and pharmacological interventions concluded that vaping cessation interventions are associated with significantly increased odds of achieving abstinence.³⁶ Limited evidence suggests that smoking cessation pharmacotherapies including nicotine replacement therapy (NRT), bupropion and varenicline may increase the likelihood of successfully quitting vaping.^37-40 For example, a recent randomised controlled trial (RCT) found that varenicline more than doubled the odds of quitting vaping compared with placebo (both were combined with counselling).⁴¹ Another found that varenicline combined with minimal behavioural support increased the likelihood of e-cigarette cessation.⁴² An RCT that examined cytisinicline (also known as cytisine and recently approved for use in Australia) with behavioural support for vaping cessation concluded that it appears to be safe and effective.⁴³ Nicotine mouth spray has been shown to effectively relieve urges to vape.⁴⁴

A small study provided support for a mobile-phone based behavioural intervention combined with NRT,⁴⁵ and another concluded that the addition of counselling to an automated text program shows promise.⁴⁶ Initial evidence also supports the effectiveness of quitlines for promoting cessation among people who exclusively vape,⁴⁷ though strategies may be needed to increase willingness and motivation to use this type of service.⁴⁸ Australian Quitline counsellors have reported increasingly receiving calls from people seeking help to quit e-cigarettes.^49,50

Although some e-cigarette users report gradually reducing use or nicotine concentrations in an attempt to quit,^18,51 the effectiveness and safety of this is unclear; as with tobacco cigarettes (see Section 3.36), people who vape may be able to compensate by utilising more liquid,^22,52 which may also increase their exposure to compounds/flavours with largely unknown toxicity.⁵³ Combining a tapering approach with behavioural support may increase the effectiveness of this strategy.⁵⁴ Workplace-based cessation programs may also be helpful for supporting employees to stop vaping,⁵⁵ and vape-free policies in the home can help to facilitate e-cigarette cessation.⁵⁶

In 2022, a panel of international experts developed a clinical resource to guide healthcare practitioners in helping their clients quit vaping. It recommends that people who vape be offered a combination of behavioural therapy strategies (tapering, CBT, etc.) with or without pharmacotherapy (NRT, varenicline, cytisine or bupropion, if available).⁵⁷ Provisional guidelines from the Royal Australian College of General Practitioners similarly recommend that health professionals consider strategies shown to be effective for smoking cessation; i.e. behavioural support and pharmacotherapy.⁵⁸ Brief interventions based on the ‘3As’ (Ask, Advise, Assist/Help) or the ‘5As’ (Ask, Advise, Assess, Assist, and Arrange; see Section 7.10) should be implemented, in line with guidelines for treating tobacco dependence.^58,59 Routinely asking patients about vaping and including this information in medical and dental records may also be helpful for guiding interventions and policies.^60,61 Screening parents in paediatric settings may help prevent children from exposure to vaping behaviours and aerosols.⁶² Including vaping in the curriculum as part of health professionals’ training would likely increase the provision of cessation advice and support for people who vape.^63-65 In Australia, the Quit Centre provides health professionals with the latest clinical information, resources and training on smoking and vaping cessation.

18.11.2 Interventions for young people

Many young people who vape report wanting to and trying to stop.^3,8,9,66 A survey of young Australians who vape found that most wanted to quit (61%) and had made a quit attempt (55%).⁶⁷ A particular challenge in the provision of e-cigarette cessation support is that while interventions are urgently needed for young people,^2,3 smoking cessation interventions (which may have some utility for helping people to quit vaping) have largely been developed for adults; there is limited evidence that either behavioural support or pharmacotherapies increase smoking cessation among young people⁶⁸ (see also Section 7.19.1). A 2023 Cochrane review concluded that there is no evidence available from RCTs to assess the potential impact of interventions targeting children and adolescent e‐cigarette or tobacco use.⁶⁹ Cessation counsellors may also lack confidence and experience in working with young people.⁷⁰ Research is needed to inform effective interventions for helping young people to quit vaping; very few cessation programs have been developed or evaluated, though some show potential.⁷¹ Further, recruiting adolescents for clinical trials of vaping cessation interventions can be difficult.⁷² One review notes the importance of considering the complexities of youth vaping (e.g., social influences, limited negative outcome expectancies, quit intentions), and potential co-use with cannabis.⁷³ Knowledge of predictors of uptake and ongoing use among young people (see Section 18.9) may also help inform targeted interventions.⁷⁴ For example, use among family/peers, perceptions of lesser harm and use of other tobacco products may reduce the likelihood of young people making progress toward quitting vaping.^75,76

Technology-based interventions show promise,³⁵ with findings from randomised clinical trials in the US showing that a tailored and interactive text message intervention promoted vaping cessation among adolescents⁷⁷ and young adults.^78,79 A review of apps for vaping cessation concluded that they tend to use similar strategies as smoking cessation apps, though noted there are relatively few apps or features designed specifically for people who vape. It recommends that vaping cessation apps employ evidence-based practices and undergo evaluations to maximise their quality, contents and features, and popularity.⁸⁰ A pilot study supported the feasibility and acceptability of a telehealth cessation intervention for young adults.⁸¹ Interventions that address and increase self-efficacy, coping skills and harm/risk perceptions may be particularly helpful among young people,^82-86 as well as identifying behavioural substitutions for vaping.⁸⁷ Interviews with young Australians additionally identified social support as an important component of interventions.⁸⁸ One small study found encouraging evidence for the use of financial incentives to promote e-cigarette cessation among young people,⁸⁹ and a case series reported that a combination of counselling and NRT increased e-cigarette cessation among youth and young adults.⁹⁰ A quitline-delivered intervention in the US was shown to be highly successful at helping young adults quit vaping, and the addition of NRT further meaningfully increased quit rates.⁹¹ Research in Canada also suggests that NRT may be helpful to young people quitting vaping.⁹² NRT is approved for use from 12 years of age in Australia (see Section 7.16), and may be considered for adolescents and young adults to help with nicotine withdrawal symptoms when quitting vaping.^93-95 A randomised clinical trial among young people aged 16–25 found that varenicline combined with behavioural counselling was well-tolerated and increased vaping cessation rates compared with placebo.⁹⁶ In line with this and emerging evidence of the effectiveness of varenicline in helping adults to quit vaping, it may be considered for young adults; however, varenicline is not currently recommended for adolescents in Australia.⁹⁵

Young people in the US report less frequent screening from healthcare providers for vaping compared with smoking;⁹⁷ training health professionals who have frequent contact with young people or parents in screening and brief interventions may help to increase their knowledge, skills and the provision of cessation support for e-cigarette users.^93,98-104 As with adults and with people who smoke, healthcare professionals should routinely provide brief interventions to young people who vape.⁹⁵ A small number of school-based cessation programs have been developed, which involve identification of students who vape, provision of information, and referral to a cessation program or in-school delivery by trained counsellors. Research so far has supported the effectiveness of these programs.¹⁰⁵ A review advocating the role of school nurses in supporting students to quit suggests that such interventions should be used in place of punitive measures.¹⁰⁵ A survey of young Australians found that school-based education on vaping was positively associated with quitting attempts.⁶⁷ Resources have also been developed for parents wishing to have conversations with their teenagers about the risks of vaping.¹⁰⁶

Broader policies and programs have been developed that aim to minimise e-cigarette use among young people and non-smokers, including restrictions on advertising and promotion, prohibiting use in smokefree areas, banning flavours that could appeal to youth, raising taxes, implementing health warnings, prohibiting sales to minors, school-based programs and public education campaigns. For example, social media campaigns have been developed to encourage young people to quit vaping.¹⁰⁷ One survey found that easy access to e-cigarettes among young Australians was associated with both a lower desire and fewer attempts to quit, highlighting the importance of preventing access among young people.⁶⁷ An overview of these strategies is provided in Section 18.10. Accessible cessation support may be particularly important for young people in Australia at the present time, as legislative reforms have restricted sales of vapes to participating pharmacies and banned sales from all other retailers (see Section 18.13).^58,108 These reforms aim to provide access to people who wish to use vapes to quit smoking or manage their nicotine dependence, while closing the loopholes that have allowed the widespread sale of nicotine vapes to adolescents.¹⁰⁹

18.11.3 Interventions for dual users of tobacco cigarettes and e-cigarettes

Although many people who smoke take up e-cigarettes as a means to quit tobacco cigarettes,^110-112 experience from both longitudinal studies and clinical trials shows that many will continue to use both.^113,114 Targeted interventions have therefore begun to be developed for dual users, who may require more intensive support to achieve complete cessation of both products.⁵⁶ One randomised trial found that a self-help intervention designed specifically for dual users¹¹⁵ improved smoking cessation, particularly during the 18 month intervention period and among dual users with higher tobacco dependence. However, there were no differences between intervention or control groups in vaping reduction or cessation.¹¹⁶ A 2023 review concluded that there was no evidence for effective interventions for dual users,³⁴ though one RCT suggests that a text message vaping cessation intervention may increase dual abstinence from e-cigarettes and cigarettes among young adults.¹¹⁷ In the US, almost all of the people who vape who contact a quitline are dual users and many want to quit vaping, therefore quitline counsellors have an opportunity to provide cessation support for both tobacco and e-cigarettes. However, providing evidence-based advice can be challenging with the currently low levels of certainty about effective cessation interventions for e-cigarette and dual users.^118,119

For those who have successfully replaced tobacco cigarettes with e-cigarettes, cessation needs to be carefully managed to minimise the risk of relapse to smoking. Evidence-based smoking cessation support including pharmacotherapies and behavioural counselling may assist people who formerly smoked who wish to quit vaping.³⁹ Extended support from cessation services or NRT may be helpful for those making the transition to using neither product.²² Clinical guidelines for vaping cessation developed by an expert panel recommend that healthcare providers advise people who are both smoking and vaping to switch completely from smoking to vaping only. For people who have quit smoking but are currently vaping, healthcare providers can encourage them to quit vaping.⁵⁷ Australian guidelines similarly recommend taking steps to achieve complete nicotine cessation following the use of vapes for smoking cessation.⁵⁸ After 12 weeks of vape use, strategies such as weaning, transitioning to NRT, or using cessation medications may be considered. Vape use is only recommended for a maximum of 12 months.⁸⁷   

In general, addressing the reasons why people start vaping will help to inform the most appropriate type of vaping cessation support, as e-cigarette users who have vaped to quit smoking may have different cessation needs to those who started vaping due to peer influences or curiosity.²² 

Related reading

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References

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