Nicotine inhalators discontinued: are vapes an alternative?

Although somewhat kept on the down low, nicotine inhalators – manufactured by the likes of Pfizer and Kenvue – have been discontinued. Are Pharmacist Only vapes the next best option?

Deepali Gupta, an advanced cardiac pharmacist at Queensland Health and co-chair of the Statewide Smoking Cessation Working Group, first heard rumblings in mid-2024 that nicotine inhalators would be discontinued.

‘This started off with some reports from overseas,’ she said. ‘The reason for discontinuation was because the resin required to make the mouthpieces can’t be sourced.’

This news affects a significant subset of patients with mental ill health, many of whom have higher rates of smoking and who currently rely on inhalators as part of their nicotine replacement therapy.

Nicorette inhaler discontinued in Australia, Pharmacies that sell non prescribed vapes in Melbourne?
byu/Angrygoat87 inquittingsmoking

‘At Queensland Health, nicotine inhalators are on the list of approved medicines for mental health and acute behaviour management patients,’ Ms Gupta said. ‘So as soon as we heard there’s a possibility they may be discontinued, we were concerned that it would affect patient care in the mental health unit.’

After confirming with the manufacturer at the time that there was sufficient stock of nicotine inhalators for at least 12 months, Ms Gupta and team were relieved. 

‘We were also advised that Kenvue would be seeking out another supplier for the resin for manufacturing of mouthpieces, which was the main reason why they were at risk of being discontinued,’ she said.

‘Then [earlier this year] we received a notice through a community pharmacist that nicotine inhalators are discontinued. And that the pharmacy group is displaying posters in their pharmacies for their clients.’

Despite reaching out to the manufacturer multiple times, no feedback was received. ‘There is also nothing on the Therapeutics Goods Administration’s website about this discontinuation,’ she added.

Why are smoking rates higher in those with mental ill health?

Among Australians aged 18 years and over, smoking rates have been steadily declining – sitting at 11.1% in 2022–23.

‘[But in my experience] if you go to a mental health ward, around 50% of people are current smokers,’ Ms Gupta said.

The reasons for this are multifactorial. Higher smoking rates are often observed in communities experiencing social and economic disadvantage, including some Aboriginal and Torres Strait Islander communities, where complex social and emotional wellbeing factors play a role.

‘[And] people who are suffering from [poor] mental health may be living in low socioeconomic situations,’ she said.

What makes nicotine inhalators more appealing?

When it comes to smoking cessation, nicotine inhalators are the preferred nicotine replacement therapy (NRT) option among patients with mental ill health, Ms Gupta said.

Explaining the precise chewing technique required to release nicotine from gum can be challenging for someone experiencing acute mental illness. Likewise, conveying that nicotine lozenges must be held in the mouth for an extended period to ensure absorption rather than being wasted in the digestive tract poses a similar difficulty.

Some patients may also experience discomfort or anxiety about having a patch on their skin and may remove it prematurely, Ms Gupta said.

‘And sprays have a very strong taste, which can put them off completely,’ she added.

Nicotine inhalators, on the other hand, are much easier for patients to adapt to.

‘They are already used to the hand-to-mouth method from smoking, and the inhalator only needs to be set up once,’ Ms Gupta said. ‘You just tell them to suck on it whenever they feel they need to smoke. That works really well to keep mental health clientele calm.’

Should vapes be used as a substitute?

Ms Gupta recently turned to a close community pharmacist friend to ask, ‘What’s the situation with nicotine inhalators?’ Confirming they haven’t been available for many months, the pharmacist suggested that vapes are in stock and can be supplied over the counter. Hearing this from a senior pharmacist with decades of experience and a patient-first ethos alarmed Ms Gupta.

‘Some people may argue that vapes can be used as NRT, however, we know the amount of nicotine supplied through vapes is significantly higher. This feeds into the nicotine addiction rather than using lower levels and targeting nicotine withdrawal,’ she said. ‘If they are looking for NRT, we should be using the TGA-approved medications.’

Understanding that nicotine dependence varies per patient is key – particularly among patients with mental ill health, who often experience high levels of dependence and
derive symptomatic relief from nicotine. Vapes may not be therapeutically appropriate for this patient population, and are also not permitted in the same spaces as smoking – including in hospitals. So for these patients, it’s crucial to have as many options available as possible.

For example, those who have high dependence may need up to three nicotine patches. Patients should also be initiated on combination NRT, similar to how pain relief is approached.

‘You need something for the whole day and then a quick-acting [therapy] for the breakthrough,’ Ms Gupta said.

In Ms Gupta’s view, NRT is not being optimally utilised prior to a step-up therapy with varenicline and bupropion. But a targeted approach works best.

‘Some people don’t want to [try] patches or gum and prefer to go straight onto tablets, so varenicline is a great option for them. Others don’t want to take more medicines and are worried about adverse effects, so it’s best to start them on NRT,’ she said. ‘It’s important to individualise treatment to see what your patient wants.’

For more information, refer to PSA’s Professional practice guidelines for pharmacists: nicotine dependence support.