As clinicians practicing specialising in smoking cessation, we are acutely aware that smoking remains the leading cause of preventable death and disease worldwide. We are also aware that the burden of tobacco is not shared equally. Smoking rates remain stubbornly high, and quit rates stubbornly low among people experiencing social disadvantage. For patients from less fortunate financial backgrounds, the health outcomes related to smoking are significantly worse, and the financial burden of smoking hits harder, particularly with the ever rising cost of cigarettes.
Traditional Nicotine Replacement Therapy (NRT), are safe, and the go-to first option for healthcare professionals, but they often yield disappointing results in these priority groups. However, a 2024 landmark Australian study led by Dr. Ryan J. Courtney and colleagues offers compelling evidence that a paradigm shift in our cessation protocols is not only supported by data but clinically necessary.
The Institutional Context: UNSW Sydney
The study was conducted through the University of New South Wales (UNSW) Sydney. Specifically, the Trial Coordinating Centre at the National Drug and Alcohol Research Centre (NDARC) managed the core aspects of the trial. NDARC is a global leader in addiction research, and the trial’s methodology reflects a rigorous, “real-world” approach to public health intervention, ensuring that the findings are applicable to the complex patients we see in daily practice.
The Clinical Intervention: Precision in Product and Dosage
One of the most significant strengths of this study, and a reason the results are so impactful, is its pragmatic approach to product selection. A common pitfall in earlier vaping studies was the use of “first-generation” devices that failed to deliver nicotine efficiently, leading to underdosing and trial failure. This UNSW study addressed this by using a dual-device strategy with modern pharmacokinetics.
Participant Inclusion Criteria
The study recruited 1,045 adults primarily through social media advertising (Facebook and Instagram). To be eligible for enrollment, individuals had to meet the following requirements:
- Smoking Status: Participants had to be daily smokers.
- Willingness to Quit: They were required to be willing to make a quit attempt within two weeks of their initial screening.
- Age: They had to be at least 18 years old.
- Socioeconomic Status (SES): Participants were required to be receiving a government pension or allowance.
1. The VNP Arm (Experimental Group)
522 Participants were provided with an 8-week supply of free products, including a choice of devices that mimic routine community practice:
- The Pod System: A Vapo alt. pod device utilizing 40 mg/mL nicotine salt e-liquid. This is a critical clinical detail. Nicotine salts have a lower pH than freebase nicotine, allowing for much higher concentrations to be inhaled with less throat irritation. This results in faster systemic absorption and a blood-nicotine “spike” that closely mimics a combustible cigarette. Closed pod systems like the Vapo alt. should be the go-to starting point for TGA Authorised prescribers of nicotine vaping products.
- The Tank System: An Innokin Endura T18 using 18 mg/mL nicotine freebase e-liquid. This device allows for a different style of inhalation (mouth-to-lung) and provides a more consistent, slower release compared to the pod.
- Flavor Profiles: Participants were not restricted to “tobacco” flavors. They could choose between tobacco, menthol, and fruit, providing the autonomy and sensory appeal that drive long-term adherence in a real-world setting.
2. The NRT Arm (Control Group)
523 participants were provided with standard oral NRT:
- Product Choice: Either 4 mg nicotine gum or 4 mg nicotine lozenges (mint flavor).
- Dosage: Up to 15 pieces per day for 8 weeks.
All participants in both groups also received a 5-week automated text-message support program to assist with behavioral change.
Results: Verified Abstinence and Adherence
The primary endpoint was 6-month continuous smoking abstinence, which was not just self-reported but biochemically verified at a 7-month follow-up via a carbon monoxide (CO) breath test (≤5 ppm).
The results were a clear departure from traditional outcomes:
- Vaping Group Success: 28.4% verified abstinence.
- NRT Group Success: 9.6% verified abstinence.
- The “Adherence Gap”: Treatment discontinuation was significantly higher in the NRT group. By the first follow-up, 23.2% of the NRT group had stopped treatment, compared to just 2.2% of the vaping group.
Rewording the Discussion: Why Did Vapes Outperform?
The study’s discussion highlights several factors that we must consider when prescribing cessation aids. The researchers suggest that the success of VNPs in this trial stems from finally overcoming the “delivery gap.”
Standard NRT (gum and lozenges) often fails because it provides a slow, steady release of nicotine that does not satisfy the acute, “top-up” cravings experienced by highly dependent smokers. By using 40 mg/mL nicotine salt pods, the study provided a “biological substitute” that successfully suppressed withdrawal symptoms more effectively than 4 mg of oral NRT.
Furthermore, the “real-world” design of providing multiple flavors and device options likely enhanced the treatment engagement. For a population facing high daily stress, a cessation tool that is satisfying, easy to use, and offers a degree of personal choice is far more likely to lead to long-term success than a clinical-feeling lozenge.
Expert Leadership and Regulatory Rigor
The credibility of this study is bolstered by its authorship.
The team also featured Dr. Ryan J. Courtney (Lead Author), Professor Hayden McRobbie, Professor Wayne Hall, and Professor Richard P. Mattick, all internationally recognized experts in addiction medicine and public health.
A key author is Professor Nicholas Zwar, PhD. Professor Zwar is a distinguished academic GP and is a member of the Therapeutic Goods Administration (TGA) Nicotine Vaping Products Advisory Committee. He is also a lead author of the Royal Australian College of General Practitioners (RACGP) national smoking cessation guidelines.
Safety and Tolerability
Safety is a key concern as prescribers. The study found that total self-reported adverse events (AEs) were actually lower in the VNP group. While vape users reported more cough and mouth/throat irritation, NRT users reported more nausea. Crucially, there were no significant differences in respiratory symptoms, such as shortness of breath, between the two groups over the seven-month period. It is key to recognise here though that the study tracked short-term adverse events only. Although this has not been compared, traditional NRT is likely significantly safer than vaping.
Clinical Takeaways and Critical Limitations
While the results are compelling, a professional medical review requires an acknowledgement of the study’s boundaries. Prescribers and patients should keep these six limitations in mind:
- Open-Label Design: Participants were aware of their treatment group. This introduces the possibility of “expectation bias,” where the VNP group may have been more motivated because they were using a more modern, technologically interesting intervention.
- Comparison Group Selection: The study compared VNPs to oral NRT (gum/lozenges). It did not compare them to “combination NRT” (e.g., nicotine patch plus gum), which is often considered the most effective form of traditional therapy.
- Short Treatment Duration: The study provided only 8 weeks of free products. We cannot be certain if a longer duration would have improved results, or how quit rates would change if patients had to fund the products themselves.
- Self-Selection Bias: The trial recruited smokers who were already willing to quit and open to using vapes. This may not reflect the broader population of smokers who are not yet in the “action” stage of change or those who have strong aversions to vaping.
- Long-term Nicotine Dependency: While the VNP group successfully quit smoking, many remained dependent on the vaporized products at the 7-month mark. As clinicians, our ultimate goal is total nicotine cessation, and the long-term health effects of extended vaping are still being studied.
- Geographic Specificity: Conducted in Australia, the results are influenced by the specific regulatory environment and the types of products available here. Results might differ in regions with different public health messaging or product availability.
Summary
The data from this UNSW-led trial is definitive: modern, high-strength VNPs and specifically the alt. 40 mg/mL nicotine salt pods are nearly three times more effective than standard nicotine gum or lozenges.
For smokers who have been unsuccessful in quitting using safer methods, the evidence now strongly supports a trial of vapes. Providing patients with a choice of vaping products, as well as access to ongoing text-based support may also increase the chances of quitting smoking.
It is key to again highlight that while it is now clear that vaping increases smoking quit rates, it is very likely to be a less safe option long term. It is best used to quit smoking, and then gradually move to safer long term quit methods, with the long-term goal of being completely nicotine free.
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