When Greg Hunt’s proposed restrictions on nicotine imports were stymied in 2022 by a small group of Liberal and National MPs, the Coalition health minister turned to another strategy: reclassifying nicotine to make it available only on prescription. His aim was to allow e-cigarettes to be used as a tool for quitting smoking but prohibit them for non-smokers, particularly children and young people.
The reclassification would encourage smokers to discuss with their GP “the best way to give up smoking, such as using other products including patches or sprays,” the government argued. If e-cigarettes were still required, the GP would write a prescription.
It looked promising on paper, but the plan failed to deliver the desired result, a fact that even Nationals leader David Littleproud now admits.
The failure had complex causes, including shortcomings in state and federal enforcement of the laws that regulate importing, wholesaling and retailing of e-cigarettes at both federal and state/territory levels. Complicating these efforts is the fact that only laboratory testing can detect whether vaping products contain nicotine, which means that importers and retailers can misleadingly label vaping products as nicotine-free to avoid scrutiny.
But there was another unanticipated obstacle to controlling e-cigarettes: the emergence of a welter of online nicotine-prescribing services offering vaping products outside traditional general practices, often with little or no contact with doctors.
These new businesses are being fuelled by a combination of unfortunate timing and poor policy design. The reclassification of nicotine as a prescription-only drug coincided with the accelerated adoption of telehealth consultations during the pandemic; more importantly, though, the new Medical Benefits Scheme number for these consultations didn’t require patients to have an existing relationship with the prescribing doctor — unlike most other telehealth services.
The new prescribing services are a long way from the GP oversight envisaged by Hunt when he introduced this restriction. They don’t provide any healthcare services other than nicotine prescribing. Their doctors don’t have an ongoing relationship with the patient. Worse, in some cases patients have no direct contact at all with a doctor; they simply fill out an online form requesting a prescription, which is then sent to them via text or email. The websites’ claim that these requests are “reviewed” by a doctor is impossible to verify
Many of these prescribing services operate outside Medicare and typically charge less than a Medicare-funded consultation for a prescription. Some also sell vaping products (or refer consumers to an affiliated supplier) and then rebate the prescribing fee against the purchase of vaping products.
Not surprisingly, GPs and health experts have raised a range of safety and quality concerns about the growth of these services. Among those to speak out is Chris Moy, a South Australian GP and former national vice-president of the Australian Medical Association, who is concerned that consultations provided by these services are disconnected from the type of holistic patient care offered by traditional general practice. Because the nicotine-prescribing doctor has no access to a patient’s history, he says, continuity of care can break down. Patients could develop side effects without the knowledge of their usual GP.
The vice-president of the Royal Australian College of General Practitioners, Bruce Willett, says that while the dangers of vaping aren’t yet fully understood, the increasing use of e-cigarettes, particularly among young people and school-age children, is deeply concerning. He believes that online prescription services come with “numerous risks” and enable nicotine products to be more easily obtained by vulnerable consumers.
“My message to anyone thinking about using these services to get a prescription for nicotine e-cigarettes is to think again — and book an appointment with your GP instead,” he adds.
Another concern being raised about these new services is the conflict of interest that could arise if prescribers have a financial interest in selling vaping products to their patients or if businesses selling vaping products have a financial relationship with a prescriber.
The prescribing and selling of medicines are deliberately kept separate in our health system to remove any possibility of doctors’ decisions being influenced by financial interests. But the law doesn’t prohibit all financial relationships between prescribers and dispensers. While the terms of the Community Pharmacy Agreement prohibit doctors from owning a pharmacy, for example, pharmacies can employ doctors perfectly legally.
That means pharmacies can set up online prescribing services employing doctors to provide electronic nicotine prescriptions that encourage consumers to fill these prescriptions at the pharmacy — by linking the prescription directly to the pharmacy, for example, or by rebating the cost of the consultation against purchases.
Pharmacies are also allowed to produce or import their own vaping products and can promote these to consumers without violating the Therapeutic Goods Advertising Code — for example, by listing them above other products when directing consumers to their website to fill their prescriptions.
Regardless of legality, Chris Moy is concerned about the potential for conflicts of interest if pharmacies or other business that sell vaping products have a financial relationship with nicotine-prescribing services. “A doctor’s sole interest should be in the health of their patient,” he says, “but the situation becomes muddied if the doctor makes a profit from selling a product they prescribe, or if they are employed by a business which does so.” Willett also stresses the need for providers to make any conflict of interest — “anything that could affect, or could be perceived to affect, patient care” — clear to patients.
Measuring exactly how many nicotine prescriptions are being provided by standalone services is impossible. The Therapeutic Goods Administration’s register of authorised nicotine prescribers lists 1635 Australia-wide, of which around fifty-five prescribe only online. But the TGA doesn’t collect information about the level and type of interactions the prescribing doctors have with their patients. Medicare keeps records of the number of nicotine prescriptions issued via telehealth but doesn’t record the proportion written in a traditional general practice setting.
Given the significant health and economic harms caused by smoking, it is clearly important to make quitting tools accessible to smokers. Recent evidence suggests that e-cigarettes can be a useful quitting tool for some smokers (although researchers’ views differ about their effectiveness). But the potential benefits of making e-cigarettes available to smokers need to be balanced against the risks of non-smokers (particularly children and young people) accessing these products.
The new standalone prescribing services make it easier for consumers to access e-cigarettes for purposes other than quitting smoking. They raise concerns about conflicts of interests between prescribers, dispensers and retailers, and create ethically questionable opportunities for healthcare professionals to profit from the spread of vaping in the Australian population.
Health minister Mark Butler’s recently announced plan to ban personal importation of nicotine is a step forward — albeit a belated one — in tackling the public health threat of vaping. But unless it is part of a comprehensive strategy that also regulates how nicotine is prescribed online, it seems likely to divert demand from overseas providers to these services, further entrenching this business model within the Australian health system. If the government is serious about reducing the rate of vaping in Australia, it needs to look carefully at this growing sector and the role government policy plays in its spread throughout the Australian community. •