Guidelines for preventive activities in general practice

Mental health and substance use

Smoking and nicotine vaping

      1. Smoking and nicotine vaping

Mental health and substance use | Smoking and nicotine vaping

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Australia has made major progress in tobacco control, with population prevalence of smoking falling substantially since the 1960s. Australia has one of the lowest smoking rates among the Organisation for Economic Co-operation and Development (OECD) countries.1 In 2019, 11% of Australians smoked tobacco daily, down from 12.2% in 2016 and 24% in 1991.2 In recent years, smoking rates have also fallen for Aboriginal and Torres Strait Islander peoples, but the prevalence remains unacceptably high (37% in 2018–19).1,3 Despite the decline in prevalence, smoking remains the behavioural risk factor responsible for the highest levels of preventable disease and premature death.1

Smoking rates are influenced by socioeconomic status, with higher rates in low socioeconomic status communities. Smoking rates remain high in key population groups, including people with mental illness. Smoking in pregnancy has serious adverse effects for both the mother and developing fetus.

Many people start smoking in during adolescence, with 80% of long-term smokers having started smoking before the age of 20 years.4 The prevalence of e-cigarette use is on the rise, even among individuals who have never smoked before. From 2016 to 2019, the percentage of people who had tried e-cigarettes increased from 8.8% to 11.3%.2 Although the use of e-cigarettes grew across various age groups, the increase was particularly significant among young adults. Among individuals aged 18–24 years, almost two-thirds (64%) of current smokers and one-fifth (20%) of non-smokers reported experimenting with e-cigarettes. In addition, among those who had tried e-cigarettes, the frequency of use also escalated, with a greater number of people using them at least once a month (rising from 10.3% in 2016 to 17.9% in 2019).2 There is increasing evidence that non-smokers who use e-cigarettes are more likely than those avoiding e-cigarettes to start cigarette smoking and become current smokers.5

Up to half of all smokers can be expected to die from a smoking-related condition.6


Recommendation Grade How often References
Ask patients whether they are currently smoking and document their smoking status.
Also ask about and document the use of vaping products.
Recommended (Strong) At every opportunity starting from the age of 10 years 1

Preventive activities and advice

Recommendation Grade How often References
All patients who smoke should be offered brief advice to quit smoking.
Set quit goals, offer Therapeutic Goods Administration (TGA)-approved pharmacotherapy (nicotine replacement therapy, varenicline or bupropion), referral to a smoking cessation service (see Further information) and follow up as appropriate.
Recommended (Strong) At every visit 1
For patients who have not been able to quit with the combination of behavioural support and approved pharmacotherapy, consider the use of nicotine e-cigarettes to assist smoking cessation. This needs to be preceded by an evidence-informed shared decision-making process where the lack of evidence on long-term safety and the current unapproved status of nicotine e-cigarettes is discussed. Conditionally recommended N/A 1,6
All patients who vape should be advised to quit vaping.
Offer brief cessation advice in routine consultations and appointments, whenever possible.
Practice point At every visit 1

The delivery of smoking cessation advice is likely to be one of most effective interventions in reducing mortality.8 Some smokers may not be ready to quit, but may still benefit from brief advice about smoking cessation.

Using the Ask Assess Help model as part of shared decision making by considering readiness to quit.

Nicotine dependence can be assessed by asking about the:

  • number of minutes between waking and smoking the first cigarette
  • number of cigarettes smoked a day
  • type of craving or withdrawal symptoms experienced in previous quit attempts.2

There is a high likelihood of nicotine dependence if the person smokes within 30 minutes of waking and smokes more than 10–15 cigarettes a day.

Referrals to Quitline, SMS cessation services and online cessation support are all effective and may complement brief interventions delivered by clinicians.

See RACGP’s Supporting smoking cessation: A guide for health professionals for more information on smoking cessation advice and follow up.

For specific recommendations for Aboriginal and Torres Strait Islander people, please refer to the Smoking section in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.

  1. The Royal Australian College of General Practitioners (RACGP). Supporting smoking cessation: A guide for health professionals. 2nd edn. RACGP, 2021 [Accessed 17 May 2023].
  2. Australian Institute of Health and Welfare. National drug strategy household survey 2019. Australian Government, 2020 [Accessed 23 February 2024].
  3. Australian Bureau of Statistics (ABS). National Aboriginal and Torres Strait Islander health survey. Canberra: ABS, 2019 [Accessed 23 February 2024].
  4. Department of Health and Aged Care. Young people and tobacco smoking. Australian Government, 2023 [Accessed 23 February 2024].
  5. Baenziger ON, Ford L, Yazidjoglou A, Joshy G, Banks E. E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: Umbrella review, systematic review and meta-analysis. BMJ Open 2021;11:e045603. doi: 10.1136/bmjopen-2020-045603.
  6. U.S. Department of Health and Human Services. Smoking cessation: A report of the surgeon general – executive summary. U.S. Department of Health and Human Services, 2020 [Accessed 23 February 2024].
  7. Hartmann-Boyce J, Lindson N, Butler AR, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2022;11:CD010216. doi: 10.1002/14651858.CD010216.pub7.
  8. Anthonisen NR, Skeans MA, Wise RA, et al. The effects of a smoking cessation intervention on 14.5-year mortality: A randomized clinical trial. Ann Intern Med. 2005;142(4):233. doi: 10.7326/0003-4819-142-4-200502150-00005.
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