Vape-quitting patients are now showing up in primary care in numbers that didn't exist three years ago — and most clinicians, in my experience, are underprepared for the consultation. The training we had in medical school covered cigarette cessation. The clinical guidelines we've internalised are largely about combustion. The patient now in front of us is a 24-year-old who has been on a 5%-strength pod-based device since university, has never smoked a cigarette in her life, and tells you she "thinks she might be addicted to her vape."
This piece is the short, practical version of how I'd suggest approaching that consultation — written for GPs, occupational health doctors, respiratory and cardiovascular specialists, and anyone else who is now seeing this patient regularly. It assumes you are comfortable with cigarette cessation but want a clearer mental model for vape specifically.
The core message: the pharmacology is the same, but three things are clinically different in vape patients — the nicotine load assessment, the dose-equivalence translation for NRT, and the behavioural environment around the device. Get those three right and the rest of the consultation is familiar territory.
1. Start by asking what they're actually inhaling
"Do you vape?" is a binary question and almost useless clinically. The patient who uses a 0%-nicotine refillable mod for flavour, the patient who uses a 20mg/mL freebase nicotine cartridge, and the patient on a 5% nicotine salt pod-based device are three completely different clinical situations — and your prescribing decisions will depend on knowing which one is in front of you.
The four questions I'd ask up-front:
- What device are you using? (disposable / pod-based / refillable mod — and is it salt-nic or freebase?)
- What strength is the liquid? (mg/mL or % — and look at the bottle if they're not sure)
- How long does one device or pod last you? (number of days per pod or per disposable is the closest proxy you'll get to daily nicotine intake)
- How long after waking until your first puff? (the same time-to-first-use marker we use in cigarette dependence assessment — under 30 minutes is significant dependence)
The combination tells you a lot. A patient on a single 2mL disposable a day at 20mg/mL is delivering roughly 30–40mg of nicotine intake per day — broadly equivalent to a 20-cigarette-a-day smoker. A patient on a 5% nicotine-salt pod and finishing one pod every two days is in a similar range. A patient who finishes a 4mL pod a day is heavier than most cigarette smokers you'll see.
Most patients underestimate their intake. They will tell you they "only vape a little" because the device is silent, doesn't smell, and doesn't have a finishable cigarette as a natural pause-point. The numbers usually tell a different story than the self-report.
2. Reset the patient's mental model
Vape patients arrive with a different mental model from cigarette patients. Cigarette patients usually know they are addicted to nicotine. Vape patients often believe they are addicted to vaping — to the device, the flavour, the social environment — but not, somehow, to the nicotine itself. Many believe their vape is "less addictive" than cigarettes. The salt-nic chemistry and the device design make this an honest mistake, not a stupid one.
Five minutes of reframing changes the whole consultation:
"You're not addicted to vaping. You're addicted to nicotine, and your vape is the most efficient nicotine delivery system that's ever been invented for the consumer market. Salt-nic chemistry was specifically designed to deliver nicotine to your brain about as fast as a cigarette does — that's why it doesn't burn your throat the way the older e-cigarettes did. The good news is that since the addiction is to nicotine, the same medications that work for cigarette quitters work for you. The device-related habits are the second piece of work, and we'll get to those."
This single reframe changes their pharmacological compliance more than anything else you'll say in the consultation. They stop seeing NRT as "weird, because I never smoked" and start seeing it as the obvious treatment for the addiction they actually have.
3. Prescribe combination NRT — at the right dose
The single most under-utilised tool in vape cessation is combination NRT: a long-acting patch for baseline coverage and a fast-acting product (gum, lozenge, mouth spray, or inhalator) for breakthrough craving. The Cochrane evidence on combination NRT is unusually strong — roughly a doubling of long-term abstinence rates compared with no pharmacotherapy, and roughly 25–35% better than monotherapy.
The dosing translation that trips up most clinicians is the patch strength. Vape patients are commonly under-dosed on the patch because the prescriber is mentally anchoring to "they don't smoke cigarettes," and so prescribes the 14mg patch instead of the 21mg. For a salt-nic pod user finishing one pod a day or more, the 21mg patch is almost always the correct starting dose. Step down at week 8.
Week 1–8: 21 mg/24-hour patch daily, plus a fast-acting product (4 mg gum or 4 mg lozenge, taken on craving — typically 8–12 pieces per day in the first two weeks, tapering as withdrawal eases).
Week 9–10: Step down to 14 mg patch.
Week 11–12: Step down to 7 mg patch, then discontinue.
Continue the fast-acting product as long as the patient is using it — long-term low-dose NRT use is materially safer than relapse. Don't push them off it artificially.
One under-recognised technical point: the fast-acting product needs to be used correctly. Most patients chew nicotine gum like normal gum and get poor absorption. The instruction is "chew briefly, then park between cheek and gum, then chew again when the taste fades" — written down, not just said.
Varenicline (where available — currently constrained in many markets) is the alternative first-line agent. Where available it is at least as effective as combination NRT, sometimes more so. The same 12-week course applies. I generally don't combine varenicline with NRT outside specialist settings.
4. The behavioural piece — what you can realistically do in a 10-minute consult
You cannot deliver structured behavioural cessation support in a 10-minute consultation. What you can do is set up the conditions for the patient to do the behavioural work themselves, and give them a clear handover to wherever you'd refer them.
Three behavioural things worth doing in the consultation itself:
(a) Set the quit date
Within the next 7 days, ideally on a Monday or the start of their work week. Patients who leave the consultation with a date are several times more likely to make the attempt than patients who leave with a vague intention to "cut down."
(b) Identify the three highest-risk moments
Vape is uniquely dangerous in the relapse phase because the device is everywhere — in pockets, on desks, beside beds. Ask the patient to name the three specific moments in their day when they reach for the vape most reflexively (often: first thing on waking, after meals, during work breaks). Help them plan a substitute action for each — usually involving the fast-acting NRT product as the bridge. This 5-minute exercise is the single highest-yield behavioural intervention you can do in the room.
(c) Remove the device from the environment, not the patient
The vape is small, accessible, and silent. Telling a patient to "have willpower" against their own pocket is asking them to lose. The behavioural ask is concrete: physically remove the device from the home and workplace before quit day. Give it to a friend, throw it away, lock it in a drawer they don't have a key to. The data on this is unambiguous — environmental removal of the substance does more than any single behavioural strategy you can offer.
One under-recognised reality: a patient who keeps a "just in case" disposable in their drawer will, in the relapse phase, use it. The reframe to give them is: "If you're keeping one for emergencies, you're not quitting — you're taking a break."
5. Verifying abstinence (and why CO breath testing won't help here)
For cigarette cessation, the carbon monoxide breath test is the cheap, fast, and definitive tool we've all relied on. It does not work for vape patients — there is no combustion, so the CO reading is whatever ambient air you're standing in.
The two practical alternatives:
- Urine cotinine (the longer-lived nicotine metabolite). The downside is that NRT and varenicline both produce positive cotinine readings during the treatment phase, so the test is only meaningfully interpretable after the patient is off all NRT — typically at the 6-month follow-up.
- Salivary cotinine strips. Same caveat as urine — the test cannot distinguish vape nicotine from NRT nicotine. Useful for verification at the 12-month mark, less useful during active treatment.
For most primary care contexts the realistic verification is self-report at 6 and 12 months, ideally with a single urine cotinine at the 12-month review point when the patient should be off NRT. This is imperfect but defensible — and considerably better than the wellness-portal "engagement metrics" that some workplace programmes have substituted for it.
6. When to refer onward
The honest framing: the patient who can't be supported through a 12-week course of combination NRT plus the brief behavioural work above is a patient who will benefit from structured behavioural support delivered over 8–12 weeks. That isn't realistically deliverable in a 10-minute primary care slot, and most workplace programmes don't deliver it either.
This is the gap I built my practice around — doctor-led, evidence-based quit coaching for cigarettes, vape, shisha, midwakh and dokha, scoped explicitly as education and behavioural support rather than telemedicine. The patient continues to work with their treating doctor (you) on the pharmacology and any clinical concerns. The coaching layer adds the structured behavioural piece that's genuinely hard to deliver inside a normal consult.
If a patient resource is useful: I produce a free 7-Day Quit Plan that I'm happy for clinicians to share with patients as a handout. It's the same first-week structure I use in coaching, written for the patient, not for you. There's no obligation and nothing for the patient to pay; it just gives them something concrete to take home.
A free patient handout, no strings attached.
The 7-Day Quit Plan is a 9-page, doctor-written PDF designed to be the patient's first-week scaffold. If it's useful to share with patients in your practice, request a copy and I'll send it through.
Request the patient handout →A closing thought for clinicians
The vape patient population is going to keep growing in primary care, and the clinical guidance is still catching up. The good news is that the underlying pharmacology is well-understood territory — combination NRT, behavioural support, structured follow-up. The bad news is that none of those are well-supported by a 10-minute consult on its own.
The best thing most of us can do in the room is: assess the actual nicotine load, reframe the addiction accurately, prescribe combination NRT at the right dose, set up the three highest-risk moments with substitute actions, and make sure the patient has somewhere to go for the behavioural work that we can't realistically deliver in primary care. If those five things happen in the consultation, the patient's odds change materially.
If any of the above is useful in your own practice, please feel free to share it onward.