Prescribing without a prescription: The clinician’s dilemma with alternative nicotine products

Clinicians increasingly face a strange position regarding alternative nicotine products: recommending products that work but aren’t medicines. The evidence for e-cigarettes as a smoking cessation aid is now high-certainty and shows they outperform licensed nicotine replacement therapy in head-to-head trials. Yet the products themselves sit outside the regulatory category clinicians are trained to trust. They are reviewed for population-level benefit rather than approved as safe and effective for the individual patient. That distinction isn’t a technicality. It shapes how confident a clinician feels about raising the option, how exposed they feel doing so, and, in some jurisdictions, whether professional guidance actively discourages the conversation altogether.

This talk uses e-cigarettes as the clearest example of a broader and growing problem, one that will only become more pressing as evidence accumulates on nicotine pouches and heated tobacco. Drawing on a recent JAMA position paper and the professional debate it provoked, I will examine why this discomfort exists, how professional bodies and national systems have resolved it differently (the UK and New Zealand embracing these products within cessation pathways, the US and Australia largely resisting), and what underlies much of the disagreement: an unresolved question about whether we are treating nicotine dependence or combustible tobacco harm. I will close with what this means in practice for clinicians navigating patient conversations in the absence of a prescription pad.