By Li-Shiun Chen, MD, MPH, ScD, and Laura J. Bierut, MD
Posted: August 14, 2019
Combustible tobacco products, primarily cigarettes, continue to be the leading cause of cancer, and in the most recent surveys, an estimated 34.3 million adults smoke (14% of the U.S. adult population).1 Whereas combustible cigarette usage continues to decrease, e-cigarettes have grown in popularity, and many patients who smoke ask their physician about e-cigarettes. However, evidence on the efficacy of e-cigarettes as a smoking cessation tool has been limited. The Cochrane review based on two trials suggested that e-cigarettes may help combustible cigarette smokers quit and may aid smokers who are unable to stop smoking altogether to reduce their cigarette consumption.2 However, the comparison of e-cigarettes with combination nicotine replacement therapy (NRT) (e.g., nicotine patch plus nicotine lozenges, which are more effective than the nicotine patch alone) on efficacy as a smoking cessation tool has been much needed.3
In a new trial by Hajek et al., undertaken in the United Kingdom, e-cigarettes were more effective at helping smokers quit combustible cigarettes than NRT of patients’ choice, including use of combination NRT.4 All smokers were provided at least four weekly counseling sessions and randomly selected to e-cigarettes or NRT for 3 months in this trial of 886 smokers attending smoking cessation services. Bio-verified abstinence from combustible cigarette use was 18% at 1 year in the e-cigarette group versus 9.9% in the NRT group. Although cessation of combustible cigarettes was significantly better in the e-cigarette group, a less positive note was that for the smokers who achieved abstinence in the e-cigarette group, most (80%) continued using e-cigarettes at 1 year. Further, approximately 40% of smokers assigned to e-cigarettes had dual use of combustible and e-cigarettes use at 1 year. More importantly, the overall success of this smoking cessation trial is only modest at best and ineffective for most.
The new study aligns with the 2018 American Cancer Society Position Statement on Electronic Cigarettes. It recommends that clinicians support all attempts to quit combustible tobacco use, no matter what approach patients use. To help smokers quit, clinicians should advise patients to use U.S. Food and Drug Administration–approved cessation aids and should work with smokers to eventually stop using all tobacco products, including e-cigarettes.5 Some smokers, despite advice and assistance, will continue to smoke cigarettes. These individuals should be encouraged to switch to the least harmful tobacco product, and switching to e-cigarettes is preferable to continued smoking of combustible cigarettes. The preponderance of scientific evidence supports that current e-cigarettes products are demonstrably less harmful than combustible cigarettes.6
E-Cigarettes and Public Health
Combustible and e-cigarettes’ effects on public health continue to rapidly evolve. For combustible cigarette smokers, e-cigarettes represent a reasonable opportunity to successfully quit combustible cigarette smoking and reduce smoking-related illnesses. For nonsmoking adolescents and young adults, initiation of e-cigarettes represents a potential health concern. There is a rapidly increasing prevalence of e-cigarette use and “vaping” among youth in the United States.7,8 The net public health outcome of e-cigarettes will depend on the balance between decreasing combustible cigarette use in adults while limiting youth initiation of smoking. The current trend shows that combustible cigarette smoking continues to decrease in youth and young adults even while vaping is on the rise,9 and it is hoped that e-cigarettes will contribute to a positive public health balance. ✦
About the Authors: Dr. Chen is an associate professor in the Department of Psychiatry and Siteman Cancer Center at Washington University School of Medicine in St. Louis. Dr. Bierut is director of the Health & Behavior Research Center, Alumni Endowed Professor of Psychiatry, and vice chair for Faculty Development at Washington University School of Medicine in St. Louis. She is also a member of Siteman Cancer Center.
1. Wang TW, Asman K, Gentzke AS, et al. Tobacco Product Use Among Adults – United States, 2017. MMWR Morb Mortal Wkly Rep. 2018;67:1225- 1232.
2. Hartmann-Boyce J, McRobbie H, Bullen C, et al. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2016;9:CD010216.
3. Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013;5:CD009329.
4. Hajek P, Phillips-Waller A, Przulj D, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019;380(7):629-637.
5. American Cancer Society Positional Statement on Electronic Cigarettes 2018. American Cancer Society. cancer.org/healthy/stay-away-from-tobacco/e-cigarette-position-statement.html. Published February 15, 2018. Accessed April 20, 2019.
6. Drope J, Cahn Z, Kennedy R, et al. Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine. CA Cancer J Clin. 2017;67(6):449-471.
7. Cullen KA, Ambrose BK, Gentzke AS, et al. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students – United States, 2011-2018. MMWR Morb Mortal Wkly Rep. 2018;67(45):1276-1277.
8. Miech R, Johnston L, O’Malley PM, Bachman JG, Patrick ME. Adolescent Vaping and Nicotine Use in 2017-2018 – U.S. National Estimates. N Engl J Med. 2019;380(2):192-193.
9. Levy DT, Warner KE, Cummings KM, et al. Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check. Tob Control. 2018 Nov 20. [Epub ahead of print].