E-cigarettes for smokers trying to quit
- 1Section for Preventive Cardiology, Dept of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
- 2Loma Linda University, Loma Linda, CA, USA
- Serena Tonstad, Oslo University Hospital, Preventive Cardiology, Pb 0424 Nydalen, Oslo 0424, Norway. E-mail: STonstad{at}llu.edu
Abstract
A more positive response to a previous correspondence regarding a study of e-cigarettes for quitting smoking https://bit.ly/33UQAgr
Reply to P.A. Katsaounou:
The letter by P.A. Katsaounou brings up major issues in the current somewhat “heated” discussion regarding the pros and cons of e-cigarettes as an aid to smoking cessation. The comments centre on the study by Hajek et al. [1], that found an almost 2:1 win for e-cigarettes compared to nicotine replacement therapy (NRT) for adult smokers attending the National Health Service Stop Smoking Services in the UK. Was the study flawed in the ways suggested by P.A. Katsaounou and, more importantly, is there any role for e-cigarettes in aiding smoking cessation?
Addiction: It is evident that one of the perceived advantages of e-cigarettes is their more rapid delivery of nicotine to the lungs and so to the brain. As stated by P.A. Katsaounou, smokers are transferring their addiction to e-cigarettes, perhaps both because of ease of access and effectiveness. In the Hajek et al. [1] study, smokers used e-cigarettes more frequently than NRT and continued their use for a longer period of time. Already after 4 weeks, use of NRT was substantially lower than e-cigarettes, despite being provided at no cost at that time-point. This is more likely due to their greater effect on addiction rather lack of sufficient support of the service for NRT or differences in smokers' expectations. This suggestion is supported by the observation of lower scores for smoking urges in e-cigarette versus NRT users at 1 and 4 weeks.
Is this an advantage or a drawback to e-cigarettes? Three-quarters of the participants had previously tried NRT. For smokers who have made previous quit attempts using established pharmacological aids, e-cigarettes may maintain their addiction, but are likely to still provide health benefits compared to continued smoking [2–4]. It would certainly be preferable for smokers to be treated with varenicline, for example, the most effective single therapy that does not carry the risk of further addiction, and certainly before attempting e-cigarettes [5]. But varenicline requires a medical appointment, with a health professional versed in its use. It requires taking medication that smokers may wish to avoid and at least some follow-up. While the Hajek et al. [1] study provided relevant evidence of e-cigarette effectiveness, it was not designed for smokers who had failed at least a single course, or preferably two [6], of varenicline, a study that remains to be done.
Effectiveness: P.A. Katsaounou questions the effectiveness of e-cigarettes noting that the 1-year quit rate among smokers assigned to NRT was less than half of that seen in a number of previous studies. The absolute effects of NRT use will depend on the baseline quit rate, which varies in different clinical and environmental settings. More intensive support boosts the NRT effect [7]. The author states that better tailoring of treatment to the smoker should have been provided. It is not clear how treatment should have been further personalised, given the fact that smokers could use any form of NRT that they wished and combinations (which are most effective than single NRT) were encouraged. Behavioural support appeared to have been given in line with the usual practice of the Stop Smoking Services.
If very intensive support (e.g. 1 h or more at start? 30 min for follow-up sessions? highly skilled behavioural therapists?) is to be given together with NRT, the availability of such treatment would be limited. It appears that in the current sociocultural environment, no specialist support cessation method in England has an uptake of over 0.5% of smokers [8]. Providing even more time-consuming care than currently may not be feasible or reach further smokers.
Furthermore, there is a paucity of evidence that smokers are more “hardened” or resistant than previously. Studies from England between 2008 and 2017 found that, contrary to expectations, cigarette dependence has decreased, and the proportion of non-daily smokers increased but quit attempts have decreased [9]. These observations indicate that changes are not predictable. Perhaps we need to change our definition of hardcore smokers. While it is not clear how the environment has changed the effectiveness of NRT, it is possible that greater acceptance of e-cigarettes has contributed, as stated by P.A. Katsaounou. But here smokers have led the way, not smoking cessation services or public health departments. And perhaps they “know” best.
P.A. Katsaounou states that the participants given NRT may have had little faith in NRT. However, smokers were included only if they had no clear preference as to treatment; furthermore, 40% had already tried e-cigarettes, indicating that they had already failed to quit smoking using e-cigarettes. She notes that the majority of the participants had previously failed their quit attempt; it must be countered that this proportion is representative of that in many studies of smoking cessation.
Safety: “All” would agree that NRT is safer than e-cigarettes. However, for smokers who do not want to use current treatments, or who have failed previous quit attempts despite treatment, the door to consideration of e-cigarettes should not be entirely closed.
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Supplementary Material
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Footnotes
Conflict of interest: S. Tonstad reports personal fees for lectures and consultancy from Pfizer, outside the submitted work.
- Received July 28, 2020.
- Accepted September 9, 2020.
- Copyright ©ERS 2020