Primary Care Corner with Geoffrey Modest MD: E-Cigarettes Help Smoking Cessation??

By Dr. Geoffrey Modest

There has been a lot of controversy about the potential benefits of using e-cigarettes to help current smokers quit vs the potential harms of e-cigs in normalizing and promoting nicotine use for nonsmokers, possibly leading to smoking the much more toxic regular cigarettes. A recent large data analysis from the UK did suggest that e-cigs may be a helpful aid for smoking cessation (see doi.org/10.1136/bmj.i4645).

Details:

  • England has a “liberal regulatory framework for e-cigarettes and has seen a considerable growth in their use”
  • This study looked a 2 sources of information over time: the Smoking Toolkit Study (monthly household, face-to-face scripted surveys of a representative UK population >16 yo, with data from 2006 on 170,490 individuals, of whom 41K were past smokers, 38K were current smokers, with about 1200 smokers being surveyed quarterly); and statistics on the use of the  English National Health Service (NHS) stop smoking services (8,029,012 people had set quit dates)

Results:

  • The prevalence of self-reported quit attempts decreased over time (45.4% in 2006 to 31.2% in 2014), but the percent of successful quit rate rose from 10.6% to 15.2%
  • There as a striking increased use of e-cigs, beginning in 2012 and increasing to 35% by 2014
  • E-cig use by smokers was positively associated with successful attempts to quit, by 0.098% [0.064 to 0.132); P<0.001] for every 1% increase in the prevalence of e-cigarette use by smokers
  • E-cig use in quit attempts was also positively associated with quit success, by058% [0.038 to 0.078; P<0.001] for every 1% increase in e-cigarette use during a recent quit attempt
  • Data were inconclusive about the association between current e-cigarette use and the overall rate of quit attempts, use of NRT (nicotine replacement therapy) bought over the counter, use of prescription treatment, or use of behavioral support. [Note: “inconclusive” does not mean “ineffective”]
  • There was evidence that expenditure on mass media was positively associated with use of stop smoking services
  • A negative association was found between e-cigarette use during a recent quit attempt and use of NRT obtained through prescription by 0.098% for every 1% increase in e-cig use in a quit attempt (P=0.04), and there was a pretty remarkable but apparently nonsignificant decrease in over-the-counter (OTC) NRT purchases from 40.0% to 20.6% of smokers [e., it appeared that the more e-cigs were used, the less NRT used. Substitution by the patients??)

Commentary:

  • The above numbers were adjusted for changes in differences in stop smoking services over time, introduction of a smoking ban in 2007, change in minimum age of sale of cigarettes from 16 to 18 yo in 2007, and changes in price of cigarettes
  • The overall decrease in smoking prevalence in England dropped 1 percentage point between 2014-5.
  • From their mathematical modeling: in 2015, quit attempts was 32.5% (of 8 million smokers) and the prevalence of e-cig use in quit attempts was 36%, so 54,288 more quitters stopped at least short to medium term. And if 2/3 relapse (the usual %), then e-cigs would have contributed to 18,000 additional long-term quitters.
  • And, a 40yo who quits smoking is likely to gain about 9 years of life
  • The generalizability to other areas may be limited by their differences to UK policies on e-cigs as well as smoking cessation supports, media campaigns, etc
  • Other studies do find a rise in e-cig experimentation in nonsmokers, though the rate of regular use is <1%
  • As mentioned in prior blogs (e.g., see http://blogs.bmj.com/bmjebmspotlight/2016/05/10/primary-care-corner-with-geoffrey-modest-md-e-cigarettes-as-a-tool-to-quitting-smokingharm-reduction/ ), I have had some impressive success with e-cigs (either initiated by the patient or by me) in getting some really long-term smokers to quit. I do regularly try the other motivational and medical therapies first, so the group who do finally quit with e-cigs is a pretty resistant one. So, my bottom line is that if e-cigs are legal and available, I do consider it part of my smoking cessation options, even as a means for harm reduction (i.e., using e-cigs to decrease cigarettes, which have 3000 additives and some known to be carcinogenic). And I do counsel adolescents in particular about the potential harm of initiating e-cig use and nicotine’s profound addiction potential.