In an important study published last month in the New England Journal of Medicine, we received much-needed and timely insights on the potential role of e-cigarettes for smoking cessation. E-cigarettes first entered the U.S. market in 2006, and recent estimates suggest that nearly one in six U.S. adults have used these products, while 3.2% are considered active users. Unlike traditional cigarettes, in which users inhale tobacco smoke, e-cigarettes heat a nicotine-containing liquid, creating a vapor. Because there is no combustion with e-cigarettes, it has been postulated that they are safer than conventional cigarettes. Indeed, early evidence seems to indicate that e-cigarettes generate fewer toxins than combustible tobacco products.
Still, public health experts appropriately worry that e-cigarettes represent another harmful nicotine product that could tempt non-smokers, particularly youth. A whopping 21% of high school students, and 5% of middle-schoolers, currently report use of e-cigarettes, and rates of e-cigarette use are rising faster than for other nicotine products in these populations. Sadly, e-cigarette companies have targeted youth populations, just as previous generations of tobacco companies did, by infusing their products with flavors that appeal to younger people, such as cherry, chocolate, and menthol. Despite these concerns, however, e-cigarettes may have an important role for helping current smokers quit.
In a New England Journal study, British researchers randomly assigned 886 adults presenting for smoking cessation services to the U.K. National Health Service to receive either e-cigarettes or traditional nicotine-replacement products, such as nicotine gum. Participants in both groups also received weekly behavioral support for at least 4 weeks. Though 1-year abstinence rates were low in both groups, participants who received e-cigarettes were substantially less likely to be using traditional cigarettes at 1 year compared to those who received other smoking cessation products (18.0% abstinence rate with e-cigarettes vs 9.9% with other nicotine-replacement products, P<0.001). Importantly, however, 80% of participants in the e-cigarette group who achieved abstinence at 1-year were still using e-cigarettes, whereas just 9% of those receiving other nicotine-replacement products were still using those products. In addition, rates of throat or mouth irritation were higher with e-cigarettes compared to other cessation products (65.3% vs 51.2%). Encouragingly, participants in the e-cigarette group reported modestly lower rates of cough and phlegm production, though not symptoms of wheeze or shortness of breath, during the study period.
What are our “Slow Medicine” insights on these findings?
First and foremost, it is critical to highlight that these findings should not in any way be misconstrued to suggest that e-cigarettes are safe. Even if preliminary evidence suggests these products may be safer than traditional cigarettes — not a high bar to achieve! — we do not know the long-term consequences of inhaling nicotine-containing vapor. It is quite possible that future research will establish links between e-cigarettes and cancer or other health complications. We must be vigilant to ensure that e-cigarette companies do not use these findings to promote their products among non-smokers, particularly youth.
Second, although it is encouraging that e-cigarettes were associated with higher cessation rates at one-year compared to traditional cessation-products, it is concerning that 80% of those who achieved abstinence at 1 year were still using e-cigarettes. In other words, the vast majority of participants assigned to e-cigarettes who achieved abstinence did not actually give up nicotine but rather switched from traditional cigarettes to e-cigarettes. While this might seem like a favorable switch, we don’t actually know how much safer — if at all — e-cigarettes actually are.
Finally, it is worth noting that e-cigarettes now come in dozens of different brands and formulations. Patients who want to use e-cigarettes as a cessation tool may end up using products that are very different from the ones used in this British study. These alternative products may have very different effects.
Where does this leave us? As much as we would like to be enthusiastic about e-cigarettes as a new option for smokers ready to make a quit attempt, we remain skeptical. At best, e-cigarettes may help a minority of smokers switch from one harmful product to another one that may be less harmful.
Nevertheless, because we recognize just how challenging smoking cessation is, we will support our patients who approach us with an interest in switching from traditional cigarettes to e-cigarettes. We will also inform our patients that traditional nicotine replacement products — such as nicotine gums and patches — appear to be more effective for achieving complete nicotine abstinence. These other nicotine products are sold as over-the-counter drugs with strict manufacturing standards, and there is considerably more evidence about their long-term efficacy and safety.
Michael Hochman, MD, MPH, directs the Gehr Center for Health Systems Science at the Keck School of Medicine. Pieter Cohen, MD, is a general internist at Cambridge Health Alliance in Somerville, Massachusetts and associate professor of medicine at Harvard Medical School.