USPSTF Declines to Back E-Cigarettes for Smoking Cessation

While research suggesting e-cigarettes may be useful for helping adult smokers quit continues to build, but the evidence remains inadequate to support a formal recommendation, the U.S. Preventative Services Task Force (USPSTF) determined.

In updated recommendations appearing in JAMA, “The USPSTF recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety,” the statement read.

The advisory group also found the data insufficient to assess the safety of established smoking cessation pharmacotherapies in pregnant women who smoke.

The task force did conclude, however, with “high certainty” that behavioral interventions can be useful for helping pregnant women quit smoking and improving perinatal outcomes.

“The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco (A recommendation),” the statement read.

While smoking rates among adults in the U.S. have declined to historic lows in recent years, 14% of the adult population — or roughly 34 million people — still smoked in 2019, according to the CDC. Tobacco use remains the leading preventable cause of death and disease in the United States.

A 2020 report from the U.S. Surgeon General on smoking and tobacco use found that, while 68% of adults who smoked reported wanting to quit — with around 55% reported attempting to do so — only around 7% of smokers successfully quit in a given year.

“Each year, more than half a million people die from smoking-related disease,” said USPSTF member Chien-Wen Tseng, MD. “There has never been a more important time to stop smoking. With the COVID-19 pandemic people are paying more attention to their health, and quitting smoking is one of the most important things someone can do for their health.”

A task force working group reviewed the evidence on smoking cessation interventions, including five trials with a total of 3,117 participants comparing nicotine-containing e-cigarettes to placebo or nicotine replacement therapy (NRT) published from 2013 to 2019. In two of these trials (2,008 participants) smokers in the e-cigarette group (with or without NRT) had significantly greater rates of cigarette abstinence compared to those in the NRT alone group, but continued use of e-cigarettes was high at 6- and 12-month follow-up.

Several recently published trials which were not included in the review also appear to support a role for e-cigarettes in smoking cessation, although absolute success rates were still very low.

In a study from England with 886 cigarette users, switching to e-cigarettes was associated with greater cigarette abstinence at 1 year compared to NRT use (18% vs 9.9%). And in a study from New Zealand, which included 1,124 cigarette smokers, adding e-cigarettes to NRT increased cigarette smoking cessation at 6 months compared to NRT alone, with 7% versus 2% of participants abstaining, respectively.

A recently published Cochrane review of 50 studies involving 12,430 participants found “moderate‐certainty evidence, limited by imprecision,” that e-cigarettes with nicotine increased quit rates at six months or longer compared to non‐nicotine e-cigarettes and compared to NRT and “very low‐certainty evidence” that e-cigarettes with nicotine increased quit rates compared to behavioral support alone or to no support.

Tseng told MedPage Today that none of the randomized trials or reviews included long-term e-cigarette use safety data, because the products haven’t been on the market long enough to establish long-term risk.

“We know people are asking their doctors about e-cigarettes, but we don’t yet have enough data to give them clear answers about the benefits and harms, especially the long-term harms,” she said.

“The good news is the evidence shows that there are very effective ways to help people quit smoking, and one of the most effective strategies is behavioral counseling.”

Relatively new pharmacology cessation strategies include combining long- and short-acting nicotine replacement therapies and starting medication before a quit date — a practice known as pre-loading.

The task force also called for studies to address the many unanswered questions about “the effectiveness of e-cigarettes for smoking cessation, as well as potential short- and long-term harms of e-cigarette use, and to understand whether there are effective and safe pharmacotherapy options for pregnant persons.”

In accompanying commentary, Brenna VanFrank, MD, and Letitia Presley-Cantrell, PhD, of the CDC’s Office on Smoking and Health, wrote that systems-level changes in healthcare delivery can help clinicians deliver smoking cessation counseling and treatments.

They noted that team-based approaches, including chronic disease management models, “can mitigate the burden of screening and treatment delivery on any one individual” and that “delivery of clinical interventions can also be increased with the linkage of payment to cessation-related quality measures and the availability and dissemination of clinical practice guidelines.”