E-Cigarettes Aid in Smoking Cessation, US Study Suggests

Individuals who use electronic cigarettes are not only more likely than nonusers to try to stop smoking conventional cigarettes, but also more likely to be successful when they do attempt to quit, according to the results of a new study.

In a nationally representative survey of US tobacco use, 65.1% of those who used e-cigarettes in addition to tobacco made an attempt to quit smoking in the past year compared with 40.1% of tobacco smokers who did not use e-cigarettes. Additionally, 8.2% of those who used e-cigarettes were successful in quitting smoking compared with just 4.8% of those who did not use the product. 

“If you just look at the data, if I’m a physician and look at this rationally, then I have to treat e-cigarettes as part of the whole toolbox if I’m talking about smoking cessation, especially for somebody who has tried lots of things before,” lead investigator Shu-Hong Zhu, PhD (University of California, San Diego), told TCTMD. “Still, it’s a difficult question to answer as it’s not a proven drug in the US. Our usual [US Food and Drug Administration (FDA)] process does not apply, as the product’s been on the market already for many years.”

The FDA now regulates the “manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution” of all electronic nicotine delivery systems, such as e-cigarettes, but the products are not approved to aid in smoking cessation.

In the study, the researchers also showed that the overall smoking cessation rate in 2014-2015 was higher than in 2010-2011. During that span, smoking cessation rates increased from 4.5% to 5.6%, an absolute difference that might appear small but would represent approximately 350,000 additional US smokers who quit in 2014-2015, say researchers.

To TCTMD, Zhu said it is extremely difficult to increase smoking cessation rates at the population level, noting that even a large federal tobacco tax in 2009 had a negligible effect on the total cessation rate in 2010-2011.

“We know tax works,” he said. “You tax people, they use less of the product. But for people already smoking, even such a dramatic tax didn’t seem to do much. This provides some context for just how hard it is to increase the smoking cessation rate at the population level. You can help some individuals, but [change] at the population level is very difficult.”

Annual Cessation Rate Increased in 2014-2015

For the study, published online July 26, 2017, ahead of print in the BMJ, data on e-cigarette use was obtained from 161,054 individuals participating in the 2014-2015 US Current Population Survey-Tobacco Use Supplement (CPS-TUS). Of those who responded to the survey, 22,548 were current smokers and 2,136 had recently quit. Only 2.0% of never smokers had used e-cigarettes, while 49.3% of those who recently quit had used the product. Among current smokers, the rate of e-cigarette use was 38.2%.

Individuals who used e-cigarettes within the past 12 months were more likely to attempt to quit smoking and were more likely to have quit smoking for at least 3 months. Comparing the population-level smoking cessation rates with past surveys, there was no significant change until 2014-2015, say researchers. In 2001-2002, 2003, 2006-2007, and 2010-2011, the annual smoking cessation rates were 4.3%, 4.3%, 4.5%, and 4.5%, respectively. In 2014-2015, as noted, the rate as 5.6%.

Zhu said that compared with 2010-2011, the annual cessation rate was higher in 2014-2015 because e-cigarette users had a significantly higher quit rate than those who did not use e-cigarettes in the past year.

Regarding the long-term safety of e-cigarettes, Zhu acknowledged that little is known. However, in a head-to-head comparison with cigarettes, the product is likely safer. “The logic is made a little bit easier in this case because cigarettes are so bad,” said Zhu. “If we compared it with something else, it wouldn’t be so obvious to me that it’s a rational thing to use.”

Samuel Wann, MD (Columbia St. Mary’s Healthcare, Milwaukee, WI), who was not involved in the study, viewed the new findings positively but noted the study has limitations, including the use of self-reported census data. He pointed out that other interventions, including educational campaigns, also might have contributed to the decline in smoking at the population level.

“Given the data they have, they are to be congratulated, but it doesn’t make me want to approve or disapprove e-cigarettes as a device to stop smoking,” he said.

Wann said he has patients who have tried unsuccessfully to quit in the past but only succeeded with the assistance of e-cigarettes, while others cut back for a short while only to return to smoking. He noted there are strong opinions on both sides, with abolitionists extremely worried about the safety of e-cigarettes, including their potential as a gateway to smoking, and those who argue e-cigarettes, even if harmful, are less so than conventional tobacco products.

In practice, Wann said he is fairly tolerant of patients trying e-cigarettes as a means to quit, but he doesn’t raise the option or encourage it.

‘Tunnel Vision’ Focus on Risks to Kids

Kenneth Warner, PhD (University of Michigan, Ann Arbor), a researcher who focuses on economic and policy aspects on disease prevention and health promotion, specifically tobacco control, told TCTMD the present study is one of the first to study effects of e-cigarettes on smoking cessation in the United States. Like Zhu, he suggests that e-cigarettes can be used in patients who have struggled to quit smoking.

“We don’t know a lot about the effects of e-cigarettes in any dimension,” said Warner. “We do know that in this country the approach that has been taken by governmental agencies and nongovernmental public health organizations is to focus, almost with tunnel vision, on the potential risks to kids.”

In this exclusive attention on children and adolescents, the US public health message with e-cigarettes has been negative, he added. In England, however, public health organizations have taken another somewhat controversial tack, stating that e-cigarettes are less harmful than smoking and that adults unable to quit smoking could try e-cigarettes as a potential cessation aid.

Warner noted that pharmaceutical aids to quit smoking, such as varenicline (Chantix) and bupropion (Zyban), as well as transdermal nicotine patches and other nicotine replacement products, have had no impact on smoking cessation rates on a population level.

“These things have been with us now for almost three decades, and we just can’t discern anything in the data to show they have made a major difference in people’s overall quit rates,” said Warner. “We know they work and they’re good for some people, but we just can’t see any kind of population-level impact.”     

In an editorial, Christopher Bullen, MD (University of Auckland, New Zealand), notes the emergence of e-cigarettes in Western countries a decade ago generated considerable debate. In addition to claims and counterclaims of the long-term risks and benefits, it remains uncertain if the products increase or decrease population smoking cessation rates. The present study, according to Bullen, sheds some light on this important topic.

“The research by Zhu and colleagues suggests that where such permissive approaches to e-cigarettes exist—ones that enable smokers to have ready access to products that deliver nicotine effectively, at a price lower than that of tobacco cigarettes—then substantial numbers of smokers will make the transition away from smoking, and a substantial population benefit can result,” he writes.