People who use e-cigarettes to quit smoking have a success rate that is almost two times higher than that of people who use nicotine replacement products, such as patches and gum, according to a study published late last week in the New England Journal of Medicine (NEJM).
“E-cigarettes were almost twice as effective as the ‘gold standard’ combination of nicotine replacement products,” said Peter Hajek, the study’s lead author and a clinical psychologist at Queen Mary University of London, in a released statement.
“Although a large number of smokers report that they have quit smoking successfully with the help of e-cigarettes, health professionals have been reluctant to recommend their use because of the lack of clear evidence from randomized controlled trials. This is now likely to change,” he added.
In Great Britain, the National Health Service, while acknowledging that e-cigarettes are not risk-free, has suggested for several years that smokers may find the products helpful when trying to quit. That’s not the case here in the United States, where the Food and Drug Administration (FDA) has not endorsed e-cigarettes to help people stop smoking.
“A consensus has emerged that e-cigarettes are safer than traditional combustible cigarettes, but it remains controversial whether e-cigarettes should be recommended as a first-line treatment to assist smoking cessation, alongside FDA-approved treatments,” writes Belinda Borrelli, who directs Boston University’s Center for Behavioral Science Research, in a commentary that accompanies the study.
The vapor from e-cigarettes contains toxins that have been shown to have adverse biologic effects on human cells and animals, she points out.
“These findings argue against complacency in accepting the transition from tobacco smoking to indefinite e-cigarette use as a completely successful smoking-cessation outcome,” she stresses.
The current study was a randomized controlled trial (RCT), which is generally considered the best way to compared two treatments to see which one is most effective. This study is also the first RCT to compare the latest generation of e-cigarettes (rather than the earlier “cig-a-like” ones that had lower levels of nicotine) to nicotine patches, gum and other replacement products.
For the study, researchers recruited 886 British smokers, mostly middle-aged, who had sought help to stop smoking through the National Health Service. None of the smokers was currently using either e-cigarettes or nicotine replacement products. The study also excluded women who were pregnant or breastfeeding.
The participants were randomly assigned to receive either a three-months’ supply of a nicotine replacement treatment of their choice (patches, gum, lozenges, sprays, inhalers or a combination of those products) or an e-cigarette starter pack with one bottle of tobacco-flavored e-liquid (liquid nicotine), which is about a two- to four-week supply. The e-cigarette group was encouraged to buy refills in the flavors and strengths of their choice.
Participants in both groups also received weekly one-on-one behavioral counseling for at least one month. The counselors also monitored the carbon monoxide levels in the participants’ breath (an objective way of detecting whether and how much someone is smoking).
A year after entering the study, the participants were contacted by phone. Those who said they had successfully quit smoking or who had cut back by at least 50 percent were invited to come back for another carbon monoxide reading. (Anyone who wasn’t reached by phone was considered to be still smoking.)
The study found that after a year, 18 percent of the e-cigarette users (79 individuals) had stopped smoking traditional tobacco products compared to 9.9 percent of the users of the nicotine replacement products (44 individuals).
In addition, the carbon monoxide tests revealed that among the people who had not completely quit smoking, the e-cigarette users were significantly more likely to have reduced their tobacco smoking by at least 50 percent.
Yet, almost 80 percent (66) of the e-cigarette users who had quit smoking continued to vape at one year. Only 9 percent (four) of the people in the nicotine replacement group who had quit smoking were still using those products at the one-year mark.
The 80 percent figure raises concerns. Although e-cigarettes are generally considered safer than traditional cigarettes, much about the chemicals (particularly the flavorings) in the vapor they produce — and thus about their long-term health effects — remains unclear.
The continued use of e-cigarettes “can be seen as problematic if e-cigarette use for a year signals long-term use, which may pose as-yet-unknown health risks,” write the study’s authors.
Neither group experienced any immediate adverse effects related to using the e-cigarettes or nicotine replacement products.
The e-cigarette participants were, however, more likely to report throat or mouth irritation than those assigned the nicotine replacement products (65.3 percent versus 51.2 percent).
On the other hand, the people in the e-cigarette group reported slightly less nausea (31.4 percent versus 37.8 percent), and they reported a greater decline in coughing and phlegm production.
The e-cigarette participants also reported less irritability, restlessness and ability to concentrate after the first week of quitting smoking than did those using the nicotine replacement products.
An unresolved debate
The study comes with several important limitations. It included only motivated people — those who had referred themselves to a stop-smoking program. In addition, all of the participants received free one-on-one counseling support.
It’s not clear if the program would work for people without similarly high levels of motivation or support.
In addition, the study’s participants were followed only for a year. And it’s not clear if the findings would apply to all types of e-cigarettes.
Experts also point out that although more people quit smoking using e-cigarettes than nicotine patches or gum, the percentage of people quitting in both groups was relatively small.
“In spite of the concerted effort and encouraging findings, it is still disappointing,” David Liddell Ashley, the previous director of the office of science in the Center for Tobacco Products at the FDA, told Vox reporter Julia Belluz.
“This points to the importance of further efforts, such as reducing nicotine in combusted products to encourage smoking cessation,” he added.
What all health experts can agree on, however, is the urgent need to find more ways to help smokers quit.
As a review of the study on a National Health Service website states, “There is no credible argument that can challenge the statement that quitting smoking is the best thing you can do for your health if you currently smoke.”
FMI: The NEJM study is behind a paywall, but you’ll find an abstract of the study on the journal’s website.