Advocates for Evidence-Based Health Policy Speakers
Should We Promote E-Cigs for Harm Reduction
In this trial, Hajek et al. randomly assigned 886 adults attending the United Kingdom’s National Health Service smoking cessation services to either nicotine replacement therapy (NRT) or electronic cigarettes in order to evaluate their relative effectiveness in smoking cessation. Individuals in the NRT group were allowed to select product combinations of their own choice (including gum, patches, lozenges, and others methods), whereas individuals in the e-cigarette group were given a starter pack with 18 mg nicotine/mL e-liquid and encouraged to select strengths and flavors of their own preference. Both groups also received supplemental behavioral support for at least four weeks.
Evaluated outcomes included sustained abstinence from cigarettes (for 4, 26, and 52 weeks), frequency of smoking urges, and respiratory side effects related to smoking tobacco. The results of the trial demonstrated a one-year abstinence rate of 18.0% in the e-cigarette group and 9.9% in the NRT group. In both groups, frequency of all reported respiratory symptoms decreased significantly with no significant differences between the two groups. In accordance with previous studies, the authors concluded that e-cigarettes were more effective for smoking cessation than NRT.
The authors largely attributed this result to the greater effectiveness of e-cigarettes in alleviating withdrawal symptoms, which were measured using the mood and physical symptoms scale. However, the differences in withdrawal symptoms were only observed during the first week after the quit date and largely tapered off by the fourth week. Because the difference in abstinence rates at one week was not reported, it is difficult to assess the validity of this claim.
It would have been helpful to have two additional control groups receiving placebo versions of each product. It stands to reason that smoking an e-cigarette is more similar to smoking a cigarette than is chewing nicotine gum, so using placebos could have accounted for any addiction to the physical act of smoking – unlike the addiction to nicotine. While this study ultimately succeeded in demonstrating the difference in the effectiveness of e-cigarettes versus NRT in smoking cessation, more research should be done in order to investigate the reasons for this difference, as well as the long-term risks of using e-cigarettes. Until then, it is difficult to speculate whether e-cigarettes ultimately result in better population health outcomes compared to current NRT products.
This Health Policy Journal Club review is written by Nathanial Riggan as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where he is a medical student.
Abstract
BACKGROUND: E-cigarettes are commonly used in attempts to stop smoking, but evidence is limited regarding their effectiveness as compared with that of nicotine products approved as smoking-cessation treatments.
METHODS: We randomly assigned adults attending U.K. National Health Service stop-smoking services to either nicotine-replacement products of their choice, including product combinations, provided for up to 3 months, or an e-cigarette starter pack (a second-generation refillable e-cigarette with one bottle of nicotine e-liquid [18 mg per milliliter]), with a recommendation to purchase further e-liquids of the flavor and strength of their choice. Treatment included weekly behavioral support for at least 4 weeks. The primary outcome was sustained abstinence for 1 year, which was validated biochemically at the final visit. Participants who were lost to follow-up or did not provide biochemical validation were considered to not be abstinent. Secondary outcomes included participant-reported treatment usage and respiratory symptoms.
RESULTS: A total of 886 participants underwent randomization. The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58; P<0.001). Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]). Overall, throat or mouth irritation was reported more frequently in the e-cigarette group (65.3%, vs. 51.2% in the nicotine-replacement group) and nausea more frequently in the nicotine-replacement group (37.9%, vs. 31.3% in the e-cigarette group). The e-cigarette group reported greater declines in the incidence of cough and phlegm production from baseline to 52 weeks than did the nicotine-replacement group (relative risk for cough, 0.8; 95% CI, 0.6 to 0.9; relative risk for phlegm, 0.7; 95% CI, 0.6 to 0.9). There were no significant between-group differences in the incidence of wheezing or shortness of breath.
CONCLUSIONS: E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support.
PMID: 30699054
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