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Can e-Cigarettes Help Smokers Quit?

  • Authors: News Author: Heidi Splete; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 3/25/2022
  • Valid for credit through: 3/25/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

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Target Audience and Goal Statement

This activity is intended for primary care physicians, pulmonary medicine specialists, addiction specialists, nurses, pharmacists, and other members of the healthcare team who treat and manage patients who smoke cigarettes.

The goal of this activity is for the learner to be better able to assess the efficacy of e-cigarettes as an aid in smoking cessation.

Upon completion of this activity, participants will:

  • Assess the efficacy of e-cigarettes in promoting cigarette abstinence in a meta-analysis of randomized trials
  • Evaluate the efficacy of e-cigarettes as a smoking cessation aid in a large cohort study
  • Outline implications for the healthcare team


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News Author

  • Heidi Splete

    Freelance writer, Medscape


    Disclosure: Heidi Splete has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

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  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

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Can e-Cigarettes Help Smokers Quit?

Authors: News Author: Heidi Splete; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/25/2022

Valid for credit through: 3/25/2023


Clinical Context

Can e-cigarettes work as a tool to quit cigarette smoking? A systematic review of 50 randomized trials by Hartmann-Boyce and colleagues, published in the October 14, 2020, issue of the Cochrane Database of Systematic Reviews, suggests that they can.[1] Overall, the risk ratio for smoking cessation in comparing e-cigarettes with nicotine replacement therapy (NRT) was 1.69 (95% confidence interval, 1.25-2.27), which equated to approximately 4 more successes in quitting per 100 attempts. E-cigarettes with nicotine were more effective at aiding smoking cessation compared with e-cigarettes without nicotine. Serious adverse events were rare overall and did not appear to be more common with the use of e-cigarettes, although less serious adverse effects such as mouth/throat irritation and headache were slightly more common with the use of e-cigarettes.

The current study uses a large observational cohort to assess how e-cigarettes might affect rates of smoking cessation. The authors focus on a period when e-cigarettes with a high concentration of nicotine were available.

Study Synopsis and Perspective

Use of e-cigarettes was not more effective than other methods at helping cigarette smokers quit, authors of new research found.

From 2013 to 2017, e-cigarette sales in the United States nearly doubled, writes Riufeng Chen, MD, from the University of California, San Diego, and colleagues in their article, published in Tobacco Control.[2] However, the subsequent effect of increased e-cigarette use on smoking cessation have not been examined, they said.

In their study, Dr Chen and colleagues analyzed data from 3578 previous-year smokers with a recent quit attempt and 1323 recent former smokers who were part of the PATH cohort in 2017. The participants reported using e-cigarettes or other products to quit cigarette smoking. The primary outcomes were at least 12 months of cigarette abstinence and tobacco abstinence in 2019. In 2017, 32.8% of established smokers reported trying to quit. Of these, 12.6% used e-cigarettes to help them quit. Cigarette abstinence for at least 12 months for these individuals was 9.9%, which was lower than for those who used either NRT or a pharmaceutical aid only (15.2%), and about half of the 18.6% abstinence in those who used no products to help them quit.

"In our study, e-cigarettes resulted in 7 fewer successful quitters than those who used pharmaceutical aids," emphasized corresponding author John P. Pierce, PhD, from the University of California, San Diego.

Among smokers attempting to quit, the adjusted risk difference for cigarette abstinence for a least 12 months with e-cigarettes vs pharmaceutical aids was −7.3%, and −7.7% for e-cigarettes vs other smoking cessation methods.

"Among recent former smokers who had switched to daily use of e-cigarettes in 2017...43.2% (95% CI 32.5% to 54.0%) had successfully quit cigarette smoking by 2019...which was similar to those who used e-cigarettes on a non-daily basis [34.6%] or to those who switched to another tobacco product, whether daily [43.6%] or non-daily [44.7%]," the researchers write.

More Research Needed

The researchers acknowledge the need to review more recent data.

"When we looked ahead to 2019, recent former smokers had started using high nicotine e-cigarettes. The effectiveness of high nicotine e-cigarettes at preventing relapse will require another follow-up PATH survey," they write. High-nicotine e-cigarettes have been noted as a close match to cigarettes in both nicotine delivery and user satisfaction.

Among recent former smokers, 2.2% reported switching to a high-nicotine e-cigarette. Although individuals who switched to e-cigarettes showed a higher rate of relapse to cigarettes than those who did not switch to other tobacco or e-cigarette products, this difference was not significant.

The study findings were limited by several factors including the observational design and inability to control for all potential confounding factors, the researchers note. However, the results were strengthened by the use of a large and representative study population and the inclusion of biological samples to validate self-reported smoking, they said.

Several Findings Surprised Study Author

Dr Pierce said he was surprised by several aspects of the study findings.

"First of all, contrary to what we expected, there was a 25% decline in using e-cigarettes to quit, compared to the previous year (not the 40% increase that was expected from the increase in e-cigarette sales) and almost no smokers were using high-nicotine products to help them quit," he said. "In this study, e-cigarettes were much less helpful (7 less successful quitters per 100) than pharmaceutical cessation aids in helping people quit," he added.

"The fact that the proportion of smokers using e-cigarettes for cessation dropped from 17% to 12% was unexpected, and it suggests that the belief that they are a cessation aid is declining," he said.

The implication for clinical practice is that e-cigarettes are not a useful tool for smoking cessation, Pierce said. "We are not finding any evidence in this very large nationally representative study that smokers who switch to getting their nicotine from e-cigarettes are less likely to relapse back to cigarette smoking," he said.

"We don't know about the high-nicotine versions," he added.

New Review Advises Against e-Cigarettes for Cessation

A recent review article published in JAMA supports the use of pharmacotherapy and behavioral support for smokers wanting to quit. In the review, Nancy A. Rigotti, MD, from Massachusetts General Hospital, Boston, and colleagues summarized the evidence for managing tobacco smoking in clinical practice.[3]

"The health risk from cigarette smoking is primarily due to chemicals produced by the burning of tobacco and not to nicotine," they note. However, the physical dependence on nicotine makes quitting a challenge, but it is one worth pursuing, the authors say.

The authors of this review identified 30 reviews, 12 randomized clinical trials, and 7 recent guidelines and evidence reviews. Their key message is that pharmacotherapy and behavioral support are most effectivewhen combined. Pharmacotherapy helps reduce the symptoms of nicotine withdrawal, whereas behavioral intervention tackles the challenge of changing learned behaviors associated with smoking, the researchers said.

Although combining medications, such as varenicline and NRT or bupropion, might improve successful quit rates, these combinations have not been well studied, they note.

With regard to e-cigarettes, the researchers cited a 2021 Cochrane review of 16,759 individuals who used e-cigarettes for smoking cessation that found no evidence of harm, but found insufficient evidence to assess the balance of risks vs benefits.

In addition to the lack of randomized trials, "the FDA regulates e-cigarettes as tobacco products, not as medical products and has not evaluated any e-cigarette for medical use as a cessation aid," the authors of the new review noted.

The review was limited by several factors, including the lack of quality assessment for the selected studies and the exclusion of pharmacotherapy not licensed in the United States.

Commenting on the JAMA article, Dr Pierce said, "This review looks like a number of Cochrane Reports that have been published recently. Of course, it only considers randomized trials and not population evidence."

Findings May Guide Patient Conversations

The Tobacco Control study was important because few studies on e-cigarettes have been conducted, said Linda Girgis, MD, a family physician in private practice in South River, New Jersey, in an interview.

"As clinicians, we do not have a lot of data available in order to make clinical decisions that are evidence based. Also, getting patients to quit smoking is often very difficult, and having more tools available is a great benefit--however, we need to have the evidence that these tools are effective," she said.

Dr Girgis also said that she was not surprised by the findings.

"Patients still have the same concerns from e-cigarettes regarding nicotine exposure, but just to a lesser degree, and we still don't know the long-term effects of e-cigarette use," she said. Based on these studies, recommending e-cigarettes for smokers looking to quit may not be the best method, she noted.

"While it may seem reasonable that exposing lungs to lower doses of nicotine will reduce harm, we need to see actual evidence of this. Also, we also need to study the additives that are frequently used in e-cigs, such as artificial flavorings, to see what harms they may pose," she emphasized.

With regard to the JAMA review, Dr Girgis said that she agreed with the recommendations for pharmacotherapy and behavior therapy as first-line treatments for smoking cessation. "There is evidence regarding the efficacy and safety of these methods, and they have been used for decades," she said.

Dr Girgis added that there is a role for e-cigarettes in smoking cessation strategies as a method of harm reduction, but pointed out the problem of many people thinking that these products are safe and not understanding the hazards they pose.

"They think they can replace smoking with e-cigarettes and be safe from the health risks associated with smoking. I think if the plan were to switch to e-cigarettes for a short period and then quit, there would be a role," Dr Girgis said. "However, replacing one risk for another may reduce harm, but doesn't eliminate it."

"To continue to use e-cigarettes indefinitely should not be the goal," she added.

The Tobacco Control study was funded by the National Institutes of Health and the Tobacco-Related Disease Research Program of the University of California. The researchers have disclosed no relevant financial relationships. The JAMA study was funded in part by a grant from the National Institute for Health Research, via Cochrane Infrastructure funds to the Cochrane Tobacco Addiction Group. Lead author Dr Rigotti disclosed funding from the National Heart, Lung, and Blood Institute and Achieve Life Sciences and personal fees from UpToDate and Achieve Life Sciences. Dr Girgis has disclosed no relevant financial relationships.

Tob Control. Published online February 7, 2022.

Study Highlights

  • Research data were drawn from the PATH Study, a longitudinal cohort study in the United States. Study participants eligible for participation in the current protocol were 3578 regular cigarette smokers who made an attempt to quit in 2016 or 2017.
  • Participants reported on their particular smoking habits and any aids they used to help them quit. They also provided a wealth of other sociodemographic and health information.
  • The main outcome of the current analysis was the efficacy of e-cigarette use as a means to help achieve abstinence from cigarettes. These results were adjusted for demographic variables, smoking habits, self-efficacy measurements, and the presence of smoking-related illnesses.
  • 32.8% of the study cohort reported an attempt to quit smoking in the past 12 months, and 12.4% reported a successful quit attempt.
  • 12.6% of those who recently tried to quit reported e-cigarette use as an aid to quitting, and 20.6% use NRT or another pharmacologic agent to help quit smoking.
  • Less than 5% of participants who used e-cigarettes reported using a high-nicotine product.
  • Variables associated with higher rates of e-cigarette use included age younger than 50 years, higher educational attainment, White race, and income higher than $35,000/year.
  • Rates of smoking cessation at 12 or more months were 9.9%, 15.2%, and 18.6% among participants who used e-cigarettes, NRT or other pharmacotherapy, or no therapeutic aids.
  • The use of e-cigarettes was similarly successful as other tobacco products, such as cigars or snus, in achieving cigarette cessation.
  • 43.2% of participants who successfully quit smoking using e-cigarettes were able to maintain cigarette cessation for more than 1 year.
  • Overall, the use of e-cigarettes was associated with a 6% to 7% reduction in sustained abstinence rates from cigarettes compared with not using e-cigarettes or using NRT specifically.
  • Participants had a less favorable view of the safety of e-cigarettes from 2016 to 2019.

Clinical Implications

  • A meta-analysis of randomized trials found that e-cigarettes, particularly those that contained nicotine, modestly improved smoking cessation rates. Serious adverse events were not increased with e-cigarette use.
  • The current study suggests that e-cigarettes are not effective in promoting cigarette abstinence and are less effective than NRT or other pharmacotherapy.
  • Implications for the healthcare team: E-cigarettes may not be effective as aids to smoking cessation. The healthcare team should first focus on more proven smoking cessation aids.


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