For those who believe that electronic cigarettes might hold promise as a smoking cessation tool, a trio of researchers have a sobering message: The highest-quality research in this area does not point to that, and in fact suggests that use of e-cigarettes in many cases can impede progress toward quitting smoking.
These researchers' recent review of published studies—an analysis that has received little attention in the addiction field so far, perhaps because it was published in a cardiology-focused journal—points to prevalent dual use of e-cigarettes and conventional cigarettes as the main culprit behind the disappointing performance of e-cigarettes in promoting smoking cessation.
“There is every reason to think that e-cigarettes would be a good thing,” says Stanton A. Glantz, PhD, professor of medicine at the University of California, San Francisco. “But the evidence is showing that they actually seem to be inhibiting cessation.”
Wading through data
In examining the available information for the review, published in the journal Circulation, Glantz and his two colleagues found that it was considerably easier to locate opinion pieces about e-cigarettes than actual peer-reviewed studies, he says.
The research team was made up of individuals with diverse expertise and a balance of views on the potential merits of e-cigarettes. Glantz has closely studied environmental exposure and secondhand smoke, while Rachel Grana, PhD, MPH, is an expert in smoking cessation and Neal Benowitz, MD, is well-versed in pharmacology. Glantz says the skeptical views of himself and Grana on e-cigarettes' value were balanced somewhat by Benowitz's more optimistic outlook that e-cigarettes may be useful in that they clearly are less toxic than conventional cigarettes.
“We sort of dragged him to be more skeptical, and he the reverse to us,” Glantz says of his colleague.
By the time the group's analysis had been submitted for peer review, a total of 81 articles formed the basis for the paper. The researchers found that just over 6% of adults in the U.S. in 2011 reported having tried e-cigarettes. Current smokers were the most common users of e-cigarettes, followed by former smokers—there was virtually no use among nonsmokers.
The researchers examined five population-based studies and four clinical trails to draw conclusions about the potential association between use of e-cigarettes and quitting conventional smoking. The studies generally found that e-cigarette use actually was associated with a lower likelihood of quitting. In one trial of different strengths of e-cigarettes, there was no statistically significant difference in one-year quit rates for placebo (a 4% quit rate at the one-year mark), low-nicotine e-cigarettes (a 9% quit rate) and high-nicotine e-cigarettes (13%).
Also, the researchers wrote, “The one clinical trial examining the effectiveness of e-cigarettes (both with and without nicotine) compared with the medicinal nicotine patch found that e-cigarettes are no better than the nicotine patch and that all treatments produced very modest quit rates without counseling.”
The studies that have been done tend to show that because many users of e-cigarettes also continue to smoke regular cigarettes, the potential effect on smoking cessation and other possible benefits are not realized. “There are high levels of dual use,” Glantz says. “As long as you're still smoking, that will wipe out most of the health benefits” of using a product that does not contain some of the noxious components found in tobacco products.
Moreover, the study stresses that most e-cigarette devices are manufactured in China and there is great variability in the engineering among the various products on the market, making it difficult for consumers to draw conclusions about the safety and effectiveness of the item they're buying.
Glantz says marketing of e-cigarettes drives a great deal of the public's attitude and behavior regarding the products. Much of the marketing focuses on messages that e-cigarettes are cheaper and cleaner than conventional cigarettes and can be used in places where regular cigarette use is banned or frowned upon. This may contribute to the dual-use phenomenon, with individuals using e-cigarettes in public settings but continuing to smoke at home/in private.
The research review also identified data indicating that viewing e-cigarette ads can cue among smokers the urge to use conventional cigarettes.
The potential role of e-cigarettes will be part of the discussion at a panel to be held this summer at the National Conference on Addiction Disorders (NCAD) in St. Louis. The Aug. 26 panel presentation will feature representatives from treatment programs and states that have successfully implemented tobacco-free mandates in treatment environments.
Impact on treatment providers
So if the potential benefits of e-cigarettes don't seem to be bearing out in research thus far, how should addiction treatment and other healthcare providers react if a patient expresses the desire to use the products to help in quitting smoking? Glantz believes first and foremost that a professional should always support a patient in the desire to quit.
If the patient insists on using e-cigarettes as part of the strategy, Glantz says, he/she should be urged to stop using conventional cigarettes so that any possible benefits of the alternative product can be realized. The professional also should inform the patient of more proven therapies for smoking cessation, such as various forms of counseling and pharmacotherapies such as varenicline and bupropion.
“The most important thing is to encourage people to keep trying,” Glantz says. “Few people succeed in quitting on the first or second try.”