Tools for Practice


#252 Electronic Cigarettes – Hoot that helps, hurts, or just hype?


CLINICAL QUESTION
Do electronic cigarettes help smokers quit smoking?

BOTTOM LINE
 Compared to nicotine replacement therapy (NRT) or placebo electronic cigarettes, two randomized controlled trials (RCTs) demonstrate that nicotine electronic cigarettes (NEC) aid in smoking cessation [number needed to treat (NNT)=13, 15]. Two other RCTs found no difference in cessation rates. Serious lung disease and deaths have been reported with electronic cigarettes (e-cigarette) use. Tetrahydrocannabinol (THC) and vitamin E acetate containing e-cigarettes should be avoided.


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EVIDENCE
Focusing on larger (>200 patients) RCTs of ≥4 weeks duration with objective documentation of abstinence.1-4 Three of four trials1,3,4 industry supported. Typical patient: ~40 years old, smoking ~0.75-1 pack/day for ~20-25 years. Continuous abstinence reported below. 
  • Smokers motivated to quit: 
    • 657 randomized to NEC, nicotine patch, or placebo electronic cigarettes (PEC).1 6-month abstinence:
      • NEC 7%, patch 6%, PEC 4% (not statistically different). 
    • 886 randomized to NEC or any other type of NRT.2 12-month abstinence: 
      • NEC 18%, NRT 10%, NNT=13. 
  • Smokers not intending to quit: 
    • 300 randomized to NEC, tapering doses of NEC, or PEC.3 12-month abstinence (NEC and tapered NEC combined): 
      • NEC 11%, PEC 4%, NNT=15. 
    • 1191 American company workers who responded to email invitations to participate in a smoking cessation trial were randomized to interventions below.4 All received cessation information. 6-month abstinence: 
      • Cessation information only: 0.7%. 
      • Cessation aids (NRT/cessation medications): 3% (not statistically different). 
      • NEC: 5% (not statistically different). 
      • Adding monetary rewards or redeemable deposits: 10% and 13%, respectively. 
  • Adverse effects inconsistently reported in RCTs: throat/mouth irritation reported.2 
Context: 
  • E-cigarettes are commonly used cessation aids.5 
  • While long-term safety data are emerging, cases of e-cigarette or vaping product use-associated lung injury (EVALI), including 48 deaths in the United States, have been reported.6 
    • THC-containing products were associated with 80% of reported hospitalized EVALI patients.6 
      • Vitamin E Acetate: might be the toxicant in THC related EVALI cases.7,8 
  • CDC recommends against the use of THC-containing vaping products.6 
  • Survey data suggests that e-cigarette use may be an independent risk factor for developing respiratory disease (COPD, asthma).9 
  • Regulations should limit adolescent/young adult exposure to e-cigarettes. 
February 3, 2020

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Author(s):

  • Michael R Kolber MD CCFP MSc
  • Tat Wong

1. Bullen C, Howe C, Laugensen M, et al. Lancet. 2014; 382(9905):1629-37.

2. Hajek P, Phillips-Waller A, Przulj D, et al. N Engl J Med. 2019; 380(7):629-37.

3. Caponnetto P, Campagna D, Cibella F, et al. PLoS One. 2013; 8(6):e66317.

4. Halpern S, Harhay M, Saulsgiver K, et al. N Engl J Med. 2018; 378(24):2302-10.

5. Rodu B, Plurphanswat N. Int J Environ Res Public Health. 2017; 14(11):E1403.

6. Lozier MJ, Wallace B, Anderson K, et al. MMWR Morb Mort Wkly Rep. 2019; 68(49):1142-48.

7. Blount BC, Karwowski MP, Morel-Espinosa M, et al. MMWR Morb Mort Wkly Rep. 2019; 68(45):1040-41.

8. Landman ST, Dhaliwal I, Mackenzie CA, et al. CMAJ 2019 December 2;191:E1321-31.

9. Bhatta DN, Glantz SA. Am J Prev Med 2019 Dec 11 [epub ahead of print].

Authors do not have any conflicts of interest to declare.