From Pages to Practice

By Amanda Fernandes, MD

Published February 27, 2019


Smoking remains the leading cause of preventable death and is responsible for 1 in 5 deaths annually. Quitting is extremely hard and by conservative standards, most people try approximately 8 to 11 times before quitting permanently.

While trying to quit smoking, Chinese pharmacist Hon Lik developed the first electronic cigarette (e-cigarette) using ultrasound to vaporize and deliver nicotine. Current e-cigarettes have three main components — a mouthpiece, electronic battery, and an atomizer that contains the liquid with nicotine and flavoring.  Although the e-cigarette is not FDA-approved as a tool for smoking cessation, it is often used and touted as one.

In a pragmatic, multicenter, randomized,  controlled trial, Hajek and colleagues compared the effectiveness of e-cigarettes to nicotine-replacement therapy in participants in the U.K. National Health Service smoking-cessation program. Although the rate of abstinence from smoking was significantly higher in the e-cigarette group, more participants continued to use e-cigarettes at 1 year, compared to those in the nicotine-replacement group who were still using nicotine-replacement products. As highlighted in an editorial, this study does not define the long-term health consequences of e-cigarettes.

The following NEJM Journal Watch summary further explains the study.


E-Cigarettes vs. Nicotine-Replacement Therapy for Smoking Cessation

In a randomized trial, 1-year abstinence from smoking was more likely with electronic cigarettes.

Proponents of electronic cigarettes often advocate use of e-cigarettes (“vaping”) to facilitate smoking cessation. In this U.K. study, researchers identified 884 adult smokers who chose a quit date and were randomized to either e-cigarettes or nicotine-replacement therapy. Those in the e-cigarette group were given starter kits; those in the nicotine-replacement group were permitted to choose from various products (e.g., patches, gum, lozenges); many used combinations of products. All participants were given multisession behavioral support.

The rates of abstinence from smoking at 1 year were 18% in the e-cigarette group and 10% in the nicotine-replacement group (P<0.001). Among abstainers in the e-cigarette group, 80% still were using e-cigarettes at 1 year; among abstainers in the nicotine-replacement group, only 9% were still using nicotine-replacement products at 1 year.

Comment: E-cigarettes were more effective than nicotine replacement in facilitating smoking cessation; however, many participants in the e-cigarette group who stopped smoking combustible tobacco continued to use e-cigarettes at 1 year. This study's 1-year abstinence rates in the 10% to 20% range are typical for pharmacologic smoking-cessation interventions. Readers with interest in this topic should have a look at the two accompanying editorials. Borrelli and O'Connor recommend that e-cigarettes be used for smoking cessation “only when FDA-approved treatments fail.” Drazen and colleagues focus particularly on nicotine addiction in young people and argue that the FDA should ban flavored nicotine products for e-cigarettes.

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Amanda Fernandes is a 2018-2019 NEJM editorial fellow.