On 2016 Jul 24, James Yeh commented:

Editor's Comment

E-Cigarettes and Smoking Cessation — Polling Results

James S. Yeh, M.D., M.P.H., and Edward W. Campion, M.D.

The goal of smoking cessation is to reduce the effect of smoking on mortality and morbidity. Despite the dramatic reduction in the prevalence of smoking over the past 50 years, the use of tobacco still contributes significantly to morbidity and mortality.[1] About 1 in 5 deaths in the United States each year can be attributed directly or indirectly to cigarette smoking, and life expectancy among smokers is 10 years shorter than that among nonsmokers.[2] Quitting before 40 years of age reduces the risk of dying from smoking-related illness by 90%.[3]

The use of e-cigarettes has become more prevalent; 16% of U.S. high-school students use e-cigarettes,[4] and about 4% of U.S. adults use e-cigarettes on a regular basis.[5] There is no doubt that e-cigarettes engender tremendous interest from the public, the medical community, and the Food and Drug Administration (FDA) with respect to their potential as lifesaving nicotine-delivery devices for persons with tobacco dependence. Recent modeling research has projected a 21% reduction in death attributed to tobacco-smoking if e-cigarettes are used.[6] However, despite the potential benefit, there remain concerns about the safety of e-cigarettes and their efficacy for smoking cessation; for this reason, the FDA has recently extended its regulatory authority to cover e-cigarettes.[7]

In June, we presented the case of Mr. O’Malley, a 29-year-old man who had been smoking since he was 15 years of age and more recently was smoking up to 1.5 packs per day.[8] Readers were invited to vote on whether to recommend that Mr. O’Malley try using e-cigarettes for smoking cessation. Mr. O’Malley had a history of obesity, hypertension, and childhood seizures. In the past, he had quit smoking “cold turkey” and had used various nicotine-replacement therapies, but he had never been able to sustain smoking abstinence for an extended period of time.

More than 35,000 readers viewed the Clinical Decision case, and 666 readers in 62 countries responded to the poll. The largest group of respondents, representing more than 45% of the votes, was from the United States and Canada (306 voters), followed by respondents from Europe (235). Two thirds of the respondents (66%) voted to recommend the use of e-cigarettes for smoking cessation, and the remaining respondents voted against recommending e-cigarettes. This result suggests that a majority of the poll respondents believe that e-cigarettes are a reasonable strategy for smoking cessation, at least for a patient such as the one described in the case vignette.

A substantial proportion of the 41 voters who submitted comments emphasized the health benefits derived from reducing or quitting tobacco use. These benefits, which include a lowering of the risks of cardiovascular-related death, lung cancer, and pulmonary symptoms, are especially important in this case of an asymptomatic young tobacco-dependent smoker who already has some risk factors for cardiovascular disease.

Commenters raised several related recurring themes. They emphasized the difficulty of current smoking-cessation regimens, such as nicotine-replacement therapy, varenicline, or bupropion, in sustaining smoking abstinence. A number of commenters considered e-cigarettes to be a reasonable complementary smoking-cessation aid to kick-start the process of reducing and quitting tobacco smoking, along with the more traditional smoking-cessation aids, with the eventual goal of weaning smokers off e-cigarette use altogether.

Many readers also commented that the quality and the safety of the e-cigarettes could not be relied on, since e-cigarettes were an unregulated nicotine-delivery device at the time. Some readers indicated their belief that e-cigarettes should be regulated by the FDA and that e-cigarettes should not be recommended until there is reliable evidence that they are less hazardous than tobacco smoking and that they are efficacious in reducing tobacco smoking. Others expressed concern about the availability of e-cigarettes to adolescents. Thus, for some, uncertainty about the performance and safety of e-cigarettes deterred them from recommending their use as a smoking-cessation aid.

REFERENCES

[1] Fiore MC, Baker TB. Treating smokers in the health care setting. N Engl J Med 2011;365:1222-31. [2] 2014 Surgeon General’s report: the health consequences of smoking—50 years of progress. Atlanta: Centers for Disease Control and Prevention (http://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm). [3] Jha P, Ramasundarahettige C, Landsman V, et al. 21st-Century hazards of smoking and benefits of cessation in the United States. N Engl J Med 2013;368:341-50 [4] Singh T, Arrazola RA, Corey CG, et al. Tobacco use among middle and high school students — United States, 2011 ̶ 2015. MMWR Morb Mortal Wkly Rep 2016;65:361-7. [5] Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS data brief no. 217. Hyattsville, MD: National Center for Health Statistics, 2015. [6] Levy DT, Borland R, Villanti AC, et al. The application of a decision-theoretic model to estimate the public health impact of vaporized nicotine product initiation in the United States. Nicotine Tob Res 2016 July 14 (Epub ahead of print). [7] FDA takes significant steps to protect Americans from dangers of tobacco through new regulation. Silver Spring, MD: Food and Drug Administration, May 5, 2016 (http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm499234.htm). [8] Yeh JS, Bullen C, Glantz SA. E-cigarettes and smoking cessation. N Engl J Med 2016;374:2172-4.

On 2016 Jun 30, Riccardo Polosa commented:

In this case study of a 29-yr old man (Mr. O'Malley) interested in giving up smoking using e-cigarettes, two experts are providing their personal recommendations.

Expert no.1, Dr Christopher Bullen, is recommending e-cigarettes for smoking cessation because he thinks that Mr. O’Malley has limited pharmacologic treatment options (contraindications for bupropion and varenecline prescription due to his history of seizures; inability to abstain from smoking on several occasions despite being on NRT).

Expert no.2, Dr Stanton Glantz, is not recommending e-cigarettes because the results of his - flawed (1) - metaanalysis shows that these products are not proven to assist smoking cessation (2).

The case study presented here is more challenging than actually appears and that for several reasons.

Mr. O'Malley is relatively young and quit rates in young adults are know to be very low as proven by the Mr. O’Malley’s history of frequent relapses. As there is no evidence demonstrating efficacy of FDA-approved smoking cessation drugs for young adults, these cannot be recommended in this specific age group.

Mr. O’Malley’s is at high risk of relapse and very little can be done to manage smokers with a history of frequent relapses (3).

Mr. O’Malley is overweight and has hypertension. Stopping smoking is known to lead to weight gain (4). Hence, it is important to consider that Mr. O’Malley - if successful - will have to deal with the burden of post-cessation weight gain with its important negative health consequences, particularly in consideration of the fact that obesity and hypertension are well known risk factors for cardiovascular disease.

Mr. O’Malley would benefit from switching to a much cleaner source of nicotine. His personal preference for the e-cigarettes should be respected and the health care provider should offer a balanced overview of their risk/benefit ratio (5,6).

More specifically, relevant to Mr. O’Malley’s case, it worth noticing that: 1) e-cigarettes have helped abstaining from conventional cigarette young adults as well (7); 2) e-cigarettes have been shown to reduce post-cessation weight gain in quitters (8); 3) smokers with elevated blood pressure who quit by switching to e-cigarettes may lower their BP in the long-term (9).

Ref.

1. Hajek P, McRobbie H, Bullen C. E-cigarettes and smoking cessation. Lancet Respir Med. 2016 Jun;4(6):e23. doi: 10.1016/S2213-2600(16)30024-8. Epub 2016 Apr PubMed PMID: 27133216.
2. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and me- ta-analysis. Lancet Respir Med 2016;4:116.
3. Caponnetto P, Keller E, Bruno CM, Polosa R. Handling relapse in smoking cessation: strategies and recommendations. Intern Emerg Med. 2013 Feb;8(1):7-12.
4. US Department of Health and Human Services JL. Health People . Washington, DC: US Government Printing Office; 1990.
5. Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf. 2014 Apr;5(2):67-86.
6. Public Health England. E-cigarettes: An evidence update. London: Public Health England, 2015.
7. Choi K, Forster J. Characteristics associated with awareness, perceptions, and use of electronic nicotine delivery systems among young U.S. Midwestern adults. Am J Public Health. 2013;103(3):556–561.
8. Russo C, Cibella F, Caponnetto P, Campagna D, Maglia M, Frazzetto E, Mondati E, Caruso M, Polosa R. Evaluation of Post Cessation Weight Gain in a 1-Year Randomized Smoking Cessation Trial of Electronic Cigarettes. Sci Rep. 2016 Jan 5;6:18763. doi: 10.1038/srep18763
9. Farsalinos K, Cibella F, Caponnetto P, Campagna D, Morjaria JB, Battaglia E, Caruso M, Russo C, Polosa R. Effect of continuous smoking reduction and abstinence on blood pressure and heart rate in smokers switching to electronic cigarettes. Intern Emerg Med. 2016 Feb;11(1):85-94.

On 2016 Jun 30, Riccardo Polosa commented:

In this case study of a 29-yr old man (Mr. O'Malley) interested in giving up smoking using e-cigarettes, two experts are providing their personal recommendations.

Expert no.1, Dr Christopher Bullen, is recommending e-cigarettes for smoking cessation because he thinks that Mr. O’Malley has limited pharmacologic treatment options (contraindications for bupropion and varenecline prescription due to his history of seizures; inability to abstain from smoking on several occasions despite being on NRT).

Expert no.2, Dr Stanton Glantz, is not recommending e-cigarettes because the results of his - flawed (1) - metaanalysis shows that these products are not proven to assist smoking cessation (2).

The case study presented here is more challenging than actually appears and that for several reasons.

Mr. O'Malley is relatively young and quit rates in young adults are know to be very low as proven by the Mr. O’Malley’s history of frequent relapses. As there is no evidence demonstrating efficacy of FDA-approved smoking cessation drugs for young adults, these cannot be recommended in this specific age group.

Mr. O’Malley’s is at high risk of relapse and very little can be done to manage smokers with a history of frequent relapses (3).

Mr. O’Malley is overweight and has hypertension. Stopping smoking is known to lead to weight gain (4). Hence, it is important to consider that Mr. O’Malley - if successful - will have to deal with the burden of post-cessation weight gain with its important negative health consequences, particularly in consideration of the fact that obesity and hypertension are well known risk factors for cardiovascular disease.

Mr. O’Malley would benefit from switching to a much cleaner source of nicotine. His personal preference for the e-cigarettes should be respected and the health care provider should offer a balanced overview of their risk/benefit ratio (5,6).

More specifically, relevant to Mr. O’Malley’s case, it worth noticing that: 1) e-cigarettes have helped abstaining from conventional cigarette young adults as well (7); 2) e-cigarettes have been shown to reduce post-cessation weight gain in quitters (8); 3) smokers with elevated blood pressure who quit by switching to e-cigarettes may lower their BP in the long-term (9).

Ref.

1. Hajek P, McRobbie H, Bullen C. E-cigarettes and smoking cessation. Lancet Respir Med. 2016 Jun;4(6):e23. doi: 10.1016/S2213-2600(16)30024-8. Epub 2016 Apr PubMed PMID: 27133216.
2. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and me- ta-analysis. Lancet Respir Med 2016;4:116.
3. Caponnetto P, Keller E, Bruno CM, Polosa R. Handling relapse in smoking cessation: strategies and recommendations. Intern Emerg Med. 2013 Feb;8(1):7-12.
4. US Department of Health and Human Services JL. Health People . Washington, DC: US Government Printing Office; 1990.
5. Farsalinos KE, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review. Ther Adv Drug Saf. 2014 Apr;5(2):67-86.
6. Public Health England. E-cigarettes: An evidence update. London: Public Health England, 2015.
7. Choi K, Forster J. Characteristics associated with awareness, perceptions, and use of electronic nicotine delivery systems among young U.S. Midwestern adults. Am J Public Health. 2013;103(3):556–561.
8. Russo C, Cibella F, Caponnetto P, Campagna D, Maglia M, Frazzetto E, Mondati E, Caruso M, Polosa R. Evaluation of Post Cessation Weight Gain in a 1-Year Randomized Smoking Cessation Trial of Electronic Cigarettes. Sci Rep. 2016 Jan 5;6:18763. doi: 10.1038/srep18763
9. Farsalinos K, Cibella F, Caponnetto P, Campagna D, Morjaria JB, Battaglia E, Caruso M, Russo C, Polosa R. Effect of continuous smoking reduction and abstinence on blood pressure and heart rate in smokers switching to electronic cigarettes. Intern Emerg Med. 2016 Feb;11(1):85-94.