E-cigs: What about helping the smokers?

A lot of the discussion of e-cigarettes has been about the millions of youth who are starting nicotine addiction with them. While the tobacco companies are obvious beneficiaries of this fact, no one — not even the companies — publicly claims that this is a good thing. The goal is to “help addicted smokers quit (cigarettes).”

I was recently asked if I didn’t agree that smokers needed help to quit (they do) and what I would offer them if not e-cigarettes.

Before answering that question, it is important to emphasize that the premise is wrong because e-cigarettes as consumer products don’t help smokers quit. While many e-cig advocates swear that e-cigs helped them personally quit smoking, population studies from all over the world consistently show that smokers who use e-cigs (as consumer products) do not quit smoking more than those who do not.

This is, of course, a statement “on the average,” so it is possible than some individuals did successfully quit cigarettes using e-cigarettes, but what this finding means is that for every such person there is another person where e-cigs made it harder to quit.

(There is evidence that e-cigs used as a medicine as part of a clinically supervised smoking cessation program are associated with more quitting, but that is not what is happening when someone goes to a vape shop or convenience store and buys one.)

Thus, telling smokers not to go out and buy an e-cig as a cessation device is no different from telling people not to use hydroxychloroquine or ivermectin to prevent or treat COVID-19. They don’t work and promoting them displaces effective interventions like COVID-19 vaccinations.

The “hard core” is melting away

An important justification for e-cigarettes is reaching the “hard core” smokers, those who “cannot or will not quit.” This idea of the hard core smoker has been around since the 1970s when smoking rates were 30-40% and most smokers were smoking a pack a day.

That is no longer the reality. Smoking prevalence was down to about 14% in 2019 nationally and much lower in places like California that have strong tobacco control programs.

Rather than boiling down to “hard core” inveterate smokers, as smoking prevalence has come down, the remaining smokers are smoking less and quitting more. The smoking population is softening not hardening.

As noted above, we have made huge progress in reducing smoking through things like large scale tobacco control programs, media campaigns, smokefree laws and policies, tax increases and other things that reduce the social acceptability of smoking and chip away at the pro-tobacco norms that the tobacco industry spent a century building. Continuing and expanding these actives is the most important thing we can do to help smokers quit.

But, what would I offer smokers who want help?

The reality is that most smokers quit without any formal intervention. The best thing that we can do is provide a supportive environment by enacting smokefree workplace and public place laws and encouraging people to make their homes smokefree. These policies both encourage quit attempts and make quit attempts more effective.

Smokefree policies are particularly important because more and more smokers are light and intermittent smokers and concern about secondhand smoke and effects on others is a more potent cessation message than the harm smoking does to them personally.

Indeed, many of these light and intermittent smokers are smoking so few cigarettes that nicotine replacement therapy (NRT) is probably a bad idea because it could increase their nicotine exposure. The same is true for e-cigarettes, which can be though of as a kind of unsupervised NRT.

E-cigarettes would probably make it harder for these people to remain smokfree because one of the motivations for smokers using e-cigs is to get inhaled nicotine where cigarette smoking is not permitted, which reduces the efficacy of smokefree environments to support cessation. (Thankfully, a growing number of places are including e-cigs in smokefree laws and policies.)

Reducing stimuli for smoking is also important. In addition to reducing the number of tobacco outlets and exposure to tobacco advertising, getting rid of smoking in movies and other entertainment media would make it easier for people to quit.

Quit lines and related services like texting work, too.

For heavier smokers, conventional therapies (NRT and other stronger drugs) work well as long as they are combined with counseling.

Combining the counseling with the drugs is crucial to having them work. That is how the drugs were tested in the randomized controlled trials that got them approved as medicines by the FDA. Without counseling, NRT is associated with less quitting. That’s one reason that the tobacco companies stopped opposing NRT and more recently have got into the NRT business.

And for people where NRT and counseling is not enough, there are stronger prescription drugs (including bupropion and varenicline) that are effective, again combined with counseling. Combining several of these drugs can also be effective. (It’s interesting that all the clinical trials of e-cigs only compare them with NRT rather than these stronger drugs.)

The real problem is not a lack of therapies, it is that they are not widely used in the medical system. Places that apply established therapies get good results. We need policy change to ensure that everyone who needs help quitting is identified and gets the help. There has been progress in this area, but there is still lots of room for improvement.

Focusing on high risk populations

In addition to fewer people smoking with the remaining smokers smoking less, smoking has become more concentrated among less-well-off people and people with mental health problems. This reality has made bringing smokefree environments and smoking cessation services closer to these people important. One particularly innovative program has focused on homeless people who smoke at high rates but are just as interested in quitting as everyone else and do as well as everyone else when given appropriate therapy. The same is true for people with substance abuse problems and mental illness.

The bottom line: We need to do more of what we know works rather than promote ineffective e-cigarettes to help smokers quit.