Cochrane Collaborative concludes that e-cigs as medicines help a few people shop smoking (again); still ignoring differences between medicines and consumer products as well as dual use

On January 8, 2024, the Cochrane Collaborative published yet another meta-analysis of randomized controlled trials concluding that e-cigarettes help a few people stop smoking. While industry and other pro-e-cigarette interests will make a big deal of this, the fact is that there is nothing new here.

Here is their primary conclusion:

There is high certainty that nicotine EC increases quit rates compared to nicotine replacement therapy (NRT) (RR 1.59, 95% CI 1.29 to 1.93; I² = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more).

Compare this to what they reported way back in November 2022:

There was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (RR 1.63, 95% CI 1.30 to 2.04; I² = 10%; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6).

Just for kicks, here is what we concluded in our meta-analysis, published in 2021:

The RCTs that compared quitting among smokers who were provided e-cigarettes to smokers with conventional therapy found e-cigarette use was associated with more quitting (relative risk = 1.555; 95% CI = 1.173, 2.061).

These risk estimates are all essentially the same.

Cochrane continues to ignore two critical points:

1. The real world evidence does not show short-term (less than a year or so) associations between smokers using e-cigarettes as consumer products with having stopped smoking and the long-term real world evidence shows less stopping cigarettes. 
2. Dual use is an important complication of giving people e-cigarettes; Cochrane does not consider dual use an adverse effect despite the fact that dual use is more dangerous than smoking alone.

And, of course, only 4 smokers per 100 given e-cigs actually stopped smoking, a tiny effect. More important, one high quality RCT that looked found that more smokers given e-cigs become dual users than stop smoking cigarettes, so giving smokers e-cigarettes likely increases harm.

Those facts likely won’t stop e-cig promoters from touting this “new” Cochrane review. In response, people should cite the recent WHO Call to Action on Electronic Cigarettes that clearly makes the distinction between e-cigarettes as consumer products and medicines, highlighting the lack of evidence that e-cigarettes, as consumer products have not been shown to help smokers “switch completely”:

Cessation strategies should be based on the best available evidence of efficacy, synergistic with other tobacco control measures and subject to monitoring and evaluation. Based on the current evidence, it is not recommended that governments permit sale of e-cigarettes as consumer products in pursuit of a cessation objective. Any government pursuing a smoking cessation strategy utilizing e-cigarettes should control the conditions under which the products are accessed to ensure appropriate clinical conditions and regulate the products as medicines (including requiring marketing authorization as medicines). The decision to pursue a smoking cessation objective, even in such a controlled form, should be made only after considering national circumstances, along with the risk of uptake and after exhausting other proven cessation strategies. [emphasis added]

As I noted above, no doubt e-cig advocates will try an make a big deal about this “new” meta-analysis. The reality is nothing has changed on this point in years.

This may well be the last Cochrane report on e-cigs and smoking, since it Cochrane UK is closing down in March 2024 because it lost its funding. If these repetitive reports are typical of its work, I’m not surprised about the funding.