E-cigarette enthusiasts, including the FDA and the NHS and others in England, and some in New Zealand and Canadian governments continue to promote “switching completely” from cigarettes to e-cigarettes as a form of harm reduction. I just found another paper that shows that the reality is that adult smokers who use e-cigarettes as a smoking cessation aid are much more likely to become dual users (continuing to use cigarettes and e-cigarettes at the same time) than to switch completely or stop using tobacco completely.
Specifically, the 2023 paper Effectiveness of ENDS, NRT and medication for smoking cessation among cigarette-only users: a longitudinal analysis of PATH Study wave 3 (2015-2016) and 4 (2016-2017), adult data by Bekir Kaplan and colleagues used the FDA’s huge Population Assessment of Tobacco and Health (PATH) to follow smokers who used e-cigarettes specifically as a way to stop smoking forward in time for a year to see what happened. They compared changes in smoking behavior among those who used e-cigarettes to quit with those who used NRT or other FDA-approved cessation medications.
Their analysis controlled for interest in quitting, level of nicotine addiction, whether they live with smokers, whether they have a friend or family member supporting their quit attempt, as well as all the usual demographic and socioeconomic factors.
Most important, of the cigarette-only users who used e-cigarettes to quit smoking with or without other methods none “switched completely” to e-cigarettes while 37.6% became dual users at follow-up a year later. 9.6% did stop all tobacco use. The remaining 52.8% emerged as cigarette-only users. In other words, among smokers who reported using e-cigarettes as a smoking cessation aid:
- None switched completely to e-cigarettes
- For ever smoker who stopped smoking and using e-cigarettes, 3.9 smokers (37.6%/9.6%) became dual users
This result, based on real-world use of e-cigarettes as consumer products, is consistent with a well-done randomized controlled trial of providing smokers with free e-cigarettes that found that for every person who stopped smoking cigarettes (including switchers who continued using e-cigarettes and quitters who did not smoke cigarettes or use e-cigarettes) in the group that were provided e-cigarettes, 2.7 smokers became dual users.
Given that dual use is 20-40% more dangerous than just smoking, the overall population effect is to increase (not reduce) overall harm. Indeed, the authors conclude, “Given uncertainty about the long-term health effect of ENDS and the likelihood of becoming dual users, people who smoke and need assistance quitting should be encouraged to use current Food and Drug Administration-approved cessation methods until more effective methods are developed.”
Given these high levels of dual use, FDA and others should stop pursuing policies to encourage smokers to “switch completely” to e-cigarettes and stop continuing to assume that providing e-cigarettes as an alternative for smokers is a justification for authorizing their marketing as “appropriate for the protection of public health.”
Here is the abstract:
Background: Research is inconclusive on the effectiveness of electronic nicotine delivery systems (ENDS) as cigarette cessation aids compared with nicotine replacement therapy (NRT) or non-NRT medication. This study compared the cigarette cessation rates for ENDS, NRT and non-NRT medication.
Method: Population Assessment of Tobacco and Health Study wave 3 cigarette-only users who used ENDS, NRT or non-NRT medication (varenicline and bupropion) to quit smoking between wave 3 and 4 were included. ‘Cessation’ was defined as being a former cigarette smoker in wave 4. χ2, logistic regression, and a sensitivity analysis with Bayes factor assessed the association between quitting smoking and method used.
Results: Among 6794 cigarette-only users, 532 used ENDS (n=75), NRT (n=289), non-NRT medication (n=68), or a combination of NRT and non-NRT medication (n=100) to quit smoking between wave 3 and 4. The percentages of quitting smoking among those who used ENDS, NRT, non-NRT medication, and a combination of NRT and non-NRT medication were 16.2% (n=14), 16.1% (n=47), 17.7% (n=13), and 14.8% (n=12), respectively (p=0.97). None of the cigarette-only users who used ENDS to quit smoking became ENDS-only users in wave 4; 37.6% became dual users of ENDS and cigarettes.
Conclusion: No differences were found when cessation rates of ENDS, NRT or non-NRT medication were compared. Given uncertainty about the long-term health effect of ENDS and the likelihood of becoming dual users, people who smoke and need assistance quitting should be encouraged to use current Food and Drug Administration-approved cessation methods until more effective methods are developed.
The full citation is: Kaplan B, Galiatsatos P, Breland A, Eissenberg T, Cohen JE. Effectiveness of ENDS, NRT and medication for smoking cessation among cigarette-only users: a longitudinal analysis of PATH Study wave 3 (2015-2016) and 4 (2016-2017), adult data. Tob Control. 2023 May;32(3):302-307. doi: 10.1136/tobaccocontrol-2020-056448. Epub 2021 Sep 15. PMID: 34526410; PMCID: PMC10176346. It is available here.
PS: Youth who specifically use e-cigarettes to stop smoking cigarettes are much less likely to stop smoking than kids who do not use e-cigarettes.
Stanton Glantz blog 