A new study published online ahead of print in the journal Addiction suggests that electronic cigarettes have been effective in helping literally thousands of smokers to cut down or quit smoking entirely, refuting a claim in last week's New England Journal of Medicine that these devices are likely to be ineffective because they deliver very little nicotine (a claim which was based entirely on a single study in which subjects were instructed to take 10 puffs on an e-cig, but no more).
(see: Etter J-F, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction 2011; doi:10.1111/j.1360-0443.2011.03505.x).
The study involved a survey of electronic cigarette usage patterns and results using two survey frames: one was subjects recruited through electronic cigarette-related web sites and forums. The other was subjects recruited though smoking or smoking cessation web sites having nothing to do with e-cigarettes. Although the first sampling frame would produce a biased sample (consisting of people with more successful experiences with e-cigarettes than in the population as a whole), the authors compared the results between the two samples to provide some indication of the extent to which the results were biased by the sampling scheme.
The most notable finding was that there were not marked differences between the experiences of e-cigarette users recruited via e-cigarette forums versus non-e-cigarette-related sites. Even among the subjects recruited from general smoking cessation sites or via Google, the overwhelming majority of ever users of electronic cigarettes (80.8%) reported that e-cigarettes helped them reduce smoking a lot (compared to 93.2% of subjects recruited via e-cigarette-related sites).
Among ex-smokers recruited at the general sites, 93.3% reported that e-cigarettes helped them quit smoking (compared to 96.1% of subjects recruited via e-cigarette sites).
Among all e-cigarette users, 92.2% stated that the device helped them to reduce smoking a lot. An overwhelming majority (88.6) reported that it is easy to abstain from smoking when using the e-cigarette.
Interestingly, the overwhelming majority (82.7%) of electronic cigarette users are worried that these devices might be banned and 79.2% of those who quit smoking using e-cigarettes are afraid that they would return to smoking if such a ban occurred. Of those who stopped smoking while on e-cigarettes, 96.0% reported that the electronic cigarette played a definitive role in helping them quit smoking.
The paper's major finding is as follows: "e-cigarettes were used largely by former smokers as an aid to quit smoking, to avoid relapse and to deal with withdrawal symptoms, much as people use nicotine replacement therapy (NRT). ... Our data suggest that e-cigarettes may help smokers to quit smoking, reduce their cigarette consumption and attenuate craving and tobacco withdrawal symptoms. Users of nicotine-containing e-cigarettes reported only slightly superior effects on withdrawal than users of non-nicotine cigarettes, suggesting that nicotine delivery explains only part of the effect of these devices on withdrawal, and that sensory and behavioural components of the e-cigarette are also important."
Another important finding is that smokers who used e-cigarettes (but did not quit entirely) still improved their health: "current smokers who used the e-cigarette had fewer respiratory symptoms than smokers who did not use it ... which we speculate might be a consequence of reduced smoking. This difference is substantial ... and very close to the difference ... reported previously between patients with moderate and severe COPD."
The paper concludes: "E-cigarettes were used mainly by former smokers as an aid to quit smoking and avoid relapse. These products were perceived as satisfactory, useful, and efficacious, and almost all users preferred nicotine-containing e-cigarettes."
The Rest of the Story
Despite the fact that the sample is non-representative and the true efficacy of electronic cigarettes is certainly lower than reported here, the findings of the study nevertheless provide strong evidence that electronic cigarettes are being used with success by many smokers to quit smoking or cut down substantially on the number of cigarettes they consume, and that e-cigarettes are being used with success by many ex-smokers to remain off cigarettes.
Based on this survey alone, there are more than 2,000 ex-smokers who are electronic cigarette users who claim that the device played an instrumental role in their success in quitting smoking. Nearly 80% of these ex-smokers fear they would return to smoking if they discontinued the use of electronic cigarettes, as recommended by Cobb and Abrams in their New England Journal of Medicine perspective article.
Given these findings, along with previous data from other surveys and anecdotal evidence from numerous other sources, the claim that electronic cigarettes are completely ineffective in smoking cessation because they do not deliver nicotine effectively is now untenable.
It is now clear that there are indeed thousands of ex-smokers who successfully quit smoking because of electronic cigarettes and who would likely return to smoking if persuaded to discontinue using electronic cigarettes in favor of an "approved" form of smoking cessation pharmacotherapy.
It is also clear that there are thousands of ex-smokers who successfully quit smoking because of electronic cigarettes and who would likely return to smoking if e-cigarettes were banned or taken off the market, as recommended by numerous anti-smoking groups, including the Campaign for Tobacco-Free Kids, American Heart Association, American Cancer Society, American Lung Association, and the American Legacy Foundation.
While there is no question that more rigorous research is needed to study the effectiveness of electronic cigarettes for smoking cessation (e.g., clinical trials), there is also no question that these products can be effective and are effective among thousands of users. This may not mean that the proportion of users who are successful is high, but it does mean that the number of people who would be harmed by taking e-cigarettes off the market or by persuading people to discontinue their use is substantial.
Thus, promoting the removal of electronic cigarettes from the market pending further research and recommending that people refrain from using the product pending further research are both strategies that will almost invariably cause substantial health harm to the population. Therefore, I do not find either of these approaches to be responsible and appropriate ones.
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