New Research Article Confirms that Advising E-Cigarette Users to Switch to FDA-Approved Products Would Be a Grave Mistake

An article published online ahead of print in the International Journal of Clinical Practice finds that the overwhelming majority of dedicated electronic cigarette users have already tried to quit smoking many times and most have tried and failed with FDA-approved smoking cessation therapies. The critical implication of this finding is that advising e-cigarette users to switch to FDA-approved drugs, as was recommended by authors of a New England Journal of Medicine commentary article last week, would have devastating public health consequences, as most of these ex-smokers would return to smoking due to their previous lack of success with NRT, Chantix, and other approved smoking cessation drugs.

(See: Foulds, J., Veldheer, S. and Berg, A. (2011), Electronic cigarettes (e-cigs): views of aficionados and clinical/public health perspectives. International Journal of Clinical Practice. doi: 10.1111/j.1742-1241.2011.02751.x)

The research involved personal interviews with 104 experienced electronic cigarette users. The major findings were as follows:

1. "Of all the e-cig users, 78% had not used any tobacco in the prior 30 days."
2. "They had previously smoked an average of 25 cigarettes per day, and had tried to quit smoking an average of nine times before they started using e-cigs."
3. "Two-thirds had previously tried to quit smoking using an FDA-approved smoking cessation medication."
4. "Three quarters started using e-cigs with the intention of quitting smoking and almost all felt that the e-cig had helped them to succeed in quitting smoking."

The Rest of the Story

This study adds to a growing body of survey-based evidence that electronic cigarettes are being used successfully by thousands of smokers to quit smoking. The proportion of users who are successful in quitting is not clear because none of these surveys has obtained a representative sample of electronic cigarette users. However, despite this limitation, the combined evidence makes it untenable at this point to opine, as Abrams and Cobb did in their New England Journal of Medicine commentary, that electronic cigarettes are likely to be ineffective for smoking cessation because of their ineffective delivery of nicotine.

Abrams and Cobb's conclusion was based on a single study in which novice e-cigarette users were instructed to take 10 puffs. What this new study finds, however, is that experienced electronic cigarette users have found ways of enhancing the nicotine delivery from these devices and do not simply take 10 puffs. For example, some have found that priming the device prior to use enhances nicotine delivery. There are also varieties with stronger batteries that may be more effective in delivering nicotine. Moreover, there is some evidence that even with poor nicotine delivery, the physical stimuli and mimicking of the smoking experience are sufficient to suppress the craving to smoke, and thus smoking cessation can be achieved even without high nicotine delivery.

Perhaps more importantly, this study documents that the overwhelming majority of electronic cigarette users who have successfully quit smoking using these devices have already failed many times before trying to quit, most often with FDA-approved smoking cessation drugs. Thus, the recommendation that these ex-smokers discontinue the use of e-cigarettes and return to nicotine replacement therapy, Chantix, or other FDA-approved drugs will most likely result in their returning to cigarette smoking, as they have already failed many times in the past with the FDA-approved methods.

In fact, the primary stimulus for the use of the e-cigarette appears to be that a long-time smoker who has failed many previous quit attempts with standard approaches wants to try something new and different that may have better success.

The rest of the story is that based on this new evidence, the recommendation that e-cigarette users switch to FDA-approved smoking cessation drugs is irresponsible. If followed, it will almost certainly result in thousands of ex-smokers resuming cigarette smoking. Many of these ex-smokers have already experienced dramatic improvement in their health, especially in their lung function and respiratory symptoms. For medical advice from physicians to result in thousands of ex-smokers returning to cigarette smoking and negating (and reversing) the health gains they have made would be quite unfortunate. This is why I argue that the recommendation made by Abrams and Cobb is irresponsible and why following that advice would be a grave mistake on a population basis.

Foulds et al. deserve credit for having the insight and judgment to make a responsible, science-based recommendation: "if the patient perceives that the e-cig is helping them to stay off cigarettes and is not reporting any health problems likely attributable to the e-cig, then the focus should be on staying smoke-free rather than e-cig free. The health risks from smoking are large and are known with certainty. Comparatively, the health risks from e-cig use are likely much smaller (if any) and temporarily switching to e-cigs will likely yield a large health benefit."