Pharmacotherapy vs. E-Cigarettes for Smoking Cessation: Pharmacology Program I

Educational Objectives

Explain potential advantages and disadvantages to the use of electronic cigarettes to help patients stop smoking.

Summary

Interviewer: Anthony N. DeMaria, MD, MACC

Take-home Messages:

• Electronic cigarettes have become very popular very quickly.
• Given known evidence and safety data, pharmacotherapy should be considered before e-cigarettes for smoking cessation; if there are no other options, e-cigarettes might be reasonable.
• Much more efficacy and safety data are needed about e-cigarettes.

Electronic or “e-” cigarettes” (ECs) are at the center of a major debate. Supporters see a device that is a lot healthier than standard cigarettes and a useful aid for smoking cessation. Those opposed detect a whiff of the early- to mid-20th century, when advertisements included pregnant women smoking cigarettes and doctors promoting their favorite brand. Cigarettes, back then, were framed as the “healthy” choice, encouraging the weight conscious to choose a smoke over a sweet — and the public fell for it.

Most of us aren’t sure what to think of vaping (the smoking of ECs). What we are sure of is the damaging effects of smoking. As a recent review in the Journal of the American College of Cardiology put it, “cardiovascular morbidity and mortality as a result of inhaled tobacco products continues to be a global health care crisis.¹” Given that, who in their right mind thinks we need a new way to deliver nicotine to the masses?

On the other hand, the same review notes that while the prevalence of smoking in the United States has thankfully fallen from 42% of adults in 1965 to 15% in September 2015, the people who continue smoking are likely to be seriously addicted and often have little interest in quitting. (As a recent headline put it: “Smokers Want More Respect from Doctors.”) Maybe it is time for a new approach.

Ready or not, ECs are here: as of early 2014, there were 466 brands and 7,774 flavors of e-cigarette products. The projection for the entire US market for “vapor devices” was $3.5 billion for 2015, a substantial leap from $2.5 billion for the previous year. By 2017, the market is expected to be over $10 billion worldwide, and it may pass conventional cigarette margins in terms of profits. To underscore the cultural impact, “vape” was the 2014 Oxford dictionary word of the year.

E-cigs: OK or E-vil?

As to determining whether ECs are helpful or harmful, important questions must be answered first: What are the health effects of ECs? Might they be an opportunity to greatly impact smoking-related illness? Or are marketers just blowing smoke and all these new devices really do is make it easy for new generations of smokers to move from vaping to puffing death sticks? (It’s hard to argue that these devices are not being targeted to kids, given the thousands of electronic cigarette flavors being sold, including chocolate, vanilla, cherry, cookies and cream, and bubble gum.)

Another important question: Do ECs really help smokers stop smoking? The answer depends on who you ask. ECs have been embraced by many smokers as a means to cut down or eliminate tobacco use. Indeed, there is some evidence that ECs are a better option than the traditional cessation aids. For example, a systematic review published in September 2015 concluded that use of ECs can reduce both the number of cigarettes smoked and withdrawal symptoms.² However, there is also evidence that they don’t lead to higher cessation rates compared to smokers who don’t use ECs.

A 2014 Cochrane Review addressed this question,³ finding only two randomized controlled trials on the topic, both of which used early EC devices that provided less nicotine than newer ones. The authors’ conclusions reflect the lack of clarity on the issue: “There is evidence from two trials that ECs help smokers to stop smoking long-term compared with placebo ECs. However, the small number of trials, low event rates, and wide confidence intervals around the estimates mean that our confidence in the result is rated ‘low.’…No evidence emerged that short-term EC use is associated with health risk.”

Brian A. Primack, MD, PhD, from the University of Pittsburgh School of Medicine, has experience with ECs as tools for smoking cessation in his family medicine practice. He said, “There is this potential, theoretical benefit where if we could somehow magically get every smoker to convert to EC tomorrow, we would reduce disease by huge amounts, but this really hasn’t panned out.” His experience has been that EC users get very excited in the beginning and may stop or reduce their tobacco use, but after the honeymoon phase, they tend to revert to smoking or to use both. “What they’ve really done is found a way of sustaining their nicotine addiction in this society, and also it is sort of saying that nicotine addiction is really OK, which is a slippery slope.”

Dr. Primack doesn’t recommend ECs as a means for quitting smoking, but he tries to support patients who come to him already using them and encourage them to drop their nicotine levels (in the e-liquid) to zero, if possible.

In the United Kingdom, the National Centre for Smoking Cessation and Training (NCSCT) has recommended “practitioners be open to EC use among smokers trying to quit, particularly if they have tried other methods of quitting and failed.” The group also offers detailed guidelines for smokers wanting to use ECs to quit, including differences in puffing on an EC versus a regular cigarette, the need to try different types of ECs to find one that works for them, and that multisessional behavioral support is likely to improve their success in quitting.

Public Health England (PHE) ignited a firestorm of criticism when it said that “using EC is around 95% safer than smoking.⁴” (PHE is an operationally autonomous executive agency of the UK government’s Department of Health.) The PHE report notes that ECs are very popular among those wishing to quit smoking, much more so than other cessation aids. They said, “It is not known whether current EC products are more or less effective than licensed stop-smoking medications, but they are much more popular, thereby providing an opportunity to expand the number of smokers stopping successfully. Some English stop-smoking services and practitioners support the use of EC in quit attempts and provide behavioral support for EC users trying to quit smoking; self-reported quit rates are at least comparable to other treatments. The evidence on ECs used alongside smoking on subsequent quitting of smoking is mixed.”

In the recent Smoking in England report, the authors found that ECs helped approximately 20,000 smokers to stop in 2014 who would not have stopped otherwise. The AHA released a policy statement on the topic at the association’s 2014 Annual Scientific Sessions.⁵ In it they said: “If a patient has failed initial treatment, has been intolerant to or refused to use conventional smoking cessation medication, and wishes to use e-cigarettes to aid quitting, it is reasonable to support the attempt. However, subjects should be informed that although e-cigarette aerosol is likely to be much less toxic than cigarette smoking, the products are unregulated, may contain low levels of toxic chemicals, and have not been proven as cessation devices.”

The authors stressed the need for more research and expressed concern about teen use, continued addiction to nicotine, and the renormalization of smoking.

In that recent policy statement, the AHA said smokers are first encouraged to quit smoking and nicotine addiction using a combination of already approved treatments.⁵ This concurs with a recent report by the World Health Organization (WHO) that states smokers should first be encouraged to quit smoking and end their nicotine addiction by using treatments, including pharmacotherapy, that have been approved.⁶ The WHO acknowledges that electronic nicotine delivery devices may have a role for some smokers who have failed treatment, have been intolerant to it, or refuse to use conventional smoking cessation medication (because it is likely that e-cigarettes contain lower levels of toxins than traditional tobacco cigarettes). The WHO advises that clinicians should educate patients considering using them that e-cigarettes are unregulated and have not been shown to be beneficial for smoking cessation.

Readings

1. Morris PB, Ference BA, Jahangir E, et al. Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes: Clinical Perspectives From the Prevention of Cardiovascular Disease Section Leadership Council and Early Career Councils of the American College of Cardiology. J Am Coll Cardiol 2015;66:1378-91. http://content.onlinejacc.org/article.aspx?articleID=2440706

2. Gualano MR, Passi S, Bert F, et al. Electronic cigarettes: assessing the efficacy and the adverse effects through a systematic review of published studies. J Public Health (Oxf) 2015;37:488-97.

3. McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database Syst Rev 2014;12:CD010216.

4. McNeill A, Brose LS, Calder R, et al. E-cigarettes: an evidence update. Public Health England August 2015. https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update (accessed October 18, 2015).

5. Bhatnagar A, Whitsel LP, Ribisl KM, et al. Electronic cigarettes: a policy statement from the American Heart Association. Circulation 2014;130:1418-36.

6. [No authors listed]. Electronic nicotine delivery systems: Report by WHO. July 21, 2014 available at: www.who.int/nmh/events/2014/backgrounder-e-cigarettes/en/

Disclosures

Augustus Hough IV, PharmD, West Palm Beach, FL
This author has nothing to disclose.

Interviewer: Anthony N. DeMaria, MD, MACC
Lantheus Medical Imaging Inc (G); CardioVascular BioTherapeutics Inc (G); Mesoblast (G); General Electric (G); Gilead (G); ResMed Foundation (O)

The planning committee reported nothing to disclose.

A = Advisory panel B = Speakers’ bureau C = Consultant fees/honoraria D = Data and Safety Monitoring Board E = Equity interests/stock options F = Fellowship support G = Grant support L = Licensing Agreement O = Other relationship R = Royalties S = Salary W = Expert witness

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AC480217

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This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

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To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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