Can E-cigarettes Help You Quit Smoking? A Medical Trial Says No

E-cigarettes were born because of people's desire to quit smoking, and quitting smoking is also one of the main selling points of e-cigarettes.

When I first saw the British Department of Public Health recommending using e-cigarettes to quit smoking, I thought it was really a magic weapon. But after looking through the 243-page report, why do I feel that the data support is a little weak???

When reading the literature, it is hard not to notice the words of insufficient evidence, lack of evidence, research design flaws, limited resources, existing evidence, low quality, and low quality. In other words, some people hope that e-cigarettes will help quit smoking, some people say that e-cigarettes will help quit smoking, and some people say that e-cigarettes will not help. Everyone has their own opinions, but none of them have any concrete ideas.

The medical community's views on e-cigarettes as a treatment related to smoking cessation are also full of differences. Most doctors are reluctant to talk about the impact of e-cigarettes on health due to the controversial nature of the topic and insufficient evidence. In this case, doctors need more evidence to help determine whether e-cigarettes should be recommended.

Okay, who calls e-cigarettes? They're a new thing? The bullet still has to fly for a while.

In June 2018, an article appeared on NEJM, A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation by a team of doctors and scientists in Philadelphia.
 
This paper is a pragmatic clinical trial that examines the role of e-cigarettes, financial rewards, and drugs in quitting smoking.

What is a practical clinical trial? Many clinical trials are efficacy trials. In order to better analyze and reflect the effects of drugs or therapies, the people participating in the trials are carefully selected to minimize individual differences and delete variables. However, the same rice supports all kinds of people. In the real world, the differences between people are huge. The purpose of practical clinical trials is to reflect as much as possible the real effects that drugs/therapies may achieve in complex realities, and they are targeted at a wider population [8].

In this smoking cessation study, 6006 smokers from 54 companies were studied. These people were randomly divided into five groups and adopted the following methods to quit smoking:
 
The nicotine replacement therapy used in Group 2 included nicotine patches, chewing gum and lozenges; and the drugs were two prescription drugs, bupropion and varenicline (the former is the generic drug bupropion, trade name Wellbutrin/Elontril/Zyban; the latter is Pfizer's Changpei Chantix).

The e-cigarettes used in this test were all provided free e-cigarettes by the e-cigarette brand NJOY (but the brand did not participate in or interfere with the test). Each set of e-cigarettes includes battery strips, chargers, and no more than 20 cigarettes containing 1% to 1.5% nicotine per week. Participants freely choose the taste of the cigarettes.

As for the financial rewards in Groups 4 and 5, it is not an ingenious approach created by this experiment. In the United States, since smoking is the number one cause of preventable disease and death, many large companies provide financial rewards to employees who successfully quit smoking. It is a regular smoking cessation method for office workers. However, there has not been enough data to prove whether this financial reward method is effective.

This time, the entire smoking cessation test lasted for six months, and the smoking cessation effect was determined by conducting biochemical tests on blood or urine samples provided by the participants.

Can you guess how many people managed to quit smoking for six months in such a real-world trial?

Just take a bold guess.
 
Illustration: Five groups of bar charts from left to right represent five different methods to quit smoking from 1 to 5.

……Isn't the 1.3% success rate of smoking cessation a bit too low? We have quoted CDC data before, and there is a success rate of less than 10%. Why are the results of this study so bleak for the same Americans? Don't tell me you're shooting a gun?# p#pagination title #e#

If you take a closer look, the selection of participants in this study adopted an opt-out consent method, which means that some smokers from 54 companies were selected and contacted by email. If the other party did not express any objection, it would be regarded as agreeing to participate in the study.

In other words, not everyone who participated in the trial had a strong subjective desire to quit smoking. Many other smoking cessation studies (including CDC statistics) have studied people with a subjective desire to quit smoking. This should be the reason for the ultra-low success rate of 1.3%: people who don't really want to quit smoking cannot quit smoking, and it's useless to pay for it.……

So, what about people who want to quit smoking?

In this study, there were still people who really wanted to quit smoking: 1191 participants were considered active smokers based on their performance during the trial period. Most of the people who successfully quit smoking in the entire trial came from this group of participants with positive attitudes, which fully demonstrated how critical subjective will is to quitting smoking!

Let's take a look at the results of each of the five smoking cessation methods.
 
In the figure, dark blue is the data analysis of the overall 6006 people, while light blue is the data of 1191 active smokers. The difference between dark blue and light blue is subjective will, which plays a decisive role.

It can be seen at a glance that Group 1's conventional method of giving you information + texting you is basically useless: out of 800 people, only one person who really wanted to quit smoking succeeded. (Why don't I find it strange at all?)

The results for free nicotine replacement/drugs/e-cigarettes in Group 2 were slightly better than those in Group 1, but did not reach statistical significance.

The free e-cigarettes in Group 3 were slightly better than the first two groups, but unfortunately, they did not reach statistical significance.……

In this trial, what really helped quit smoking was the financial incentives in Groups 4 and 5. Especially in the active group, 9.5% and 12.7% of people successfully quit smoking for six months, and half of them successfully maintained the results of smoking cessation for twelve months.

What's more interesting is that from a cost perspective, under the economic incentive method, the per capita cost of successful smoking cessation is actually lower than that of the nicotine replacement/drug and e-cigarette groups (table below).
 
The average cost for all participants (middle column) and the cost per case of successful cessation of smoking (right column). Top to bottom are five ways to quit smoking.

Surprised? Are you surprised?

Therefore, the results of this study show that whether it is nicotine patches, drugs, or e-cigarettes, the effect of helping to quit smoking may not be as good as expected (from a statistical point of view), but the effect of financial incentives may be good.

Coincidentally, JAMA Intern Med (Journal of the American Medical Association Internal Medicine) also published a trial in December 2017 to study the role of financial encouragement in smoking cessation [9]. Most of the participants in the trial were low-income, ethnic minorities in the Boston area, who smoked an average of 15 cigarettes a day. The 352 people were divided into two groups. One group received a regular free smoking cessation manual and resource list, and the other group received additional personal guidance and financial encouragement to quit smoking for six months/twelve months on the basis of this routine (a reward of $250 for six months and an additional $500 for twelve months). In this trial, by the twelfth month, the smoking cessation success rate in the regular group was 2%(4/175), while the smoking cessation success rate in the financially encouraged group was 12%(21/177).
 
In March 2019, NEJM published another smoking cessation study from the UK, recruiting 886 smokers to conduct a multi-center, practical randomized clinical trial to compare the effects of e-cigarettes and nicotine replacement therapy as an aid to smoking cessation [10].

In the study, quitters in the e-cigarette group received a free e-cigarette starter pack with cigarette liquid supplements (e-cigarettes that were more suitable for personal preference were purchased additionally), while the other group received a three-month dose of nicotine replacement therapy (patch, chewing gum, spray, etc., according to personal preference).# p#pagination title #e#

One year later, the concentration of carbon monoxide in the breath of smokers was measured and found that 18% of the e-cigarette group had quit smoking, while only 9.9% of the nicotine replacement group had quit smoking (table below).
 
Smoking cessation rates at different time points and smoking reduction at week 52 (first column).

Therefore, the authors of the paper believe that e-cigarettes can better help quit smoking than nicotine replacement therapy.

This conclusion is consistent with the data from the aforementioned 6006-person smoking cessation trial: the auxiliary effect of e-cigarettes is better than that of nicotine replacement therapy (although the 6006-person smoking cessation trial was several percentage points lower due to the participants 'weak subjective desire to quit smoking).

In this regard, NEJM also published a review article [11], pointing out that the trial results must be viewed in conjunction with data from other FDA-approved smoking cessation aids: FDA-approved nicotine replacement therapy or the smoking cessation drug bupropion had a one-year smoking cessation success rate of 20%, while the smoking cessation drug Valenick was slightly better than bupropion. In this study from the UK, the smoking cessation success rate achieved by e-cigarettes also fell within the same range, which was not particularly excellent from a statistical perspective.

Commentators also mentioned that although people currently believe that e-cigarettes are safer than traditional cigarettes, they must not forget that safety data on the long-term use of e-cigarettes is still blank. The British smoking cessation study also found another important finding: One year after starting smoking cessation, 80% of people in the e-cigarette group still use e-cigarettes, while only 9% of people in the nicotine substitution group are still using nicotine substitution therapy, indicating that people who use e-cigarettes as a smoking cessation aid are more inclined to use e-cigarettes for a long time. Considering the toxins contained in e-cigarette smoke, although it is safer than traditional cigarette smoke, it still has potential adverse biological effects in cells or animal models. The safety of long-term use of e-cigarettes is still quite worrying.

As a result, commentators believe that whether e-cigarettes should be recommended as a front-line treatment to help quit smoking compared to FDA-approved treatments remains controversial, and due to the lack of long-term safety data, it is unclear how long e-cigarettes should continue to be used. Therefore, it is recommended that the use of e-cigarettes be considered only when FDA-approved treatment methods fail, and that the dose and duration of use should be carefully managed when using it.

In addition, in July 2019, JAMA Intern Med published a French e-cigarette smoking cessation study, which pointed out an issue that should not be ignored when using e-cigarettes to quit smoking: relapse rates [12]. The study tracked 2025 people who had quit smoking for two years and found that those who used e-cigarettes instead of traditional cigarettes to achieve the goal of quitting smoking would pick up traditional cigarettes again and rejoin the ranks of smokers within two years. The probability is higher than that of people who did not use e-cigarettes to help quit smoking, which is 1.7 times higher than that of people who did not use e-cigarettes to help quit smoking (figure below).
 
The blue curve in the figure is the relapse rate after quitting smoking with e-cigarettes, and the orange curve is the relapse rate after quitting smoking without using e-cigarettes.

The study found that although e-cigarettes can help quit smoking in the short term, the relapse rate after quitting smoking is higher, and in the long run, it may not be an excellent and effective method to quit smoking.

Based on the above considerations, page 47 of the "2019 Global Tobacco Epidemic Report" released by the World Health Organization and WHO on July 26, 2019 clearly stated that the use of e-cigarettes as an aid to smoking cessation is not recommended.
 
Today, this report is the latest conclusion on the effectiveness of e-cigarettes in smoking cessation. However, the various debates about e-cigarettes will never end there. After all, even if we ignore the efficacy of smoking cessation, e-cigarettes as a new thing have huge hidden benefits. Whether it is harmful, how much it is, and whether it can be promoted are the focus of struggle among all parties.