Tobacco Cessation: E-cigarettes versus Nicotine Replacement Therapy

Jenna Gullickson, Pharm.D., CentraCare Health: St. Cloud

Background: Conflicting evidence is available when comparing e-cigarettes to nicotine replacement therapy (NRT) during a tobacco cessation attempt. Limited data indicates that switching from cigarette smoking to e-cigarette use is expected to reduce health risks. Another area of debate surrounds the risks and benefits of e-cigarette use in general. 

Objective: To determine if use of e-cigarettes in tobacco cessation attempt facilitates success when compared to NRT.

Study Design: This study is a two-group, pragmatic, multi-centered, randomized, controlled trial, which occurred across three National Health Service sites from May 2015 to February 2018. Exclusion criteria included the following: pregnant/breastfeeding, strong preference for or against NRT or e-cigarettes, and current use of NRT or e-cigarettes. Non-pregnant, non-breastfeeding patients aged 18 years and older who were currently smoking and had a desire to quit were randomized to NRT or e-cigarettes. In the NRT group, use of combination products (patch, gum, lozenge, nasal spray, inhaler, mouth spray, mouth strip, and microtabs) were encouraged and supplied for up to three months. In the e-cigarette group, a refillable starter pack and one refill of nicotine e-liquid was provided. Participants were encouraged to try e-liquids of different strengths and flavors as well as purchase refills online or from local vape shops. Behavioral support was provided for all participants which included weekly one-on-one sessions with local clinicians and carbon monoxide monitoring for at least four weeks following the quit date. The primary outcome was sustained abstinence for one year and secondary outcomes included abstinence between weeks 4 and 52 and respiratory symptoms.

Results: Out of a total of 886 patients included in the study, the one-year abstinence rate in the e-cigarette group was 18%, compared to a 9.9% abstinence rate in the NRT group (RR 1.8 [95% CI 1.30 - 2.58]). Of the participants abstinent for one year, participants in the e-cigarette group were more likely to continue use of the assigned product at 52 weeks (80%) when compared to the NRT group ( 9%). Throat or mouth irritation were more frequent for the e-cigarette group (65.3%) when compared to the NRT group (51.2%). Nausea occurred more often in the NRT group (37.9%) when compared to the e-cigarette group (31.3%). Reduction in cough and phlegm production from baseline to 52 weeks was reduced to a greater degree in the e-cigarette group. No significant differences were found between groups for symptoms of wheezing or shortness of breath. 

Conclusions: E-cigarette use along with behavioral support was found to be more effective for a successful tobacco cessation attempt when compared to NRT with behavioral support. A limitation of the study includes the potential barrier in generalizability to a population with less strict follow-up. Overall, e-cigarettes may allow for individualizing the desired nicotine dose. However, health risks of long-term e-cigarette use have not been fully identified. 

Key Point: Education on risks and benefits of e-cigarettes vs. NRT for tobacco cessation is necessary, especially with limited evidence-based data for e-cigarette use. 

References:

  1. Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380(7):629-637.