2 Studies Highlight ‘Tradeoffs’ of E-Cigarettes

Could e-cigarettes help smokers of regular, combustible cigarettes quit? Or are they getting a new generation hooked on nicotine? Two new studies provide some answers, but also raise some questions. 

In a study published January 30, 2019 in the New England Journal of Medicine, British researchers found e-cigarettes worked almost twice as well as nicotine-replacement therapies (NRT), such as patches and gum, at helping smokers quit regular cigarettes. This is the first large, randomized study to test whether modern e-cigarettes can help people quit smoking.

Another study, published February 1, 2019 in JAMA Network Open, found that American teens and tweens who use e-cigarettes are more than 4 times as likely to try a regular cigarette than those who never tried e-cigarettes.

“It leaves me worried and hopeful,” said Jeffrey Drope, PhD, American Cancer Society Scientific Vice President, Economic and Health Policy Research. “Worried about the association between vaping and smoking for young people, particularly in light of the popularity among youth of products like JUUL.  Hopeful because there is better evidence that there is likely utility in e-cigarettes as either a cessation tool or at least to get people away from combustible products.”

Drope also points to the statement made in September 2018 by US Food and Drug Administration (FDA) Commissioner Scott Gottlieb, MD. Gottlieb said, “In closing the on-ramp to kids, we’re going to have to narrow the off-ramp for adults who want to migrate off combustible tobacco and onto e-cigs.” And he said, “The FDA won’t tolerate a whole generation of young people becoming addicted to nicotine as a tradeoff for enabling adults to have unfettered access to these same products.”

Do e-cigarettes work as a quit-smoking tool?

The first study, led by researchers at Queen Mary University of London, involved 886 smokers in England who sought stop-smoking services. About half the group received NRT of their choice (patches, gum, lozenges, sprays, other oral products, or a combination) and half received an e-cigarette starter pack. All the participants also got weekly counseling for at least 4 weeks.

After 1 year, 18% of e-cigarette users were smoke-free, compared with 9.9% of NRT users. The study authors say their findings show e-cigarettes can help some people quit smoking.

But in an editorial in response to the paper, Belinda Borrelli, PhD, and George T. O'Connor, MD, both of Boston University, urge caution before recommending e-cigarettes as a quit-smoking device. They say some FDA-approved medications have success rates as high as those seen for e-cigarettes in the study, and should be tried first. They also note that 80% of those who stopped smoking using e-cigarettes were still vaping at the end of the year. In the other group only 9% of those who stopped smoking were still using NRT.

The long-term health effects of both vaping and second-hand vaping are still unknown, although it’s widely believed that vaping is less harmful than smoking combustible cigarettes.

Do e-cigarettes lead the way to regular cigarettes for kids?

In the other study, researchers from Boston University looked at data from the Population Assessment of Tobacco and Health (PATH) Study (2013-2016) to learn whether kids who use e-cigarettes are more likely to start smoking combustible cigarettes. The PATH study included 6,123 young people between ages 12 to 15 years who had never used e-cigarettes, combustible cigarettes, or any other tobacco product when the study began. The researchers followed them for 2 years.

They found that 8.6% reported trying e-cigarettes as their first tobacco product, 5% reported another non-cigarette tobacco product, and 3.3% reported using cigarettes first. By the end of the study period, 6.1% of the kids who had never used a tobacco product had smoked a cigarette at least once, and 2.1% percent were current smokers.

Cigarette use by the end of the study was higher among prior e-cigarette users (20.5% percent) and prior users of other tobacco products (21.1%), compared with those who had not used tobacco before (3.8%). Those who tried e-cigarettes first were 4 times as likely to smoke a cigarette compared with those who had not tried any tobacco product. The researchers calculate that 43,446 current smokers ages 12-15 years got their start with e-cigarettes.

The link between prior e-cigarette use and trying smoking was actually stronger among kids classified as “low-risk” for smoking.

The study authors say their research supports the idea that e-cigarettes are “a catalyst for cigarette initiation among youths” and strengthens the argument for government regulation that would limit marketing of e-cigarettes to young people.

Studies are not the last word on e-cigarettes

Drope is careful to point out that neither of these studies offers definitive answers about e-cigarettes. “To be certain, these are important findings, but we need to build on them. For example, we need to understand better who is more likely to quit by using e-cigarettes, what types of e-cigarette use most likely lead to quitting, and how we incorporate counseling or other cessation strategies with e-cigarettes.  For the youth vape/smoking association, again, we need to understand better which youth are more predisposed to move on to cigarettes, and what kinds of devices and behaviors most likely lead to switching to a more harmful product.  We still have a lot to learn.”