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Electronic Cigarettes vs Varenicline for Smoking Cessation in Adults: A Randomized Clinical Trial

Author/s: 
Anna Tuisku, Mikko Rahkola, Pentti Nieminen, Tuula Toljamo

Importance: Little is known about the relative effectiveness of nicotine-containing electronic cigarettes (ECs) compared with varenicline as smoking cessation aids.

Objective: To determine the relative effectiveness of ECs in smoking cessation.

Design, setting, and participants: This randomized placebo-controlled single-center trial was conducted in northern Finland. Participants aged 25 to 75 years who smoked daily and had volunteered to quit smoking were recruited from August 1, 2018, to February 20, 2020, via local media. The trial included 52 weeks of follow-up. All data analyses were conducted from September 1, 2022, to January 15, 2024. The participants, study nurses, and researchers were masked to group assignment.

Intervention: The participants were assigned by block randomization to receive 18 mg/mL of nicotine-containing ECs together with placebo tablets, varenicline with standard dosing together with nicotine-free ECs, or placebo tablets together with nicotine-free ECs, all combined with a motivational interview, with the intervention phase lasting for 12 weeks.

Main outcome and measure: The primary outcome was self-reported 7-day conventional cigarette smoking abstinence as confirmed by the exhaled carbon monoxide level on week 26. The analysis followed the intent-to-treat principle.

Results: Of the 561 recruited participants, 458 (81.6%) eligible participants (257 women [56%]; 201 men [44%]; mean [SD] age, 51 [11.6] years) were randomized. The primary outcome occurred in 61 of 152 participants (40.4%) in the EC group, 67 of 153 (43.8%) in the varenicline group, and 30 of 153 (19.7%) in the placebo group (P < .001). In the pairwise comparison, placebo differed statistically significantly from ECs (risk difference [RD], 20.7%; 95% CI, 10.4-30.4; P < .001) and varenicline (RD, 24.1%; 95% CI, 13.7-33.7; P < .001), but the difference was statistically insignificant between ECs and varenicline (RD, 3.4%; 95% CI, -7.6 to 14.3; P = .56). No serious adverse events were reported.

Conclusions: This randomized clinical trial found that varenicline and nicotine-containing ECs were both effective in helping individuals in quitting smoking conventional cigarettes for up to 6 months.

Keywords 
e-cigarettes cigarettes Varenicline smoking smoking cessation

Association of Smoking Cessation and Cardiovascular, Cancer, and Respiratory Mortality

Author/s: 
Blake Thomson, Farhad Islami

There were an estimated 28 million current cigarette smokers in the US, and approximately twice as many former smokers, in 2021.1 Smoking cessation is associated with large reductions in excess mortality compared with continued smoking,2 but the timescale over which cause-specific mortality benefits of cessation may develop is unclear.3-6 Quantifying excess cause-specific mortality among former smokers by years since quitting may inform clinical decision-making and screening programs.

Keywords 
tobacco e-cigarettes smoking cessation lifestyle behaviors

Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis

Author/s: 
Bhatta, DN, Glantz, SA

INTRODUCTION:

E-cigarettes deliver an aerosol of nicotine by heating a liquid and are promoted as an alternative to combustible tobacco. This study determines the longitudinal associations between e-cigarette use and respiratory disease controlling for combustible tobacco use.

METHODS:

This was a longitudinal analysis of the adult Population Assessment of Tobacco and Health Waves 1, 2, and 3. Multivariable logistic regression was performed to determine the associations between e-cigarette use and respiratory disease, controlling for combustible tobacco smoking, demographic, and clinical variables. Data were collected in 2013-2016 and analyzed in 2018-2019.

RESULTS:

Among people who did not report respiratory disease (chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or asthma) at Wave 1, the longitudinal analysis revealed statistically significant associations between former e-cigarette use (AOR=1.31, 95% CI=1.07, 1.60) and current e-cigarette use (AOR=1.29, 95% CI=1.03, 1.61) at Wave 1 and having incident respiratory disease at Waves 2 or 3, controlling for combustible tobacco smoking, demographic, and clinical variables. Current combustible tobacco smoking (AOR=2.56, 95% CI=1.92, 3.41) was also significantly associated with having respiratory disease at Waves 2 or 3. Odds of developing respiratory disease for a current dual user (e-cigarette and all combustible tobacco) were 3.30 compared with a never smoker who never used e-cigarettes. Analysis controlling for cigarette smoking alone yielded similar results.

CONCLUSIONS:

Use of e-cigarettes is an independent risk factor for respiratory disease in addition to combustible tobacco smoking. Dual use, the most common use pattern, is riskier than using either product alone.

Keywords 
e-cigarette or vaping product use-associated lung injury vaping e-cigarettes smoking lung injury tobacco copd respiratory disease

Update: Characteristics of Patients in a National Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injuries — United States, October 2019

Author/s: 
Moritz, E.D., Zapata, L.B., Lekiachvili, A, Glidden, E, Annor, F.B., Werner, A., Ussery, E, Hughes, M.M., Kimball, A, DeSisto, C.L., Kenemer, E.H., Shamout, M, Garcia, M.C., Reagan-Steiner, S, Petersen, E.E., Koumans, E.H., Ritchey, M.D., King, BA, Jones, CM, Briss, PA, Delaney, L, Patel, A, Polen, KD, Sives, K, Meaney-Delman, D, Chatham-Stephens, K, Lung Injury Response Epidemiology/Surveillance Group

What is already known about this topic?

CDC and partners are investigating the ongoing outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI) in the United States, the District of Columbia, and one U.S. territory.

What is added by this report?

As of October 22, 2019, a total of 1,604 cases of EVALI, including 34 deaths, were reported to CDC. Based on data collected as of October 15, 2019, use of tetrahydrocannabinol (THC)-containing products in the 3 months preceding symptom onset was reported by 86% of patients. The median age of EVALI patients who survived was 23 years, and the median age of EVALI patients who died was 45 years.

What are the implications for public health practice?

Most EVALI patients report using THC-containing products before symptom onset. CDC recommends that persons should not use e-cigarette, or vaping, products containing THC. Because the specific compound or ingredient causing EVALI is not known, persons should consider refraining from use of all e-cigarette, or vaping, products.

 

TABLE. Characteristics of patients with electronic cigarette (e-cigarette), or vaping, product use–associated lung injury (EVALI) reported to CDC — United States, August–October 2019*

 
Characteristic No. /Total No. (%†)
EVALI patients who survived EVALI–associated deaths All EVALI patients
Sex
Male 947/1,349 (70) 17/29 (59) 964/1,378 (70)
Female 402/1,349 (30) 12/29 (41) 414/1,378 (30)
Age group (yrs)
13–17 735/1,335 (55)§ 2/29 (7)§ 196/1,364 (14)
18–24 541/1,364 (40)
25–34 339/1,335 (25) 5/29 (17) 344/1,364 (25)
35–44 165/1,335 (12) 7/29 (24) 172/1,364 (13)
45–64 79/1,335 (6) 8/29 (28) 87/1,364 (6)
65–75 17/1,335 (1) 7/29 (24) 24/1,364 (2)
Median age, yrs (range)
Overall 23 (13–72) 45 (17–75) 24 (13–75)
Male 23 (13–68) 55 (17–71) 23 (13–71)
Female 25 (13–72) 43 (27–75) 25 (13–75)
Race/Ethnicity      
White 283/365 (78) 15/18 (83) 298/383 (78)
Black or African American 22/365 (6)** 1/18 (6)** 9/383 (2)
American Indian or Alaska Native 4/383 (1)
Asian, Native Hawaiian, or other Pacific Islander 5/383 (1)
Other 5/383 (1)
Hispanic 60/365 (16) 2/18 (11) 62/383 (16)
Substances used in e-cigarette, or vaping, products ††,§§
THC-containing products, any use 733/848 (86) 16/19 (84) 749/867 (86)
Nicotine-containing products, any use 545/848 (64) 7/19 (37) 552/867 (64)
Both THC- and nicotine-containing products, any use 451/848 (53) 4/19 (21) 455/867 (52)
THC-containing products, exclusive use 282/848 (33) 12/19 (63) 294/867 (34)
Nicotine-containing products, exclusive use 94/848 (11) 3/19 (16) 97/867 (11)
No THC- or nicotine-containing products reported 21/848 (2) 0/19 (0) 21/867 (2)

 

Abbreviation: THC = tetrahydrocannabinol.
* Reported as of October 15, 2019.
† Percentages might not add up to 100% because of rounding.
§ Data for the 13–17 and 18–24 age groups were combined to protect patient identity.
 Whites; blacks or African Americans; American Indians or Alaska Natives; Asians, Native Hawaiians and other Pacific Islanders; and Others were non-Hispanic. Hispanic persons could be of any race.
** Data for persons in the following race/ethnicity groups were combined to protect patient identity: black or African American; American Indian or Alaska Native, Asian, Native Hawaiian, or other Pacific Islander, and Other.
†† In the 3 months preceding symptom onset; categories not mutually exclusive.
§§ Data on both THC- and nicotine-containing product use required to be included.

Keywords 
vaping lung injury e-cigarettes EVALI e-cigarette or vaping product use-associated lung injury

Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance

Author/s: 
Schier, JG, Meiman, JG, Layden, J, Mikosz, CA, VanFrank, B, King, BA, Salvatore, PP, Weissman, DN, Thomas, J, Melstrom, PC, Baldwin, GT, Parker, EM, Courtney-Long, EA, Krishnasamy, VP, Pickens, CM, Evans, ME, Tsay, SV, Powell, KM, Kiernan, EA, Marynak, KL, Adjemian, J, Holton, K, Armour, BS, England, LJ, Briss, PA, Houry, D, Hacker, KA, Reagan-Steiner, S, Zaki, S, Meaney-Delman, D, CDC 2019 Lung Injury Response Group

On September 6, 2019, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr). As of August 27, 2019, 215 possible cases of severe pulmonary disease associated with the use of electronic cigarette (e-cigarette) products (e.g., devices, liquids, refill pods, and cartridges) had been reported to CDC by 25 state health departments. E-cigarettes are devices that produce an aerosol by heating a liquid containing various chemicals, including nicotine, flavorings, and other additives (e.g., propellants, solvents, and oils). Users inhale the aerosol, including any additives, into their lungs. Aerosols produced by e-cigarettes can contain harmful or potentially harmful substances, including heavy metals such as lead, volatile organic compounds, ultrafine particles, cancer-causing chemicals, or other agents such as chemicals used for cleaning the device (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, or other drugs; for example, "dabbing" involves superheating substances that contain high concentrations of THC and other plant compounds (e.g., cannabidiol) with the intent of inhaling the aerosol. E-cigarette users could potentially add other substances to the devices. This report summarizes available information and provides interim case definitions and guidance for reporting possible cases of severe pulmonary disease. The guidance in this report reflects data available as of September 6, 2019; guidance will be updated as additional information becomes available.

Keywords 
e-cigarettes pulmonary disease nicotine cannabis vaping

A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy

Author/s: 
Hajek, Peter, Phillips-Waller, Anna, Przulj, Dunja, Pesola, Francesca, Smith, Katie Myers, Bisal, Natalie, Li, Jinshuo, Parrott, Steve, Sasieni, Peter, Dawkins, Lynne, Ross, Louise, Goniewicz, Maciej, Wu, Qi, McRobbie, Hayden J.

BACKGROUND

E-cigarettes are commonly used in attempts to stop smoking, but evidence is limited regarding their effectiveness as compared with that of nicotine products approved as smoking-cessation treatments.

METHODS

We randomly assigned adults attending U.K. National Health Service stop-smoking services to either nicotine-replacement products of their choice, including product combinations, provided for up to 3 months, or an e-cigarette starter pack (a second-generation refillable e-cigarette with one bottle of nicotine e-liquid [18 mg per milliliter]), with a recommendation to purchase further e-liquids of the flavor and strength of their choice. Treatment included weekly behavioral support for at least 4 weeks. The primary outcome was sustained abstinence for 1 year, which was validated biochemically at the final visit. Participants who were lost to follow-up or did not provide biochemical validation were considered to not be abstinent. Secondary outcomes included participant-reported treatment usage and respiratory symptoms.

RESULTS

A total of 886 participants underwent randomization. The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58; P<0.001). Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]). Overall, throat or mouth irritation was reported more frequently in the e-cigarette group (65.3%, vs. 51.2% in the nicotine-replacement group) and nausea more frequently in the nicotine-replacement group (37.9%, vs. 31.3% in the e-cigarette group). The e-cigarette group reported greater declines in the incidence of cough and phlegm production from baseline to 52 weeks than did the nicotine-replacement group (relative risk for cough, 0.8; 95% CI, 0.6 to 0.9; relative risk for phlegm, 0.7; 95% CI, 0.6 to 0.9). There were no significant between-group differences in the incidence of wheezing or shortness of breath.

CONCLUSIONS

E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support. (Funded by the National Institute for Health Research and Cancer Research UK; Current Controlled Trials number, ISRCTN60477608.)

Keywords 
e-cigarettes smoking nicotine
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