May 20th, 2014

People using e-cigarettes to quit smoking 60 percent more likely to succeed than those using NRT sold over the counter

The survey of e-cigarette use published today is great news for those of us who long suspected that e-cigarettes are effective in helping people stop smoking. So now we have a population study (i.e. a survey of real users’ experience, not a trial) that shows very positive results for e-cigarettes, but also showing NRT users have no better success rates than those quitting cold turkey, at least without behavioural support. This is part of a pattern of positive results from UK survey data…

Update 21 May. May I suggest reading this posting in conjunction with Carl Phillips’ excellent EP-ology blog: Understanding the West el al. paper on e-cigarettes an smoking cessation. This explores the important dimension of self-selection in this survey and the fact that people are different: i.e. those who chose a particular method may be more likely to succeed by their chosen method. As a result, I’ve changed the title to this blog, in a way that I hope explains the main point.

Before: E-cigarettes 60 percent more likely to help smokers quit than NRT sold over the counter

After: People using e-cigarettes to quit smoking 60 percent more likely to succeed than those using NRT sold over the counter

End of update.

From the article press release:

People attempting to quit smoking without professional help are approximately 60% more likely to report succeeding if they use e-cigarettes than if they use willpower alone or over-the-counter nicotine replacement therapies such as patches or gum, reveals new research published in Addiction.

Brown, Beard, Kotz, Michie & West, ‘Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study’, Addiction, May 2014.

This paper follows excellent survey data from ASH-UK which shows:

An estimated 2.1 million adults in Great Britain currently use electronic cigarettes [about 20% of the total].

About one third of users are ex-smokers and two-thirds are current smokers.

The main reason given by current smokers for using the products is to reduce the amount they smoke while ex-smokers report using electronic cigarettes to help them stop smoking.

And this on top of data from the Smoking Cessation Toolkit Survey [PowerPoint download], which concluded:

Evidence conflicts with the view that electronic cigarettes are undermining tobacco control or ‘renormalizing’ smoking, and they may be contributing to a reduction in smoking prevalence through increased success at quitting smoking.

But all this splendidly positive news begs some questions:

1. Should NRT continue to be licensed for sale over the counter as a smoking cessation medicine without behavioural support?

2. How should the NICE guidance on tobacco harm reduction be amended? It appears to recommend products that do not work that well or maybe for a subset of users, but advises against products that do?

3. Isn’t the MHRA supposed to validate ‘efficacy’? So what happened?

4. E-cigarettes seem to be working well ‘out in the wild’ but with some notable exceptions they attract considerable vocal opposition from the health lobby (Chief Medical Officer and various crumbling pillars of public health and medical establishment). Will this lobby now recognise that their puritanical but evidence free campaigns against these products are campaigns against effective smoking cessation / harm reduction and therefore that they are probably harming people?

5. Much of the public health lobby persists in wanting e-cigarettes regulated as medicines. Given they seem to be working well at the moment, what problem do they think this will solve? Have they considered what problems medicine regulation might induce into this working market? For example, creating a banal, unexciting, ineffective product category that doesn’t meet smokers’ need but is safe to use but dangerous because it is liable to end up in more smoking?

6. Should we rely more on surveys and ‘real world’ population data and stop elevating randomised controlled clinical trials as an all-purpose ‘gold standard’ in this field. The reality is that controlled trials measure one thing while artificially holding as much else as possible at as a constant. That is not how this work in reality – people make choices about what products to use and self selection is an important feature of smoking cessation that is purposefully eliminated in RCTs. so does the Cochrane Review approach this subject appropriately?

7. What should stop smoking services now say to smokers? Will the thoughts of Louise Ross, the enterprising service manager who has embraced e-cigarettes, be combed over for clues? Should pharmacies now ignore the advice of Chief Pharmaceutical Officers (of course they should, it was terrible advice to start with).

8. Does this reveal the EU Tobacco Products Directive 2014/40/EC to be already obsolete, on the very day it enters into force? I hope a survey this large will tell us what strength of e-cigarette liquids were in use. Is there anything here that suggests that a ban on e-cigarette advertising is justified – in fact banning e-cigarette advertising would be simply protecting cigarettes and NRT that is ineffective in most real world settings.

9. Will the WHO and FCTC Secretariat stop being so negative now?

10. What does it mean for those countries like Australia and Canada that have tried to ban e-cigarettes by classifying them as medicines and have denied their smokers the opportunity to use these products (thankfully with near complete failure) and denied themselves the opportunity to survey their use in the way this study has been done. they are making policy in a state of ignorance.

Please let me know in the comments if you think it raises new implications or I’m missing the point in raising the questions above? Discuss!