(Excerpts from February 2019 Uptodate): There is a growing appreciation that use of e-cigarettes poses fewer risks compared to smoking traditional cigarettes in adults.

A randomized trial published in the New England Journal of Medicine investigating interventions for cessation from combustible tobacco smoking compared three months of e-cigarettes with nicotine replacement therapy (NRT, approved by the US Food and Drug Administration for smoking cessation); both groups received at least four behavioral support sessions (N Engl J Med. 2019;380(7):629).

The study 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/mL), 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.

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.

E-cigarettes were more effective than NRT (combustible tobacco abstinence rates at one year 18 percent for e-cigarette group; 9.9% for NRT group).

However, at one year, 80% of the e-cigarette group continued use of e-cigarettes while the NRT continuation rate was 9%.

Clinicians should encourage smokers who inquire about quitting smoking to use FDA-approved smoking cessation aids as first-line pharmacotherapy. If a smoker is not willing to use these approaches and asks about e-cigarettes, the clinician need not discourage e-cigarette use as long as the smoker is informed about the uncertainties of the safety and efficacy of the device.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA