ARNS Statement regarding e-cigarettes21/10/2013
- More research is required which replicates real smoking cessation strategies
- Regulation of e-cigarette and related devices may help developing this potential future treatment
- Patient should be encouraged to attend and be referred for smoking cessation
Electronic nicotine delivery devices (ENDDs) are commonly known as e-cigarettes and thought to be growing in popularity and use in the United Kingdom by the general public. They are an electronic device that mimics real cigarettes. They deliver nicotine through vapour rather than smoke, and usually look like a cigarette with a light and steam produced to look like a real cigarette which required a chargeable battery. The nicotine content is variable and can be purchased in several strengths; marketing is generally for replacing nicotine consumption than quitting smoking (NHS, 2012).
There are also devices that deliver vapour with nicotine known as ‘vaping’; these also have a variety of strengths, flavours and with Shisha. A new format discussed at European Respiratory Society Congress 2013 is d-cigarettes. These are digital and are speculated to have a more controlled delivery of nicotine and mimic manufactured cigarette delivery.
Tobacco is smoked to obtain nicotine, principally to relieve symptoms of nicotine withdrawal. Although nicotine has few serious adverse effects on health, the smoker exposes themselves to serious harm from tar and gases including oxidant gases and carbon monoxide (NICE, 2012). E-cigarettes and similar devices could be seen as ‘harm reduction’ and there is a good body of evidence developing to support this (AHS, 2013).However,currently the evidence for smoking cessation is stronger (NICE, 2012). E-cigarettes are not regulated medicines so the ingredients and amount of nicotine contained within each e-cigarette may vary – the MHRA are planning to introduce regulation from 2016.
E-cigarettes and related devices may in the future once regulated become a useful tool in the smoking cessation field as part of a treatment plan that includes behavioral support. It is clear that more research is required to evidence this approach and this research needs to compare like for like. Evidence shows that the smokers have the best chance at quitting (NICE, 2008) if they have medication with behavioral support for at least 12 weeks and that a combination approach to nicotine replacement therapy is more effective. This means that future research needs to compare e-cigarettes/ devices with combination or as part of a combination.
In clinical practice the lack of robust evidence makes it difficult for clinicians to recommend e-cigarettes or related devices however we know that culture is often ahead of strategy and patients are widely using them. A patient should still be offered smoking cessation referral as quitting is thought to have better outcomes than just harm reduction and using e- cigarette/ devices should not deign access. Patients can be informed of the lack of robust evidence to help their informed choice whilst remaining non judgmental.
References:
Ash (2013) e-Cigarettes briefing available at:
NHS (2012) NHS choices information available at:
NICE (2008) Smoking cessation guidance available at:
NICE (2012) Smoking cessation summary available at:
Summary of Evidence:Electronic nicotine delivery devices (ENDDs) (e-cigarettes)
Lancet2013 Sep 9 early online, editorial: Nicotine electronic cigarettes may not be more effective than nicotine patches or placebo cigarettes for smoking cessation in patients intending to quit.
Randomized controlled trial with inadequate statistical power due to high dropout.657 adults with intention to quit smoking randomized to 1 of 3 interventions from 1 week pre- to 12 weeks post-quit day.
nicotine 16 mg electronic cigarettes
nicotine patch 21 mg daily
placebo electronic cigarettes
- all patients were offered voluntary telephone counselling
- compliance at 6 months ranged from 8%-35% among groups
- 22% were lost to follow-up but all patients were included in intention-to-treat analyses
- continuous abstinence was composite of self-reported abstinence (defined as ≤ 5 tobacco cigarettes during entire follow-up) plus biochemically verified abstinence (defined as exhaled breath carbon monoxide < 10 ppm)
- continuous abstinence at 6 months in (no significant differences)
7.3% in nicotine electronic cigarette group (risk difference [RD] vs. patch of 1.51, 95% CI -2.49 to 5.51)
5.8% in nicotine patch group
4.1% in placebo electronic cigarette group (RD vs. nicotine cigarettes of 3.16, 95% CI -2.29 to 8.61)
no significant differences among groups in adverse events
PLoS One 2013;8(6):e66317full-text: Electronic nicotine delivery device (electronic cigarettes) might be more effective than placebo cigarettes in promoting tobacco cessation in patients not intending to quit
Based on randomized controlled trial with high loss to follow-up.300 smokers aged 18-60 years without intention to quit randomized to 1 of 3 groups for 12 weeks.
7.2 mg nicotine cartridges up to 4 per day
7.2 mg nicotine cartridges for 6 weeks followed by 5.4 mg nicotine cartridges for 6 weeks up to 4 per day
placebo cartridges up to 4 per day
- no concurrent behavioural intervention was offered as patients had no intention to quit smoking
- patient self-report of tobacco use was verified by use of carbon monoxide measure
- 39% of patients lost to follow-up
- all 3 groups had significant decrease in cigarette consumption from baseline (p < 0.001)
- no significant differences in quit rates at 52 weeks
13% with 7.2 mg nicotine cartridges
9% with 7.2 mg nicotine cartridges for 6 weeks followed by 5.4 mg nicotine cartridges for 6 weeks
4% with placebo cartridges
- no correlation appeared between decrease in tobacco smoking and either number of cartridges smoked or nicotine concentration in cartridge so both nicotine groups were combined in post-hoc analysis
- in intent-to-treat analysis with both nicotine groups combined vs. placebo cartridges
abstinence at 12 weeks with nicotine ENDD 14% vs. 4% (p = 0.008)
abstinence at 52 weeks 11% vs. 4% (p = 0.04)
no significant differences in patients achieving ≥ 50% reduction in number of cigarettes used per day
See also a 2012 rapid review by the Canadian Agency for Drugs and Technology in Health.