Should You Recommend E-cigs To Help Patients Quit Smoking?
Editor’s note: This article is part of series from Medscape on vaping.
In 2014, after smoking cigarettes for 40 years, Kati Markowitz decided to switch to vaping. She had heard the newer electronic cigarettes might be less harmful. And, at the time, she said, she wasn’t aware of other options to try to quit smoking.
For 7 years, she vaped every day.
Then Markowitz received news she’d hoped never to hear: She had lung cancer. A nodule detected in a CT scan had grown. She was scheduled for treatment — the removal of an entire lobe from her right lung. But first, she said, her surgeon told her she had to quit vaping, which reduces the risk for post-operative complications and enables a healthy recovery.
Markowitz had thought switching to vaping would be less harmful than smoking cigarettes. Now, she no longer believes that’s true.
“Did I fool myself by hoping to get lucky and not have any bad repercussions? Yes, I did,” Markowitz said, adding that she wonders if vaping contributed to her lung cancer, or if she’ll experience other negative health effects in the future.
Researchers are divided on if e-cigarettes are as effective in smoking cessation as other nicotine replacement therapies like gums and lozenges. They also say more research is needed on the long-term health impacts of vaping to ultimately determine if vapes are a safe replacement — like gums and lozenges — for cigarettes.
“There is scientific research to support vaping as a cessation tool, but we wouldn’t use it as a first line of defense because we still need longitudinal studies to understand the long-term risk of e-cigarettes,” said Monica Hanna, MPH, assistant director of the Nicotine and Tobacco Recovery Program at RWJBarnabas Health’s Institute for Prevention and Recovery in Eatontown, New Jersey. “We also need research to understand exactly how we could use e-cigarettes as a cessation device.”
Vaping to Quit
The first prototypes of e-cigarettes were developed in the 1930s, although what are now known as vapes weren’t sold by manufacturers until the 2000s in the United States, following an invention by a former health official in China. The vape was touted by both researchers and manufacturers over the years of development as a way to quit smoking cigarettes.
The Consumer Advocates for Smoke-free Alternatives Association (CASAA), a nonprofit group that supports vaping and accepts donations from the e-cigarette industry, has compiled more than 13,000 testimonials from people who say vaping helped them give up smoking.
Studies show mixed results that using vapes can help traditional smokers quit.
Dr Peter Shields
A November 2022 Cochrane review showed a “high certainty of evidence that people are more likely to stop smoking traditional cigarettes for at least 6 months using e-cigarettes, or ‘vapes,’ than using nicotine replacement therapies, such as patches and gums.” The meta-analysis examined 78 studies with more than 22,000 participants. And a 2019 study with 886 participants published in the New England Journal Medicine found smokers who tried vaping to quit were twice as likely after a year to have stopped smoking cigarettes than those who used nicotine replacement therapy.
“In terms of the global research, it’s pretty clear that vaping can help smokers quit,” said Peter Shields, MD, a professor in the department of internal medicine at The Ohio State University College of Medicine, in Columbus, who specializes in the treatment of lung cancer.
But a 2013 study published in the Lancet, and another from 2020, found only a modest improvement in cessation outcomes when participants used e-cigarettes paired with patches compared with patches alone.
Dr Thomas Eissenberg
“For a disruptive technology that was supposed to end combustible tobacco use, there seems very little large-scale disruption,” said Thomas Eissenberg, PhD, co-director of Virginia Commonwealth University’s Center for the Study of Tobacco Products in Richmond, Virginia.
Michael Joseph Blaha, MD, MPH, director of clinical research at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease in Baltimore, Maryland, pointed to research that shows a portion of people who start vaping to quit smoking end up using both products — or become so-called “dual” users.
Dr Michael Joseph Blaha
“I do think there is fairly high-quality evidence that vaping can lead to more cessation, but at the tradeoff of more long-term dual users and more overall nicotine addiction,” Blaha said. “Vaping remains a third-line clinical tool after nicotine replacement therapy and FDA-approved cessation medications.”
The US Food and Drug Administration (FDA) has not approved any e-cigarette or vaping device for smoking cessation, like it has for patches and gums, which means manufacturers cannot market their products as helping tobacco smokers quit.
“There is potential for vaping as a cessation device, but the evidence so far is too small to say for sure that vaping is a more effective tool than others for combustible tobacco cessation,” Hanna, from RWJBarnabas Health’s Institute for Prevention and Recovery, said.
Reducing Harm and Improving Health?
Vapes have also been touted as a boon to individual and public health since cigarette smoking is the leading cause of preventable disease and disability in the US, responsible for more than 480,000 deaths per year in the United States, according to the US Centers for Disease Control and Prevention.
Quitting smoking lowers the risk of developing various cancers, heart disease, stroke and other serious diseases. The aim of nicotine replacement therapy is to help smokers quit by gradually providing the body with smaller doses of nicotine over time, and without exposing the body to toxic chemicals found in cigarettes.
“No one should say that e-cigarettes are safe, but compared to cigarettes, the data is consistent: they are not as harmful, and when a smoker switches, it’s better for them,” Shields said. “Like with other nicotine replacement therapies, if there is a risk that someone stops vaping and returns to smoking, I would rather have them as long-term vapers since it is generally considered to be less harmful than combustible tobacco.”
The FDA has allowed a handful of companies to market their electronic nicotine delivery systems as safer than traditional cigarettes by gaining approval through the Premarket Tobacco Product Applications (PMTA) process. In 2021, the agency announced its first PMTA authorization of an electronic cigarette to R.J. Reynolds for three of its tobacco-flavored vaping products. Regulators approved more products from three additional companies in 2022.
But the FDA has also denied others, including two products in 2023 from R.J. Reynolds, stating “the applications lacked sufficient evidence to demonstrate that permitting the marketing of the products would be appropriate for the protection of the public health.”
Questions remain among some researchers on the effects of vaping if used long term. Data on the health effects of vapes are just beginning to emerge, and are mainly from studies of animals or cells. Measuring health effects among vape users will entail decades more of study since Americans only gained access to the products in the 2000s.
Eissenberg said vaping likely does not cause the same diseases as cigarette smoking, but that does not mean they are not harmful. Ingredients found in e-cigarettes, such as heated propylene glycol, vegetable glycerin, and flavors, have only been used as food ingredients. The potential diseases caused by vapes are still unknown because inhaling these heated ingredients is new. He also said he had “no issue” with an adult smoker vaping to help them quit smoking — as long they do so for a short period.
“I am very concerned that long-term use in adults could lead to considerable disease and death,” Eissenberg said. “Simply put, the human lung evolved for one purpose: gas exchange of oxygen in, carbon dioxide out. Anything else that enters the lung is a challenge to the organ.”
But Kenneth Warner, PhD, dean emeritus at the University of Michigan School of Public Health in Ann Arbor, said breaking the addiction to traditional cigarettes could reduce high rates of lung cancer in lower income communities where rates of smoking are comparatively high.
Dr Kenneth Warner
About three times as many Americans smoked (12.6%) than vaped (4.7%) in 2021, but those who live in households with lower incomes are more likely to smoke. According to the CDC, use of tobacco is higher among adults who were uninsured (27.3%) or who had Medicaid coverage (28.6%) than among those with private insurance (16.4%). People with annual family incomes of less than $12,500 also are more likely to be diagnosed with lung cancer than those with family incomes of $50,000 or more. Public health researchers have attributed those disparities in part to higher rates of smoking in lower-income households.
Warner said many lower-income and other Americans may never quit smoking cigarettes because they believe making the switch to e-cigarettes will not benefit their health. A 2022 study published in the American Journal of Preventive Medicine found that the percent of Americans who thought vaping was more harmful than smoking quadrupled between 2018 and 2020, from 6.8% to 28.3%. A third of respondents thought vaping was as harmful as smoking.
“We’ve convinced a large percentage of the American public that vaping is as harmful as smoking when it could be helping people quit smoking,” Warner said. “People are dying right now.”
Markowitz did quit smoking by taking up vaping. But now she questions if her lung cancer prognosis would have been delayed, or even avoided, if she’d tried a traditional method like a lozenge or gum instead. She vaped once an hour for most of her 7 years of using the devices.
“For people who are trying to stop smoking, I would recommend something like the patch instead,” Markowitz said.
The Consumer Advocates for Smoke-free Alternatives receives funding from the vaping industry.
Blaha, Eissenberg, Hanna, Shields, and Warner reported no funding from the tobacco or e-cigarette industry. Blaha and Warner receive tobacco-related research funding from the FDA. Warner is a member of the FDA’s Tobacco Products Scientific Advisory Committee.
Kerrie Rushton is a freelance writer living in Maryland.
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