Evidence is mounting that electronic cigarettes can be useful as a tool in helping people to quit smoking under the right circumstances. But a University of Colorado Department of Medicine faculty member says there are still questions to be answered about potential harm from e-cigarettes.
Gina Kruse, MD, a visiting associate professor in the Division of General Internal Medicine, co-authored a recent commentary in the Emergency Medical Journal. The commentary was in response to a research paper in the journal that reported results of a study involving patients and others who smoke in emergency departments in the United Kingdom who were offered e-cigarettes as part of a smoking-cessation program.
The U.K. study reported that “an opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop-smoking services is effective for sustained smoking abstinence with few reported adverse events.”
A great opportunity
Kruse’s research focus is delivery of tobacco cessation services. In their commentary, written at the invitation of the journal’s editors, she and her co-authors offer several caveats to the U.K. research.
“Any comment on e-cigarettes is incomplete without consideration of the public health impact beyond their use among adults who smoke,” the commentary says.
"We thought it would be a great opportunity to talk about this work,” Kruse says of her commentary. “This is one of a few articles testing e-cigarettes as cessation interventions that have come out in the past year, and this one is particularly interesting because it was set in emergency departments, which is a novel setting for e-cigarette cessation trials because the folks involved were not necessarily coming in for smoking cessation. They were approached about it.”
Kruse’s commentary notes that more than half of the people approached in EDs who currently smoke agreed to take part in the U.K. study, suggesting “that the ED could be a fruitful setting for engaging patients with cessation interventions.” But the commentary says that the results’ applicability to other health-care settings “is uncertain” for various reasons.
Popular among youths
Use of e-cigarettes – sometimes called vaping – has increased since 2020, and they are the most commonly used tobacco product among youths. An estimated 4.5% of U.S. adults use e-cigarettes, 10% of high school students and 4.6% of middle-school students.
According to the U.S. Centers for Disease Control and Prevention, e-cigarettes are not safe for youths and young adults, pregnant people, and adults who do not currently use tobacco products. And “scientists still have a lot to learn about whether e-cigarettes are effective in helping adults quit smoking,” although they show potential, the CDC says. Studies show that many adults who start using e-cigarettes as a way to quit smoking instead wind up both vaping and smoking.
Kruse says that the U.K. has different policies toward e-cigarettes than in the U.S. – differences that may limit the applicability of the U.K. study on this side of the Atlantic.
For example, she says, “the U.K. has policies that regulate the amount of nicotine that can be in e-cigarettes, which isn't really something we have in the U.S. Because of that variability in policy, it’s worth considering whether the devices patients would be using here are the same ones in the U.K.”
More information needed
Other issues raised by Kruse and her co-authors:
- The U.K. study says that, in addition to e-cigarettes, participants were referred to the local Stop Smoking Service, typically offering behavioral advice and free access to nicotine replacement therapy, which can include gum, patches and lozenges. But the study did not report data on how many participants used both e-cigarettes and the Stop Smoking Services including nicotine replacement therapy, leaving unanswered questions of whether the addition of evidence-based cessation treatments were more or less effective in curtailing smoking than just e-cigarettes alone.
- Most U.K. study participants given e-cigarettes to quit smoking were still using them several months later. “We need more information on the long-term use of e-cigarettes after cessation of combustible cigarettes, owing to concerns that persistent use is likely to be seen as a favorable finding by the e-cigarette industry that would profit from continued nicotine dependence,” the commentary says.
- And Kruse and her colleagues also said that “not enough research is being done to understand how to most effectively prevent e-cigarette use among adolescents, while making them available in a targeted way for cessation. We need to measure the harms to adolescents hand in hand with the potential for benefits to combustible cigarette users if we are to generate informed policies and practices about these devices.”
The really tricky part
Kruse notes that Colorado has various restrictions in place aimed at keeping e-cigarettes out of the hands of minors. For example, they can’t be sold to people under age 21, they can’t be used in public indoor spaces, they can only be sold by licensed vendors, and currently they are taxed at 56% of list price. But the risk of e-cigarettes migrating from adults to youths remains, she says.
“The point is, how do you make e-cigarettes available to people who are smoking as a cessation device, and not give access to young people? We’re still learning how to regulate these products and keep young people safe. That’s the really tricky part.”
Overall, Kruse says, “smoking cessation has been held up as one of the greatest public health successes, because of the large decline in smoking prevalence in the U.S. in the last 50-plus years, and also one of our greatest failures, because of just how inequitable that decline and continued use have been. There’s wide variability in in the prevalence of tobacco use across groups and populations, and part of that is disparities in access to evidence-based cessation treatments.”
Co-authoring the commentary with Kruse are Jonathan Samet, MD, former dean of the Colorado School of Public Health; and Joaquin Barnoya MD, MPH, an adjunct professor at the school.
April 26, 2024