Can Prescribing a Cigarette Help Smokers Quit?

Primary care providers have long struggled with how to best counsel smokers and  help them give up the bad habit. A variety of nicotine replacement methods (transdermal patches, gum, spray, etc), adequately substitute for the nicotine found in cigarettes but have had intermittent success rates when it comes to cessation. Nonetheless, when compared to placebo, these agents are superior and can increase the rate of quitting two-fold.¹ To date, these have been the mainstay of pharmacotherapy for smoking cessation. The introduction of the electronic cigarette (e-cigarette), however, may have changed the landscape yet again.

In a randomized controlled trial presented at the European Respiratory Society and published simultaneously in The Lancet², a group from New Zealand was able to demonstrate that e-cigarettes and traditional replacement methods were comparable in efficacy and safety. The trial enrolled 657 adults who wanted to quit smoking and had variable levels of nicotine dependence (>5 or ≤5 Fagerstrm test for nicotine dependence) and randomized them in a 4:4:1 ratio to 16 mg nictoine e-cigarettes, nicotine patches (one 21 mg patch daily), or placebo e-cigarettes without nicotine for 13 weeks (1 week before quit day through 12 weeks after quit day). All participants received voluntary low level behavioral counseling via telephone. At 6 months, biochemically assessed abstinence (exhaled carbon monoxide measurement <10 ppm) was found to be 7.3% with nicotine e-cigarettes, 5.8% with patches, and 4.1 % with placebo e-cigarettes (risk difference: 1.51X and 3.16X, respectively).  Because of the overall low rate of abstinence, the trial was inadequately powered to demonstrate the superiority of e-cigarettes over nicotine patches. Notably, there were no increased adverse events observed with e-cigarettes over patches during the follow-up period.

This trial offers an exciting new possibility for a therapy that may be effective in helping smokers to quit and maintain abstinence. However, with this new technology also comes the potential for uncertainty.  It remains to be seen whether e-cigarettes are safe and effective in the long term and whether abstinence achieved with this therapy will be sustained. Furthermore, their widespread availability and appeal brings up the danger of potentially encouraging more young people to smoke. The Centers for Disease Control and Prevention has reported that the use of e-cigarettes in middle- and high-school students doubled from 2011 to 2012 with 20% of individuals using e-cigarettes who had never used traditional cigarettes.³ So, for some patients, this may be a valuable next step to stopping; until more data becomes available, however, use with caution is advised.

References:
1. Rigotti NA. Clinical practice. Treatment of tobacco use and dependence. N Engl J Med. 2002;346:506-512.
2. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, Walker N. Electronic cigarettes for smoking cessation: a randomised controlled trial.  The Lancet. 9 September 2013. doi:10.1016/S0140-6736(13)61842-5. (Abstract)
3.e-cigarettes: a moral quandary. The Lancet. 2013;382:914. (Full text)