Effect of unguided e-cigarette provision on uptake, use, and smoking cessation among adults who smoke in the USA: a naturalistic, randomised, controlled clinical trial

How do people quit smoking using e-cigarettes? A mixed-methods exploration of participant smoking pathways following receiving an opportunistic e-cigarette-based smoking cessation intervention

BACKGROUND AND AIMS

Pathways of transitioning from tobacco smoking to vaping after receiving an e-cigarette-based smoking cessation intervention have been minimally explored.

STUDY AIMS

1) identify pathways between intervention delivery and final follow-up; 2) describe baseline and post-intervention statistical data in relation to smoking/vaping behaviour of the different pathway groups; 3) explore qualitative participant perspectives contextualising pathway groups.

DESIGN

Embedded mixed-methods analysis of data collected for the Cessation of Smoking Trial in the Emergency Department (COSTED) randomised controlled trial.

SETTING

Recruitment from 6 Emergency Departments (5 in England and 1 in Scotland) between January and August 2022.

PARTICIPANTS

366 adult smokers who were randomised to receive the COSTED intervention and provided data at 6-month follow-up. Qualitative subsample of 24 participants interviewed after follow-up.

INTERVENTIONS

Brief smoking cessation advice, provision of an e-cigarette starter kit and referral to the local Stop Smoking Service.

MEASUREMENTS

Descriptive statistical reporting of identified pathways and smoking/vaping behaviour at baseline and 6-month follow-up. Semi-structured phone/video interviews analysed thematically.

FINDINGS

13.4% (n = 49) of participants quit smoking within 1 month of receiving the intervention, 19.1% (n = 70) quit between 1 and 6 months, 24.9% (n = 91) reduced cigarettes per day (CPD) by at least 50%, and 42.6% did not experience a significant smoking reduction. Approximately a third of participants who quit reported not vaping at follow-up. Reporting dual use was associated with a reduction in CPD. Appoximately a third reported experimenting with a different device to the one provided as part of the intervention. Quitters reported themes of satisfaction with vaping, changes in environment facilitating quitting and motivation to quit.

CONCLUSIONS

Dual use of cigarettes and e-cigarettes can result in a reduction of smoking and may preclude quitting smoking. Sustained e-cigarette use is not always necessary for quitting success. Success depends on personal context as well satisfaction with vaping.

Reduced Nicotine Cigarettes and E-Cigarettes in High-Risk Populations: 3 Randomized Clinical Trials

Importance

Prohibiting the sale of commonly preferred e-cigarette flavors (eg, fruity and sweet) to discourage use among youths poses a risk of diminishing efforts to decrease smoking in adults.

Objective

To compare reductions in smoking achieved in adults with psychiatric conditions or lower educational level using very low nicotine content (VLNC) cigarettes alone, combined with e-cigarettes limited to tobacco flavor (TF), or combined with e-cigarettes in participant-preferred flavors.

Design, Setting, and Participants

Three randomized clinical trials were conducted for 16 weeks from October 2020 through November 2023 at the University of Vermont, Brown University, and Johns Hopkins University. Participants were adults who smoked daily and were not planning to quit in the next 30 days. These participants were from 3 at-risk populations: those with affective disorders, exemplifying mental illness; those with opioid use disorder, exemplifying substance use disorders; and females of reproductive age with a high-school education or less, exemplifying lower educational level. Participants were randomly assigned to 1 of 4 experimental conditions: (1) normal nicotine content (NNC) cigarettes only; (2) VLNC cigarettes only; (3) VLNC cigarettes plus e-cigarettes with classic TF (hereafter, VLNC + TF); and (4) VLNC cigarettes plus e-cigarettes with preferred flavors (hereafter, VLNC + PF).

Interventions

The NNC cigarettes contained 15.8 mg nicotine/g tobacco, the VLNC cigarettes contained 0.4 mg nicotine/g tobacco, the VLNC + TF had pods containing 5% nicotine by weight and only classic TF, and the VLNC + PF had pods containing 5% nicotine in 8 flavors (including fruity and sweet) from which participants selected 3 flavors.

Main Outcomes and Measures

The primary outcome was mean total cigarettes smoked per day (CPD) during week 16. Tobacco-related biomarkers were assessed, including total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a tobacco-specific carcinogen.

Results

A total of 326 participants (mean [SD] age, 40.09 [10.79] years; 243 females [74.5%]) from 3 randomized clinical trials were included. The VLNC cigarettes decreased total CPD, with least square (LS) means (SEMs) of 22.54 (1.59) in the NNC, 14.32 (1.32) in the VLNC, 11.76 (1.18) in the VLNC + TF, and 7.63 (0.90) in the VLNC + PF conditions. Each VLNC condition differed significantly from NNC, with an adjusted mean difference (AMD) of -8.21 (95% CI, -12.27 to -4.16; P < .001) in the VLNC, -10.78 (95% CI, -14.67 to -6.90; P < .001) in the VLNC + TF, and -14.91 (95% CI, -18.49 to -11.33; P < .001) in the VLNC + PF conditions. Participants in the VLNC + PF condition also decreased smoking below the VLNC and the VLNC + TF conditions (AMDs, -6.70 [95% CI, -9.84 to -3.55; P < .001] and -4.13 [95% CI, -7.05 to -1.21; P = .02]); the VLNC and VLNC + TF conditions did not differ significantly. Consistent with decreases in CPD, NNAL levels in the VLNC + PF condition were lower than in all other conditions, with AMDs (in pmol/mg creatinine) of -0.94 (95% CI, -1.41 to -0.47; P < .001) compared with the NNC condition, -0.47 (95% CI, -0.87 to -0.08; P = .03) compared with the VLNC condition, and -0.46 (95% CI, -0.83 to -0.10; P = .04) compared with the VLNC + TF condition.

Conclusions and Relevance

These results provide further evidence that a reduced-nicotine standard for cigarettes has the potential to decrease smoking and tobacco-toxicant exposure in high-risk populations and that these effects may be enhanced when adults can access e-cigarettes in commonly preferred flavors.

Trial Registration

ClinicalTrials.gov Identifiers: NCT04092387, NCT04090879, NCT04092101.

The prospective relationship between a-priori intentions for and patterns of e-cigarette use among adults who smoke cigarettes

BACKGROUND

Electronic (e-)cigarettes may help adult cigarette smokers achieve cigarette cessation, depending on patterns of e-cigarette use. Among cigarette smokers who do not use e-cigarettes, it is unclear if and how a-priori intentions for use are related to uptake patterns. Longitudinal studies have focused on established e-cigarette users or adolescent and young adult populations exclusively.

METHODS

Within a nationwide randomized clinical trial (N = 638), adult cigarette smokers not currently using e-cigarettes were randomized (2:1) to receive (or not) one-month sampling of e-cigarettes. An exploratory factor analysis (EFA) was performed on an established 15-item measure assessing a-priori intentions for e-cigarette use to identify latent variables. Among those receiving e-cigarette products, regression models examined relationships between intentions and: 1) uptake (yes/no), 2) frequency (number of days per week), and 3) amount (puffing episodes per day) of e-cigarette use at one-month follow-up.

RESULTS

Two factors emerged from the EFA: 1) cigarette-related intentions (e.g., cigarette cessation, no smell) and 2) novel appeal of e-cigarettes (e.g., flavors). Three items remained and were treated as separate intentions: "feels like cigarette smoking", "curiosity", and "affordability". In the final multivariable models, "feel like cigarette smoking" predicted more frequent e-cigarette use (β = 0.187, SE = 0.086, p = 0.03); however, none of the five factors/intentions were significantly associated with uptake or amount of use.

CONCLUSIONS

For adult cigarette smokers not currently using e-cigarettes, a-priori intentions for using e-cigarettes might not be predictive of if or how these products will be used in the future, suggesting that motives may not drive use behavior.

[Intended and unintended effects of e-cigarettes in clinical studies: a plea for (more) transparency]

E-cigarettes are used in clinical trials to facilitate smoking cessation. Due to the health risks associated with the use of e-cigarettes, the results of clinical trials should be fully reported, including continued exclusive use and dual use of tobacco and e-cigarettes. Nicotine cessation outcomes should be reported as the primary endpoint as well as the analysis of tobacco cessation alone. As there is currently no robust evidence that reducing cigarette consumption provides substantial health benefits, cigarette consumption reduction should not be used as a health outcome in clinical trials. Continued nicotine dependence should be included as an "adverse event" in the reporting of trial results.

Prevalence, demographic, socio-economic, and lifestyle factors associated with cigarette, e-cigarette, and dual use: evidence from the 2017-2021 Scottish Health Survey

Understanding the correlation between demographic, socio-economic, and lifestyle factors with e-cigarette use, cigarette smoking, and dual use is essential for targeted public health interventions. This study examines the prevalence of these behaviors in Scotland and identifies the associated factors. We conducted a repeated cross-sectional analysis of the Scottish Health Survey data from 2017 to 2021, leveraging data from 12,644 participants aged 16 and older: 2271 cigarette smokers, 687 e-cigarette users, 428 dual users, and 9258 never users. Weighted prevalences were calculated by age group, sex, and survey year, followed by weighted multinomial logistic regression to explore associated factors. The overall prevalences were 72.0% (95% CI 70.9-73.1) for never users, 18.9% (95% CI 17.9-19.9) for cigarette smokers, 5.5% (95% CI 5.0-6.1) for e-cigarette users, and 3.6% (95% CI 3.2-4.0) for dual users. From 2017 to 2021, cigarette smoking declined from 21.7% (95% CI 19.6-23.9) to 13.1% (95% CI 11.5-15.0), e-cigarette use from 6.5% (95% CI 5.4-7.8) to 4.8% (95% CI 3.6-6.4), and dual use from 3.7% (95% CI 2.9-4.6) to 2.7% (95% CI 1.9-3.7). Age was a critical factor, with the 25-34 age group more likely to use e-cigarettes (p = 0.007) and the 35-44 age group more likely to engage in dual use (p = 0.006) compared to the 16-24 age group. Males had higher odds of e-cigarette use than females (p = 0.031). White individuals had higher odds of using e-cigarettes (p = 0.023) and being dual users (p = 0.017) compared to non-whites. Previously married individuals had higher odds of dual use than singles (p = 0.031). Larger household sizes were linked to reduced odds of all three behaviors (p = 0.001). Rural residents were less likely to use e-cigarettes compared to urban residents (p = 0.025). Higher education correlated with lower odds of all three behaviors (p = 0.001). Manual occupation increased the likelihood of dual use (p = 0.042). Lower income and higher deprivation significantly increased the odds of all three behaviors (p < 0.001). Excessive alcohol consumption was associated with increased odds of the three behaviors (p < 0.001). Poor sleep quality correlated with increased odds of dual use (p = 0.002) and cigarette smoking (p < 0.001). Adherence to physical activity guidelines was associated with reduced odds of all three behaviors (cigarette smoking p < 0.001, e-cigarette use p = 0.031, dual use p = 0.016). In conclusion, this study showed a decline in the prevalence of cigarette smoking, e-cigarette use, and dual usage from 2017 to 2021 in Scotland. Significant associations with demographic, socio-economic, and lifestyle factors highlight the need for targeted public health interventions.

Increased e-cigarette use prevalence is associated with decreased smoking prevalence among US adults

BACKGROUND

If US adults who smoke cigarettes are switching to e-cigarettes, the effect may be observable at the population level: smoking prevalence should decline as e-cigarette prevalence increases, especially in sub-populations with highest e-cigarette use. This study aimed to assess such effects in recent nationally-representative data.

METHODS

We updated a prior analysis with the latest available National Health Interview Survey data through 2022. Data were cross-sectional estimates of the yearly prevalence of smoking and e-cigarette use, respectively, among US adults and among specific age, race/ethnicity, and sex subpopulations. Non-linear models were fitted to observed smoking prevalence in the pre-e-cigarette era, with a range of 'cut-off' years explored (i.e., between when e-cigarettes were first introduced to when they became widely available). These trends were projected forward to predict what smoking prevalence would have been if pre-e-cigarette era trends had continued uninterrupted. The difference between actual and predicted smoking prevalence ('discrepancy') was compared to e-cigarette use prevalence in each year in the e-cigarette era to investigate whether the observed decline in smoking was statistically associated with e-cigarette use.

RESULTS

Observed smoking prevalence in the e-cigarette era was significantly lower than expected based on pre-e-cigarette era trends; these discrepancies in smoking prevalence grew as e-cigarette use prevalence increased, and were larger in subpopulations with higher e-cigarette use, especially younger adults aged 18-34. Results were robust to sensitivity tests varying the analysis design.

CONCLUSIONS

Population-level data continue to suggest that smoking prevalence has declined at an accelerated rate in the last decade in ways correlated with increased uptake of e-cigarette use.

Implementation, enrollment, and engagement in an opt-out telehealth pharmacist-assisted tobacco treatment program for patients seen in oncology outpatient clinics

OBJECTIVE

To describe the workflow, reach, cost, and self-reported quit rates for an opt-out tobacco treatment program (TTP) for patients seen in 43 oncology outpatient clinics.

METHODS

Between May 25, 2021, and December 31, 2022, adult patients (≥18 years) visiting clinics affiliated with the Medical University of South Carolina Hollings Cancer Center were screened for smoking status. Those currently smoking were referred to a telehealth pharmacy-assisted TTP. An attempt was made to contact referred patients by phone. Patients reached were offered free smoking cessation counseling and a 2-week starter kit of nicotine replacement medication. A random sample of 420 patients enrolled in the TTP were selected to participate in a telephone survey to assess smoking status 4 to 12 months after enrollment.

RESULTS

During the reference period 35,756 patients were screened and 9.3% were identified as currently smoking. Among the 3319 patients referred to the TTP at least once, 2393 (72.1%) were reached by phone, of whom 426 (12.8%) were ineligible for treatment, 458 (13.8%) opted out of treatment, and 1509 (45.5%) received treatment. More than 90% of TTP enrollees smoked daily, with an average of 13.1 cigarettes per day. Follow-up surveys were completed on 167 of 420 patients, of whom 23.4% to 33.5% reported not smoking; if all nonresponders to the survey are counted as smoking, the range of quit rates is 9.3% to 13.3%.

CONCLUSION

The findings demonstrate the feasibility of reaching and delivering smoking cessation treatments to patients from a diverse set of geographically dispersed oncology clinics.

Effectiveness of e-cigarettes as a stop smoking intervention in adults: a systematic review

BACKGROUND

This systematic review aims to identify the benefits and harms of electronic cigarettes (e-cigarettes) as a smoking cessation aid in adults (aged ≥ 18 years) and to inform the development of the Canadian Task Force on Preventive Health Care's (CTFPHC) clinical practice guidelines on e-cigarettes.

METHODS

We searched Ovid MEDLINE®, Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non-Indexed Citations, PsycINFO, Embase Classic + Embase, and the Cochrane Library on Wiley. Searches were conducted from January 2016 to July 2019 and updated on 24 September 2020 and 25 January 2024. Two reviewers independently performed title-abstract and full-text screening according to the pre-determined inclusion criteria. Data extraction, quality assessments, and the application of Grading of Recommendations Assessment, Development and Evaluation (GRADE) were performed by one independent reviewer and verified by another.

RESULTS

We identified 18 studies on 17 randomized controlled trials that compared e-cigarettes with nicotine to e-cigarettes without nicotine and e-cigarettes (with or without nicotine) to other interventions (i.e., no intervention, waitlist, standard/usual care, quit advice, or behavioral support). Considering the benefits of e-cigarettes in terms of smoking abstinence and smoking frequency reduction, 14 studies showed small or moderate benefits of e-cigarettes with or without nicotine compared to other interventions; although, with low, very low or moderate evidence certainty. With a focus on e-cigarettes with nicotine specifically, 12 studies showed benefits in terms of smoking abstinence when compared with usual care or non-nicotine e-cigarettes. In terms of harms following nicotine or non-nicotine e-cigarette use, 15 studies reported mild adverse events with little to no difference between groups and low to very low evidence certainty.

CONCLUSION

The evidence synthesis on the e-cigarette's effectiveness shows data surrounding benefits having low to moderate evidence certainty for some comparisons and very low certainty for others, indicating that e-cigarettes may or probably increase smoking cessation, whereas, for harms, there is low to very low evidence certainty. Since the duration for outcome measurement varied among different studies, it may not be long-term enough for Adverse Events (AEs) to emerge, and there is a need for more research to understand the long-term benefits and potential harms of e-cigarettes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018099692.

Cigarette and ENDS dual use longitudinal transitions among adults in the Population Assessment of Tobacco and Health (PATH) Study, Waves 4-5 (2016-2019)

Introduction

The study assessed longitudinal transitions among adult (18 and older) past 30-day daily and non-daily dual users of cigarettes and electronic nicotine delivery systems (ENDS).

Methods

Using data from Wave 4 (W4; 2016/17) and Wave 5 (W5; 2018/19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal cohort study of US adults, multivariable regressions were conducted among W4 dual users of cigarettes and ENDS to examine past 30-day cigarette smoking at W5. The study also analyzed changes in frequency of past 30-day smoking and cigarettes smoked per day between W4 and W5, stratified by W4/W5 daily/non-daily ENDS use among W4 daily and non-daily cigarette smokers.

Results

Among W4 dual users, those smoking daily and using ENDS non-daily had higher odds of daily cigarette smoking at W5 than daily users of both products (AOR: 2.32, 95 % CI: 1.38-3.90). W4 daily smokers who used ENDS daily at Wave 5 smoked cigarettes on fewer days at Wave 5 than W4 daily smokers who were either daily ENDS users at Wave 4 (B = -4.59; SE = 1.43, p < 0.01) or non-daily ENDS users at Wave 4 (B = -4.55; SE = 1.24, p < 0.001). Among W4 non-daily cigarette smokers, W4 non-daily ENDS users who used daily at W5 smoked cigarettes on fewer days (B = -4.04, SE = 1.82) at W5 than those who were non-daily ENDS users at W4 and W5.

Conclusions

Findings highlight the importance of frequency of ENDS use in reducing cigarette smoking and could inform smoking cessation interventions among daily cigarette smokers.

Population-Based Disease Odds for E-Cigarettes and Dual Use versus Cigarettes

BACKGROUND: E-cigarettes are promoted as less harmful than cigarettes. There has not been a direct comparison of health effects of e-cigarettes or dual use (concurrently using e-cigarettes and cigarettes) with those of cigarettes in the general population. METHODS: Studies in PubMed, EMBASE, Web of Science, and PsychINFO published through October 1, 2023, were pooled in a random-effects meta-analysis if five or more studies were identified with a disease outcome. We assessed risk of bias with Risk Of Bias In Non-randomized Studies of Exposure and certainty with Grading of Recommendations, Assessment, Development, and Evaluations. Outcomes with fewer studies were summarized but not pooled. RESULTS: We identified 124 odds ratios (94 cross-sectional and 30 longitudinal) from 107 studies. Pooled odds ratios for current e-cigarette versus cigarette use were not different for cardiovascular disease (odds ratio, 0.81; 95% confidence interval, 0.58 to 1.14), stroke (0.73; 0.47 to 1.13), or metabolic dysfunction (0.99; 0.91 to 1.09) but were lower for asthma (0.84; 0.74 to 0.95), chronic obstructive pulmonary disease (0.53; 0.38 to 0.74), and oral disease (0.87; 0.76 to 1.00). Pooled odds ratios for dual use versus cigarettes were increased for all outcomes (range, 1.20 to 1.41). Pooled odds ratios for e-cigarettes and dual use compared with nonuse of either product were increased (e-cigarette range, 1.24 to 1.47; dual use, 1.49 to 3.29). All included studies were assessed as having a low risk of bias. Results were generally not sensitive to study characteristics. Limited studies of other outcomes suggest that e-cigarette use is associated with additional diseases. CONCLUSIONS: There is a need to reassess the assumption that e-cigarette use provides substantial harm reduction across all cigarette-caused diseases, particularly accounting for dual use.

Adult smokers' Complete Switching Away from Cigarettes at 6, 9, and 12 Months after Initially Purchasing a JUUL e-Cigarette

Background: Electronic nicotine delivery systems (ENDS) have the potential to benefit public health if smokers completely switch from cigarettes to ENDS. Methods: A cohort of adult smokers (age ≥ 21) who purchased a JUUL Starter Kit was followed for 12 months after the initial purchase. We defined "switching" as past-30-day abstinence from smoking (even if JUUL use had stopped), and analyzed factors associated with achievement and maintenance of self-reported repeated point-prevalence switching (RPPS) at three follow-ups, i.e., no past-30-day smoking at months 6, 9, and 12. Results: RPPS was reported by 21.6% of the 12,537 evaluable smokers. Smokers with lighter smoking history and lower cigarette dependence at baseline were more likely to report RPPS. RPPS was also associated with daily use of JUUL (Month-3: OR = 2.32, 95% CI = 2.02-2.68; Month-6: OR = 1.73, 95% CI = 1.42-2.10), and with greater subjective reinforcing effects from JUUL use (assessed by the mCEQ, Month-3: OR = 1.46, 95% CI = 1.38-1.56; Month-6: OR = 1.11; 95% CI = 1.02-1.20). Even among smokers who did not meet the criteria of RPPS (i.e., who smoked at least once), 35.5% reported past 30-day point-prevalence switching on at least one follow-up, and their cigarette consumption was substantially reduced compared to baseline. Conclusions: Approximately one-fifth of adult smokers reported 30-day point-prevalence abstinence at 6, 9, and 12 months after purchasing JUUL. Greater use of JUUL and stronger subjective reinforcing effects were associated with nonsmoking, validating the potential for ENDS to substitute for smoking, with potential for positive impacts on individual and population health.

A Practical Framework for Novel Electronic Nicotine Delivery System Evaluation: Chemical and Toxicological Characterization of JUUL2 Aerosol and Comparison with Reference Cigarettes

Electronic nicotine delivery systems (ENDSs) are designed as a non-combustible alternative to cigarettes, aiming to deliver nicotine without the harmful byproducts of tobacco combustion. As the category evolves and new ENDS products emerge, it is important to continually assess the levels of toxicologically relevant chemicals in the aerosols and characterize any related toxicology. Herein, we present a proposed framework for characterizing novel ENDS products (i.e., devices and formulations) and determining the reduced risk potential utilizing analytical chemistry and in vitro toxicological studies with a qualitative risk assessment. To demonstrate this proposed framework, long-term stability studies (12 months) analyzing relevant toxicant emissions from six formulations of a next-generation product, JUUL2, were conducted and compared to reference combustible cigarette (CC) smoke under both non-intense and intense puffing regimes. In addition, in vitro cytotoxicity, mutagenicity, and genotoxicity assays were conducted on aerosol and smoke condensates. In all samples, relevant toxicants under both non-intense and intense puffing regimes were substantially lower than those observed in reference CC smoke. Furthermore, neither cytotoxicity, mutagenicity, nor genotoxicity was observed in aerosol condensates generated under both intense and non-intense puffing regimes, in contrast to results observed for reference cigarettes. Following the proposed framework, the results demonstrate that the ENDS products studied in this work generate significantly lower levels of toxicants relative to reference cigarettes and were not cytotoxic, mutagenic, or genotoxic under these in vitro assay conditions.