January 30, 2019

expert reaction to randomised, controlled trial of ecigs vs NRT in smoking cessation

Research published in The New England Journal of Medicine (NEJM) demonstrates that E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support.

Prof Paul Aveyard, Professor of Behavioural Medicine at the University of Oxford, said:

“Previous trials had suggested that e-cigarettes were effective and that, in the short-term, that they were also safe and tolerable.  This trial really adds to our confidence in this finding.  However, for the first time, the trial shows that e-cigarettes are roughly twice as effective as nicotine replacement treatment (NRT).  The study suggests that e-cigarettes, at least used in this context, may be the most effective ‘pharmacotherapy’ we have to help people stop smoking, but we need further head-to-head trials to be sure about this.

“It’s important to note that the authors used a modern e-cigarette, whereas previous trials used older cigalike e-cigarettes.  We’ve known that modern e-cigarettes deliver more nicotine and more rapidly than cigalike products and we have thought that this should make them more effective.  This study suggests this reasoning was correct.

“Many stop smoking services are already supporting their clients to use e-cigarettes and this study suggests this is an effective thing to do and they should continue doing so and others, who were waiting for more evidence, may now feel this is appropriate.

“Although only 18% of people stopped smoking, we should put this figure in its proper context.  Participants in this study received behavioural support and nicotine replacement treatment or e-cigarettes.  We have really strong evidence that getting support and using NRT works well.  Based on this, we can calculate that without any help at all, only around 3% of people would have stopped smoking.  That means that 15% of people who got the behavioural support and e-cigarette together stopped smoking because of that combination, about five times more than might have been the case if they’d gone it alone and cold turkey.  Some people can stop smoking without help, but some find themselves in a grip of an addiction and the typical person in this study had been like that all their adult lives.  It’s not surprising that so many people were not cured with this treatment, but many will overcome their smoking in time and with repeated attempts. 

“Recognising the grip that smoking can have for some, we need to help as many people as possible to give themselves the best chance of success by using aids like e-cigarettes each time they try to stop smoking.”

Prof Ann McNeill, Professor of Tobacco Addiction at the Institute of Psychiatry Psychology & Neuroscience, King’s College London, said:

“This is a very well-carried out randomised controlled trial using the highest standards of reporting and it demonstrates that unlicensed e-cigarettes were almost twice as effective as licensed nicotine replacement therapies for smokers attending Stop Smoking services.

“Smokers trying to quit have been choosing e-cigarettes over other types of support for some time. The research indicates that health professionals and Stop Smoking services should reach out to smokers who want to use e-cigarettes and support them in making this life-changing step.”

Prof Robert West, Professor of Health Psychology and Director of Tobacco Studies at UCL, said:

“This study is of huge significance.  It provides the clearest indication yet that e-cigarettes are probably more effective than products such as nicotine gum and patches.  It fits previously published trend data showing an increase in quit success rates in England and the US linked to more people using e-cigarettes.

“For the NHS to prescribe e-cigarettes to smokers would require a licence from the medicines regulators. However, smokers and health professionals should certainly be made aware of these results so that they can make informed decisions about whether to try them.

“This was a very high quality study and shows strong evidence that ecigs help smokers quit.  Next, we would like to know how effective ecigs are when used without any support from a health professional.  Population-level studies suggest they are still effective but it would be good to get evidence from randomised controlled trials.

“Given that ecigs may cause some harm when used over many years I would encourage users to think of them as a stop-gap, but they are far better than smoking – ex-smokers should not stop using them if they are worried they may go back to cigarettes.”

Dr Jamie Hartmann-Boyce, Senior Researcher in Health Behaviours at the University of Oxford, said:

“This is a large, well-conducted, and much needed study, in which people given electronic cigarettes were more likely to successfully quit smoking than those given nicotine replacement (e.g. gum or patches).

“It adds to a growing body of evidence that electronic cigarettes with nicotine can help people quit smoking. At one year, approximately 80% of people who were given an electronic cigarette were still using it. More research is needed on the effects of long-term electronic cigarette use, but experts agree electronic cigarettes are considerably less harmful than smoking, so switching from smoking to vaping is likely to bring substantial health gains.

Dr Jamie Brown, Deputy Director of the Tobacco and Alcohol Research Group at UCL, said:

“This landmark trial has been conducted to the highest standards and provides compelling evidence that when offered alongside behavioural support e-cigarettes are more effective than traditional nicotine replacement therapies. It is notable that the comparison is with combinations of different nicotine replacement therapies, such as a patch and gum, which is regarded as one of the gold-standard treatment options within stop smoking services.

“This study should reassure policymakers and health professionals – mainly beyond the UK – who have until now been hesitant to recommend e-cigarettes for smoking cessation on the basis that there was a lack of high-quality trial evidence.”

“The result complements population-level evidence that e-cigarettes have been contributing to the falling prevalence of cigarette smoking in England.”

* ‘A randomised trial of e-cigarettes versus nicotine replacement therapy’ by Peter Hajeket al. will be published in the New England Journal of Medicine at 10pm UK time on Wednesday 30 January, which is also when the embargo will lift. 

Declared interests

Prof Robert West undertakes research and consultancy for companies that develop and manufacture smoking cessation medicines but not e-cigarettes or tobacco products. His research is funded by Cancer Research UK. 

Dr Brown: I have received unrestricted funding to conduct smoking cessation research from Pfizer who manufacture the smoking cessation medication varenicline (Champix). I do not, and will not, take funds from e-cigarette manufacturers or the tobacco industry.

Dr Hartmann-Boyce: no conflicts.

Prof McNeill: no conflicts.

Prof Paul Aveyard: I have led a trial in which GSK donated free nicotine patches.