“High Certainty” Evidence That Vapes Are Better Quitting Aids Than NRT

November 22, 2022

Cochrane, a research institute considered something of a benchmark in evidence-based public health interventions, has released an updated review that finds vaping products help adults quit cigarettes more than traditional nicotine replacement therapies, like patches and gums.

Specifically, the authors of the Cochrane report, including Jamie Hartmann-Boyce of Oxford and Nancy Rigotti of Harvard Medical School, concluded that there “was high certainty that quit rates were higher in people randomized to nicotine EC [e-cigarettes] than in those randomized to nicotine replacement therapy.”

The latest review now includes 78 studies—40 of them randomized controlled trials (RCTs) that involved more than 22,000 adults who smoked and assessed “the effectiveness, tolerability, and safety of using electronic cigarettes” to help them quit. The review has added 22 studies since the last update in 2021.

“Nicotine e-cigarettes can help people stop smoking for at least six months,” wrote the Cochrane authors. “Evidence shows they work better than nicotine replacement therapy, and probably better than e-cigarettes without nicotine. They may work better than no support, or behavioral support alone, and they may not be associated with serious unwanted effects.”

The authors hinted that the picture might improve further in future. “[W]e still need more evidence,” they wrote, “particularly about the effects of newer types of e-cigarettes that have better nicotine delivery than older types of e-cigarettes, as better nicotine delivery might help more people quit smoking.”

“People who use safer nicotine are happy to learn that science shows what we already know, from our own lived experience.”

A previous version of the Cochrane review found that there was “moderate-certainty evidence” that e-cigarettes showed higher quit rates than NRT. Now that it has become “high certainty,” many tobacco harm reduction proponents are drawing attention to how the evidence is only growing.

“People who use safer nicotine are happy to learn that science shows what we already know, from our own lived experience,” Charles Gardner, the president of INNCO, a nonprofit that advocates for safer nicotine alternatives, told Filter. “Each time Cochrane has conducted the review, the evidence strengthened. This is how science is supposed to work, as an ever-increasing approximation of objective truth.”

The updated Cochrane review comes on the heels, too, of the United Kingdom’s “Nicotine Vaping in England 2022” report, which reconfirmed in “the short and medium term, vaping poses a small fraction of the risks of smoking,” and presented robust evidence that there’s “significantly lower exposure to harmful substances from vaping compared with smoking, as shown by biomarkers associated with the risk of cancer, respiratory and cardiovascular conditions.”

In the past few months, tobacco control advocates in favor of harm reduction have called on Brian King, the relatively new director of the Food and Drug Administration’s Center for Tobacco Products (CTP), to do a better job at communicating the relative risks between vaping and smoking. The public at-large—and, alarmingly, many physicians—are still under the impression that vaping is just as risky (or even more so) as smoking combustible cigarettes. States continue to adopt prohibition-oriented policies, as the FDA sorts through the remaining e-cigarette marketing applications. So far, it has authorized just a handful of tobacco-flavored vaping products, leaving people wondering if the agency will ever authorize a single other flavor (including menthol).

“This evaluation of e-cigarettes for smoking cessation should prompt some e-cigarette companies to consider going through the FDA’s drug evaluation procedure (through the agency’s Center for Drug Evaluation and Research, CDER) to gain a jump on the competition in the formal smoking cessation treatment arena, although CDER itself may have to adapt their thinking to acknowledge that the benefits and risks of any smoking cessation treatment needs to be evaluated against the enormous harm caused by cigarette smoking,” Kenneth Warner, a former dean at the University of Michigan’s School of Public Health, told Filter.

“The trials generally understate the impact of vaping … so the Cochrane estimates are best seen as super-cautious.”

While the review doesn’t address why vapes might be more effective quitting aids than NRT, vapers and harm reductionists have long contended that the mechanisms of vaping—the inhalation and hand-to-mouth movements that mimic smoking for people accustomed to cigarettes—could be key to the difference.

“Cochrane confirms with great credibility that people using vaping products have better prospects of quitting,” Clive Bates, the former director of Action on Smoking and Health (ASH) in the United Kingdom, told Filter. “That aligns with all the evidence from observational studies, population trends, economic studies and, above all, user testimony. The days when vaping opponents could say ‘we just don’t know’ are now long gone.”

“The trials generally understate the impact of vaping because they miss the diversion effect [from smoking to vaping] on youth, the accidental quitters who never intended to stop and those who transition from smoking to vaping over a longer period than a typical trial,” he continued. “So the Cochrane estimates are best seen as super-cautious.”



Photograph by Vaping360 via Flickr

Alex Norcia

Alex was formerly Filter’s news editor. He previously worked as a reporter and copy editor at VICE, and has been published in the New York Times Magazine, the Columbia Journalism Review, the Los Angeles Times and the New Republic, among other outlets. He was also previously a freelance editorial consultant for the Foundation for a Smoke-Free World; The Influence Foundation, which operates Filter, has received grants from the Foundation for a Smoke-Free World. He is currently based in Los Angeles.

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