18B.7Potential positive impacts

Material under review: November 2017     

Suggested citation: Greenhalgh, EM, & Scollo, MM. InDepth 18B: Electronic cigarettes (e-cigarettes). In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2017. Available from: http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes

Consumers of e-cigarettes report mixed reasons for their use. Some use them as a substitute for cigarettes, either in an attempt to reduce consumption, or to enable nicotine use in situations where use of traditional cigarettes would not be allowed or acceptable. As indicated in Section 18B.5, risks associated with smoking are unlikely to be reduced by e-cigarettes if users continue to smoke tobacco cigarettes in the long term. Crucial to assessing the potential benefits of increasing use of e-cigarettes, then, is whether such use will increase or decrease the likelihood of a smoker eventually quitting tobacco.1 This question might be broken down into a number of sub-questions, namely whether use of e-cigarettes increases or decreases
 

  • the likelihood of smokers making quit attempts
  • the likelihood of a given quit-attempt being successful
  • the likelihood of reducing use of cigarettes eventually leading to quitting.


18B.7.1 Increasing quit attempts

Many smokers report using e-cigarettes as a cessation aid.2, 3 A large study in England found no clear association between e-cigarette use and prevalence of quit attempts, although such use was associated with a decrease in the use of prescription NRT.4 A number of other studies, however, have found smokers who use e-cigarettes are more likely to attempt to quit conventional cigarettes.5-11 Some showed that such attempts did not appear to translate to increased quitting success,5, 6, 10 while others found an increased rate of sustained cessation among e-cigarette users.8, 11    

18B.7.2 Increasing success in quitting

Several evidence reviews of the effectiveness of e-cigarettes as a cessation aid have been published in recent years, with mixed findings. A meta-analysis in published in 2014 concluded that “ENDS use in the real world is associated with significantly lower odds of quitting smoking cigarettes.”12  A 2016 systematic review and meta-analysis of e-cigarette use and smoking cessation in real-world and clinical settings identified 38 studies (20 with control groups) and found that the odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes.13   

On the other hand, a systematic review published in 2015 concluded that e-cigarettes appear to be an effective smoking cessation tool.14  A systematic review and meta-analysis of 2015 concluded that use of e-cigarettes is associated with smoking cessation and reduction. Products containing nicotine appeared to be more effective for cessation than those without nicotine.15 The Cochrane Collaboration published an updated review in 2016,16 and in line with their earlier findings,17 concluded that using an e-cigarette containing nicotine increased the chances of quitting in the long term compared to using an e-cigarette without nicotine. However, limitations with the data led to the authors’ rating their confidence in the results of the review as ‘low.’ Several other recent systematic reviews and meta-analyses have cautiously concluded that e-cigarettes may increase cessation, but also note the limited/low quality nature of the evidence.18-24 One suggests that existing studies’ methods and reporting are too different to reliably pool results and draw conclusions, and calls for larger and more uniform clinical trials.22   

One reason for the different patterns of finding in different reviews may result from differences among study participants in the intensity and duration of e-cigarette use: sustained8 and frequent25-28 e-cigarette users appear to be more likely to successfully quit than those who use the products short-term or intermittently. Infrequent e-cigarette users—who comprise the majority of users—may be less likely to quit, with research showing an association between non-daily use and both lower motivation to quit25 and lower rates of successful cessation.28   

Despite some manufacturers promoting e-cigarettes as a cessation aid, there is currently insufficient evidence to conclude that the products are helpful for quitting.12, 29    

18B.7.3 Cutting down as a step towards quitting

Large declines in daily consumption of conventional cigarettes in users of e-cigarettes have been noted in several studies,30, 31 and reviews.15, 17 However, evidence suggests that the health benefits of reducing consumption of conventional tobacco products are minimal.  Several large cohort studies have found that smokers who reduce their consumption do not significantly reduce their risk of premature death.32, 33 Smoking just 1–4 cigarettes per day significantly increases a person’s risk of dying from smoking-related disease.34 This lack of health benefits is often attributed to compensatory smoking: those who cut down tend to inhale each cigarette more deeply, and smoke more of it.35 (See Section 18.3 for further detail).

A number of studies have shown that dual use of NRT and cigarettes can help alleviate the issue of compensation,36-38 leading some to advocate for long-term use of NRT in combination with cutting down as a harm reduction strategy.39, 40 Researchers have suggested that it may be possible that the use of e-cigarettes while smoking could similarly reduce intake of nicotine and toxins from each cigarette. However, data on the long-term safety of e-cigarettes is lacking, and they may be less safe than existing, licenced NRT products.6   

The main benefit of cutting down seems to be its role as a step toward quitting.32, 41 While cutting down cigarettes may be a less effective strategy than going ‘cold turkey’,42 a 2015 review exploring the usefulness of cutting down determined that smokers who reduce the number of daily cigarettes smoked are more likely than smokers who do not cut down to attempt to quit and actually achieve smoking cessation. This is particularly the case when the quit attempt is combined with NRT.43 NRT-assisted reduction appears to be an effective intervention for achieving sustained smoking abstinence, particularly for smokers not currently intending to quit (or quit abruptly),44, 45 and is effective and cost effective compared to no quit attempt.41  E-cigarettes may similarly prove to be a useful form of NRT in combination with smoking reduction as part of ‘cutting down to quit’, but further research is needed on the efficacy of the products in this context.43   

18B.7.4 Modelling of net impact of use of e-cigarettes on smoking prevalence and tobacco-related disease

Given the uncertainty of the rapid increase in e-cigarette use on smoking behaviours and public health, researchers have attempted to model hypothetical scenarios and estimate possible outcomes. One study modelled the potential future effects of e-cigarette use on smoking behaviour and concluded that, based on current usage patterns, smoking prevalence appears to be far more sensitive to e-cigarette effects on smoking cessation than initiation. Results from the model suggested that if e-cigarettes increase both uptake and quitting of conventional cigarettes, the effects on uptake would have to be extremely large (i.e., increase over 200%) to offset even small cessation effects on population smoking prevalence.46   

Another study similarly concluded that a substantial gateway effect (of vaping to smoking by never smokers) or an increase in the magnitude of harms from e-cigarettes relative to cigarettes (or both) would be required before the harms to public health outweigh the benefits of e-cigarette uptake. The authors estimate a net public health benefit associated with e-cigarettes resulting in 21% fewer smoking-attributable deaths and a 20% reduction in life years lost.47   

Another study that modelled the potential health effects of increasing e-cigarette use concluded that—in order for there to be any benefits to public health—most e-cigarette users need to be current smokers interested in quitting or people who would have otherwise gone on to be smokers.  Other scenarios, such as e-cigarette use renormalising smoking, dual use, or significant uptake by young people (those young people who would otherwise never have smoked tobacco cigarettes) have the potential to increase population-level harm. The authors suggest that the likelihood of negative scenarios eventuating will ultimately depend on the regulatory environment, with benefits to public health being more probable with strict regulations on the sale, promotion, and use of the products; i.e., regulations that encourage use only by smokers, and only without simultaneous use of tobacco products.48   

Recent news and research

For recent news items and research on this topic, click here (Last updated March 2018)  

   

 

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