Original Research
27 March 2018

Association of E-Cigarette Use With Smoking Cessation Among Smokers Who Plan to Quit After a Hospitalization: A Prospective Study

Publication: Annals of Internal Medicine
Volume 168, Number 9

Abstract

Background:

Many smokers report using e-cigarettes to help them quit smoking, but whether e-cigarettes aid cessation efforts is uncertain.

Objective:

To determine whether e-cigarette use after hospital discharge is associated with subsequent tobacco abstinence among smokers who plan to quit and are advised to use evidence-based treatment.

Design:

Secondary data analysis of a randomized controlled trial. (ClinicalTrials.gov: NCT01714323 [parent trial])

Setting:

3 hospitals.

Participants:

1357 hospitalized adult cigarette smokers who planned to stop smoking, received tobacco cessation counseling in the hospital, and were randomly assigned at discharge to a tobacco treatment recommendation (control) or free tobacco treatment (intervention).

Measurements:

Self-reported e-cigarette use (exposure) was assessed 1 and 3 months after discharge; biochemically validated tobacco abstinence (outcome) was assessed 6 months after discharge.

Results:

Twenty-eight percent of participants used an e-cigarette within 3 months after discharge. In an analysis of 237 propensity score–matched pairs, e-cigarette users were less likely than nonusers to abstain from tobacco use at 6 months (10.1% vs. 26.6%; risk difference, −16.5% [95% CI, −23.3% to −9.6%]). The association between e-cigarette use and quitting varied between intervention patients, who were given easy access to conventional treatment (7.7% vs. 29.8%; risk difference, −22.1% [CI, −32.3% to −11.9%]), and control patients, who received only treatment recommendations (12.0% vs. 24.1%; risk difference, −12.0% [CI, −21.2% to 2.9%]) (P for interaction = 0.143).

Limitations:

Patients self-selected e-cigarette use. Unmeasured confounding is possible in an observational study.

Conclusion:

During 3 months after hospital discharge, more than a quarter of smokers attempting to quit used e-cigarettes, mostly to aid cessation, but few used them regularly. This pattern of use was associated with less tobacco abstinence at 6 months than among smokers who did not use e-cigarettes. Additional study is needed to determine whether regular use of e-cigarettes aids or hinders smoking cessation.

Primary Funding Source:

National Heart, Lung, and Blood Institute.

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Comments

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Robert Sklaroff, M.D., William Godshall, M.P.H., Stephen Gambescia, Ph.D. 1 June 2018
Smokers Should Be Encouraged to Vape
TO THE EDITOR:

An oblique attack upon the utility of e-cigarettes (1) fails to raise the intuitive and profound procedural flaws in both the study-methodology and the results-assessment; incomplete disclaimers in the discussion section yield only the boiler-plate conclusion that “more research is necessary” when exhaustive support for Electronic Nicotine Delivery Devices (“ENDS”) has already been established, both over the years (2) and recently (3).

Indeed, it was oxymoronic to draw any conclusions regarding the efficacy of ENDS when their potential use by smokers was overtly poisoned in the stated methodology: “Counselors did not recommend e-cigarettes to smokers; rather, when asked, they advised that the safety and efficacy of e-cigarettes were unknown, and they encouraged smokers to use tobacco cessation medications approved by the U.S. Food and Drug Administration (FDA).”

The outcome was further skewed by the provision of “sustained” smoking cessation counseling (that promotes Big Pharma drugs and opposes vaping) and free Big Pharma drugs; absent was any gesture to teach any patients (neither the aforementioned nor the “standard care” cohort) how to vape, let alone to provide ENDS paraphernalia or to encourage attempts in this arena.

Furthermore, omitted was the fact that workplace vaping (including in hospitals) had been banned in Massachusetts in 2011 and at the University of Pittsburgh Medical Center a year hence.

These selection-bias flaws are notably glaring because the prospective design was primarily, allegedly directed at assessing the efficacy of ENDS; presumably, smokers were to vape only if they stumbled upon hearing of its potential utility and chose to contravene recently-delivered inpatient admonitions.

The negative impact of the publication of such studies is illustrated by having accompanied this academic article by a patient-handout that would predictably dissuade smokers from even trying to vape; it is amplified when the results are misrepresented by claims that “smokers who use e-cigarettes are significantly less likely to quit” (4).

The study simply shows that smokers who didn’t stop smoking by following recommended treatments may have been more likely to try ENDS than those who quit successfully; no data allow for the assessment of the efficacy of ENDS.

It is oxymoronic to withhold a recognized and effective cessation-method due to stated-intent to await the analysis of studies that could not be completed for years, if not decades (5), particularly when the investigators fail to ensure the smokers are apprised—in a “fair and balanced” fashion—of the desirability of risk-reduction.

1. Rigotti NA, et al. Association of E-Cigarette Use With Smoking Cessation Among Smokers Who Plan to Quit After a Hospitalization: A Prospective Study. Ann Intern Med. 2018;168(9):613-620. [DOI: 10.7326/M17-2048].

2. Godshall B. THR Updates. Accessed at http://www.ecigarette-politics.com/bill-godshall-thr-updates.html on 5/28/2018.

3. McNeill A, Brose LS, Calder R, Bauld L & Robson D. E-cigarettes and heated tobacco products: evidence review. Public Health England (Last updated 3/2/2018). Accessed at https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review on 5/28/2018.

4. Glantz S. 18th Study Shows that Smokers Who Use E-cigs Are Significantly Less Likely to Quit Smoking. UCSF Center for Tobacco Research Control & Education. Accessed at https://tobacco.ucsf.edu/18th-study-shows-smokers-who-use-e-cigs-are-significantly-less-likely-quit-smoking

5. Sklaroff, R., Godshall, W., & Gambescia, S. F. (17 March 2017). Vaping isn't smoking, it's a disease prevention method. The Hill. http://thehill.com/blogs/pundits-blog/healthcare/324534-vaping-should-be-recognized-as-a-disease-prevention-public

Disclosures: No conflicts

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 168Number 91 May 2018
Pages: 613 - 620

History

Published online: 27 March 2018
Published in issue: 1 May 2018

Keywords

Authors

Affiliations

Nancy A. Rigotti, MD
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (N.A.R., Y.C., S.M.K., D.E.L., S.R., D.E.S.)
Yuchiao Chang, PhD
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (N.A.R., Y.C., S.M.K., D.E.L., S.R., D.E.S.)
Hilary A. Tindle, MD, MPH
Vanderbilt University School of Medicine, Nashville, Tennessee (H.A.T.)
Sara M. Kalkhoran, MD, MAS
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (N.A.R., Y.C., S.M.K., D.E.L., S.R., D.E.S.)
Douglas E. Levy, PhD
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (N.A.R., Y.C., S.M.K., D.E.L., S.R., D.E.S.)
Susan Regan, PhD
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (N.A.R., Y.C., S.M.K., D.E.L., S.R., D.E.S.)
Jennifer H.K. Kelley, RN, MA
Massachusetts General Hospital, Boston, Massachusetts (J.H.K.)
Esa M. Davis, MD, MPH
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (E.M.D.)
Daniel E. Singer, MD
Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (N.A.R., Y.C., S.M.K., D.E.L., S.R., D.E.S.)
Acknowledgment: The authors thank Tim Gomperts for assistance with manuscript preparation and their research staff for assistance in conducting the study.
Grant Support: By grant R01-HL11821 from the National Heart, Lung, and Blood Institute of the National Institutes of Health.
Disclosures: Dr. Rigotti reports a grant and nonfinancial support from Pfizer and personal fees from UpToDate outside the submitted work. Dr. Kalkhoran reports personal fees from UpToDate outside the submitted work. Dr. Singer reports personal fees from Pfizer outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2048.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement: Study protocol, statistical code, and data set: Available through written agreement with the authors (e-mail, [email protected]).
Corresponding Author: Nancy Rigotti, MD, Tobacco Research and Treatment Center, Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA 02114; e-mail, [email protected].
Current Author Addresses: Drs. Rigotti, Chang, Kalkhoran, Levy, Regan, and Singer and Ms. Kelley: Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, Suite 1600, Boston, MA 02114.
Dr. Tindle: Vanderbilt Division of General Internal Medicine and Public Health, 2525 West End Avenue, Suite 370, Nashville, TN 37203.
Dr. Davis: University of Pittsburgh Medical Center, 230 McKee Place, Suite 600, Pittsburgh, PA 15213.
Author Contributions: Conception and design: N.A. Rigotti, Y. Chang, H.A. Tindle.
Analysis and interpretation of the data: N.A. Rigotti, Y. Chang, H.A. Tindle, S.M. Kalkhoran, D.E. Levy, D.E. Singer.
Drafting of the article: N.A. Rigotti, Y. Chang.
Critical revision of the article for important intellectual content: N.A. Rigotti, Y. Chang, H.A. Tindle, S.M. Kalkhoran, D.E. Levy, S. Regan, E.M. Davis, D.E. Singer.
Final approval of the article: N.A. Rigotti, Y. Chang, H.A. Tindle, S.M. Kalkhoran, D.E. Levy, S. Regan, J.H.K. Kelley, E.M. Davis, D.E. Singer.
Provision of study materials or patients: H.A. Tindle, J.H.K. Kelley, E.M. Davis.
Statistical expertise: Y. Chang.
Obtaining of funding: N.A. Rigotti, H.A. Tindle.
Administrative, technical, or logistic support: H.A. Tindle, J.H.K. Kelley.
Collection and assembly of data: N.A. Rigotti, H.A. Tindle, S. Regan, E.M. Davis.
This article was published at Annals.org on 27 March 2018.

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Nancy A. Rigotti, Yuchiao Chang, Hilary A. Tindle, et al. Association of E-Cigarette Use With Smoking Cessation Among Smokers Who Plan to Quit After a Hospitalization: A Prospective Study. Ann Intern Med.2018;168:613-620. [Epub 27 March 2018]. doi:10.7326/M17-2048

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