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Thursday, November 16, 2017

Comments

Yes it can and it does. Vaping is probably the most successful quitting aid out there, especially when paired with the proper support. Far too many people in the anti-smoking lobby are letting perfect be the enemy of good enough.

Using nicotine to stop using nicotine makes no sense

Thank you for this posting, Bill. You are certainly grappling with tough questions where the evolution of evidence, and its application to practice, is subject to an array of interpretations.

I'm not sure, however, how to reconcile your characterization of the conclusions of the Cochrane Review ("The evidence doesn’t support using electronic cigarettes to quit smoking (Hartmann-Boyce et al., 2016)") with their actual conclusions:

"Authors' conclusions:
There is evidence from two trials that ECs help smokers to stop smoking in the long term compared with placebo ECs. However, the small number of trials, low event rates and wide confidence intervals around the estimates mean that our confidence in the result is rated 'low' by GRADE standards. The lack of difference between the effect of ECs compared with nicotine patches found in one trial is uncertain for similar reasons. None of the included studies (short- to mid-term, up to two years) detected serious adverse events considered possibly related to EC use. The most commonly reported adverse effects were irritation of the mouth and throat. The long-term safety of ECs is unknown. In this update, we found a further 15 ongoing RCTs which appear eligible for this review." (http://www.cochrane.org/CD010216/TOBACCO_can-electronic-cigarettes-help-people-stop-smoking-and-are-they-safe-use-purpose)

Certainly Cochrane's conclusions are guarded and qualified, but in my mind, they certainly lean towards recommending ecigs for smoking cessation.

And it is obviously not answerable, but I wonder how the coach might have pursued his quit attempt if you had provided him with this link from the UK National Health Service?

https://www.nhs.uk/smokefree/help-and-advice/e-cigarettes

Disclosures:
My employer, PinneyAssociates, provides consulting services on tobacco harm minimization (including nicotine replacement therapy and vapor products) to Niconovum USA, RJ Reynolds Vapor Company, and RAI Services Company, all subsidiaries of Reynolds American Inc. In the past three years, PinneyAssociates has consulted to NJOY on electronic cigarettes. I also own an interest in intellectual property for a novel nicotine medication.

I'd like to respond to the thoughtful comments posted by Jgitchell.

Thanks for commenting, Joe. I appreciate your careful attention to this post and time you took to engage with me. As you note, we're caught in an interesting and exciting time that could transform tobacco control as we know it. At the same time, the rapidly evolving state of the science makes it challenging to know what to do - both from practitioner and consumer perspectives. I'm pretty sure that all of us share the same goal of wanting to reduce the death and disease caused by tobacco smoking. And many of us have struggled for years with patients, friends, and family members who have tried many times to quit and ultimately not been successful. I believe that any new and innovative treatment deserves a fair chance to prove that it can help - and I hold no inherent bias one way or the other. If it works - great, let's deploy with great fanfare and minimal fuss.

My goal in this piece was to highlight the struggles that I face on a regular basis with what to recommend to people who ask for my advice on how to quit, and to offer concrete options for people who want to quit. I tend to be very conservative with my clinical recommendations, and am most comfortable with referring people to solid evidence-based recommendations (hence my suggestion that the coach at least consider treatment options that have a long, and rigorous science base to support them). My reading of the Cochrane review is less optimistic than your reading, largely because the quality of evidence so far is substandard and because more high quality studies are needed. I'd want to see see a larger body of evidence from high quality RCTs before I start recommending vaping as a way to quit. I thought my piece was very careful to acknowledge that vaping poses less harms than combustible cigarettes (this seems very clear) and that the evidence base was evolving and could change my recommendations if asked again.

My hope is that I'll be able to recommend a wider variety of options to anyone that asks in the near future - but I'll wait to see where the balance of evidence takes me before moving too far in any one direction. Is this too conservative an approach? Maybe - but I think the consequences are too great from recommending largely unproven (unproven because not enough high quality studies have been conducted to show positive effects) treatments too early. Thanks again!

Bill - I hope you'll indulge a few more thoughts from me as they hit me after reading your reply to my post.

First, I'm not sure I understand your point as to how our "readings" of Cochrane differ. I quoted the authors' conclusions, not an interpretation of their review. So is your point that their acknowledged uncertainty is so great, even though the available RCT-evidence points towards the products helping, that you just won't accept their conclusion?

Second, there are other supporting arguments of the potential utility of these products* for helping people quit.

The fact that they deliver nicotine to the blood and in much the same if not higher levels as NRT products (https://www.ncbi.nlm.nih.gov/pubmed/28070620) would seem to move your Bayesian priors towards assuming that they would help (given the evidence base supporting NRT for cessation; http://www.cochrane.org/CD000146/TOBACCO_can-nicotine-replacement-therapy-nrt-help-people-quit-smoking. NB: This is not an original argument from me. Deborah Arnott expressed this most clearly at the US E-Cig Summit in May and I bet it is spelled out in the RCP2016 or somewhere else but I haven't bothered to track it down).

Population-level analyses that don't have all/most of the limitations of the studies cited by Kalkhoran and Glantz in their review are consistent with the products increasing cessation (eg https://www.ncbi.nlm.nih.gov/pubmed/24846453, https://www.ncbi.nlm.nih.gov/pubmed/25301815, https://www.ncbi.nlm.nih.gov/pubmed/28747333, https://www.ncbi.nlm.nih.gov/pubmed/28802179, https://www.ncbi.nlm.nih.gov/pubmed/29059341, and much more feeble (driven by its first author's limitations...) and not as directly related, but I can't resist the self-promotion: https://www.ncbi.nlm.nih.gov/pubmed/27933678). Do you view this evidence as informing the coach's question?

I look forward to your further thoughts, Bill. Thank you.

*It is fair and important to acknowledge that the wide variety of products and liquids has an array of impacts--it offers lots of choices to consumers, but it also means that it is much tougher to generalize to "e-cigarettes" as one might to "nicotine gum".

Disclosures:
My employer, PinneyAssociates, provides consulting services on tobacco harm minimization (including nicotine replacement therapy and vapor products) to Niconovum USA, RJ Reynolds Vapor Company, and RAI Services Company, all subsidiaries of Reynolds American Inc. In the past three years, PinneyAssociates has consulted to NJOY on electronic cigarettes. I also own an interest in intellectual property for a novel nicotine medication.

I know that I'm a bit like a dog with a bone on this stuff, Bill, but with that confession stated, have you seen these two recent pieces in Addiction? I found the commentary provocative and the review paper essentially renders null and void the Kalkhoran & Glantz 2016 citation you used to support your "evidence is mixed" conclusion.

Do you agree? If not, why not? And if yes, would you consider changing anything in your initial post?

Weier M. Moving beyond vaping as a cessation-only practice - http://onlinelibrary.wiley.com/doi/10.1111/add.14095/full

Villanti et al. How do we determine the impact of e-cigarettes on cigarette smoking cessation or reduction? Review and recommendations for answering the research question with scientific rigor - http://onlinelibrary.wiley.com/doi/10.1111/add.14020/abstract

Disclosures:
My employer, PinneyAssociates, provides consulting services on tobacco harm minimization (including nicotine replacement therapy and vapor products) to Niconovum USA, RJ Reynolds Vapor Company, and RAI Services Company, all subsidiaries of Reynolds American Inc. In the past three years, PinneyAssociates has consulted to NJOY on electronic cigarettes. I also own an interest in intellectual property for a novel nicotine medication.

Thanks again for staying engaged with this piece, Joe. These articles make interesting points - I think the framework provided by Villanti et al. could be useful. My main point is that the balance of evidence from high quality RCTs does not (yet) support the use of vaping as a cessation tool - I'd like to see more than three RCTs and more data on longer term safety before making any recommendations to smokers that want to quit. It would also be nice to have some standardization of ingredients, delivery mechanics, and dosing with e-cigarettes or vaping devices before doing so. I realize that smokers say that they can and have quit smoking with these devices - anecdotal evidence and self-report correlational studies seem to support this assertion - but my evidence-based clinical recommendations remain as stated in the original essay. I don't think our RCT standards for evidence-based treatment - those that have been used for years and with other treatments for any number of disorders - should change for e-cigarettes.

I really hope to hope to reach a different conclusion in a year or two or three as the results of additional studies are published. But for the time being, I'll refer to the 2008 public health guidelines (Fiore et al., 2008).

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