Disclosures: Pechacek reports no relevant financial disclosures. Hays reports no relevant financial disclosures.
February 24, 2020
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Are e-cigarettes a viable tool to help patients with cancer quit smoking?

Disclosures: Pechacek reports no relevant financial disclosures. Hays reports no relevant financial disclosures.
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Click here to read the Cover Story, “Smoking cessation should be ‘pillar’ of the cancer treatment protocol.”

POINT

Maybe, when combined with behavioral support.

Any smoker who has been diagnosed with cancer should quit smoking completely as soon as possible. Quitting smoking increases the potential to more effectively treat the cancer, not only in the most common smoking-related sites, such as the lungs and throat, but also all other sites, including the breast and colon.

Terry Frank Pechacek
Terry Frank Pechacek

Although e-cigarettes are not currently approved by the FDA as a smoking cessation aid, health experts suggest that e-cigarettes may help nonpregnant adult smokers when used as a complete substitute for all cigarettes and other smoked tobacco products.

However, the evidence from the few published studies evaluating e-cigarettes as a smoking cessation aid is mixed or insufficient. For instance, in a viewpoint on this topic, Bhatnagar and colleagues cited study data showing that use of e-cigarettes did not increase tobacco abstinence at 6-month follow-up among 1,357 hospitalized adult smokers who planned to stop smoking and received counseling in the hospital. However, they also cited a study showing that e-cigarette use was associated with reduced smoking among 1,263 highly nicotine-dependent, young adult cigarette smokers.

If a patient with cancer wants to use e-cigarettes rather than an FDA-approved smoking cessation aid, the quit attempt should also involve a quality smoking cessation resource, like the programs at all high-quality comprehensive cancer centers or www.smokefree.gov. In addition to the telephone counseling quit line, this website offers 24/7 support with an app for smartphones. Apps such as these offer help based upon an individual’s patterns of smoking, moods, motivation to quit and personal quitting goals.

Trials have shown that this type of additional assistance significantly increases the likelihood of successfully quitting the use of cigarettes and other smoked tobacco products. In a trial published in The New England Journal of Medicine, Hajek and colleagues in the U.K. showed that when accompanied by behavioral support, e-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, as demonstrated by a greater abstinence rate at 1 year (18% vs. 9.9%; RR = 1.83; 95% CI, 1.3-2.58). However, in the U.S., Rigotti and colleagues found that among hospitalized smokers who used e-cigarettes to help them quit, even with smoking cessation counseling, fewer successfully quit at 6 months after discharge than nonusers (10.1% vs. 26.6%; risk difference, –16.5%; 95% CI, –23.3 to 9.6). Additionally, several studies suggest that most smokers who attempt to quit on their own using e-cigarettes continue to smoke and only use e-cigarettes as a substitute for cigarettes, which evidence suggests may not reduce the risk for cancer.

References:

Bhatnagar A, et al. J Am Heart Assoc. 2019;doi:10.1161/JAHA.119.012742.

Croyle RT, et al. N Engl J Med. 2019;doi:10.1056/NEJMp1813913.

Hajek P, et al. N Engl J Med. 2019;doi:10.1056/NEJMoa1808779.

Rigotti NA, et al. Ann Intern Med. 2018;doi:10.7326/M17-2048.

Weaver SR, et al. PLoS One. 2018;doi:10.1371/journal.pone.0198047.

Terry Frank Pechacek, PhD, is research professor of health management and policy in the department of health policy and behavioral sciences at Georgia State University School of Public Health. He can be reached at tpechacek@gsu.edu. Disclosure: Pechacek reports no relevant financial disclosures.

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COUNTER

Based on evidence, the answer is: “We do not know.”

E-cigarettes have been used in only a few clinical trials in general populations of cigarette smokers and not among those with a known cancer. E-cigarettes have shown some promise for helping smokers quit, with effects similar to nicotine-replacement therapy. In the United Kingdom — where e-cigarettes are much better regulated than they are in the United States — the National Health Service has reported a general decline in cigarette smoking prevalence. This may be due, in part, to the availability of regulated e-cigarette products and encouragement from the National Health Service to use these products to aid in smoking cessation.

J. Taylor Hays, MD
J. Taylor Hays

In the United States, observational data suggest that most adults who use e-cigarettes also are using standard cigarettes — and thus are dual users — and probably do not gain significant benefit because they are still exposed regularly to tobacco smoke. Using data from the 2016 Behavior Risk Factor Surveillance System, Mirbolouk and colleagues found that among 15,240 current e-cigarette users, most (54.6%) currently smoked cigarettes, whereas only 30.4% were former cigarette smokers and 15% never smoked cigarettes.

In addition, observational studies in general populations of cigarette smokers have suggested that people who use e-cigarettes while trying to quit smoking are more likely to use cigarettes at some follow-up point than those who try to quit smoking without using e-cigarettes. A study by Borderud and colleagues showed that, of 1,074 patients with cancer who smoked, e-cigarette users were twice as likely to be smoking at follow-up as nonusers in an intention-to-treat analysis (OR = 2; 95% CI, 1.2-3.3). National Comprehensive Cancer Network guidelines state there is insufficient evidence to recommend e-cigarettes for patients with cancer as part of smoking cessation efforts, alone or in combination with evidence-based smoking cessation methods.

Strong evidence collected for many years shows that behavioral therapy combined with use of approved smoking cessation medications results in smoking quit rates that are superior to any other approach. My advice to a person who has cancer and is committed to quitting is to use approved medications along with effective behavioral therapy provided by a counselor in person, by telephone or by digital connection, such as live chat. If counseling resources are not available, online resources can be helpful in developing a quit plan when combined with medication.

Further, because we do not know the cause of e-cigarette- or vaping-associated lung injuries (EVALI) and about 10% to 20% of patients with EVALI do not report using THC containing e-liquids, there remains concern that some nicotine-containing e-liquids may cause acute lung injury. There also is concern that people exposed regularly to nicotine e-cigarettes may experience long-term low-grade injury that could lead to chronic lung disease.

References:

Al-Delaimy WK, et al. Am J Public Health; 2015;doi:10.2105/AJPH.2015.302896.

Borderud SP, et al. Cancer. 2014;doi:10.1002/cncr.28811.

Ellington S, et al. MMWR Morb Mortal Wkly Rep. 2020;doi:10.15585/mmwr.mm6902e2.

Hajek P, et al. N Engl J Med. 2019;doi:10.1056/NEJMoa1808779.

Mirbolouk M, et al. Ann Intern Med. 2018;doi:10.7326/M17-3440.

National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Smoking Cessation. Version 2. 2019.

NHS Digital. Statistics on Smoking, England – 2019. Available at: digital.nhs.uk/data-and-information/publications/statistical/statistics-on-smoking/statistics-on-smoking-england-2019. Accessed Jan. 22, 2020.

J. Taylor Hays, MD, is an internal medicine specialist at Mayo Clinic in Rochester, Minnesota. He can be reached at hays.taylor@mayo.edu. Disclosure: Hays reports no relevant financial disclosures.