Electronic cigarettes in physician practice: a complex debate

Abstract

E‐cigarettes, or electronic nicotine delivery systems (ENDS), have been suggested as a potential aid for smoking cessation, but many questions about their efficacy and safety remain unanswered. Until very recently, the evidence for ENDS in smoking cessation was largely based on observational studies or randomised controlled trials with methodological flaws and did not provide adequate evidence to support strongly ENDS for smoking cessation. Concerns about the uptake of ENDS by nonsmoking populations (such as adolescents) remain. More recent evidence may indicate the effect of ENDS in smoking cessation, but many questions remain unanswered. In this article, we address recent claims that failure to recommend ENDS for smoking cessation represents unethical practice. We strongly dispute this claim, analysing the many complex issues that clinicians working in smoking cessation should consider.

Prevalence and correlates of receipt by smokers of general practitioner advice on smoking cessation in England: a cross‐sectional survey of adults

“…NRT bought over‐the‐counter) [ 14 ]. However, whether health professionals should be recommending e‐cigarettes to smokers remains an issue of some debate in the medical community [ 17 , 18 ], with clinicians unaware or unconvinced by the evidence on efficacy and concerned by possible long‐term health effects [ 19 , 20 ]. Several organizations in the United Kingdom, including Public Health England, the Royal College of Physicians and the Royal College of General Practitioners, now recommend that clinicians give advice on e‐cigarettes as one option to help their patients quit smoking [ 20 ].…”

A narrative review evaluating the safety and efficacy of e-cigarettes as a newly marketed smoking cessation tool

“…This is an important point as e-cigarettes have bypassed the usual manner of phased trials to licensing and as such there is ongoing work to try and understand the place that they may have within public health. 19…”

“…Overall, this result seems to offer some basis for e-cigarette use possibly in the context of tailored support in reducing tobacco consumption. 19 In the Efficiency and Safety of an ECLAT trial that involved 300 current smokers with no intention to quit, participants were randomised between 7.2 mg/5.4 mg e-cigarettes and non-nicotine cigarettes; the results showed decreased cigarette consumption (confirmed by self-assessment and eCO measurement) and sustained abstinence but was once again limited by its small study size and not significant size effect. 12 Furthermore, a Cochrane systematic review suggested that the small number of RCTs and wide confidence intervals meant that no definitive conclusion could be made but did show that patients would likely reduce consumption when using e-cigarettes.…”

“…Cross-sectional studies have shown that youths who engage in e-cigarette use are two to four times more likely to smoke tobacco-based cigarettes in later life, with one 2017 meta-analysis estimating that the pool OR of smoking initiation was 3.62 between ever versus never e-cigarette use. 19,57…”

“…This is an important point as e-cigarettes have bypassed the usual manner of phased trials to licensing and as such there is ongoing work to try and understand the place that they may have within public health. 19 When considering the toxicity profile of e-cigarettes, it is important to consider that the contents of the 'e-liquids' is seldom characterised or disclosed by the manufacturers. Moreover, it has been noted that significant e-liquid variation exists within units of the same manufacturer including reported nicotine content; with nicotine contents of >100 mg/ mL freely available for purchase.…”