We all know how extremely serious the problem of smoking is and we know about the many bad things that can happen due to cigarette smoking. Half of the people who are regular and long-term smokers will die from smoking-related causes.
For us as mental health clinicians, what is worse is that people with mental health problems are significantly more likely to be smokers than those without mental health problems.
So, it is very important that we should:
1. Routinely ask all our patients whether they smoke
2. Either provide treatment for tobacco use disorder ourselves or refer the patient to a good tobacco use disorder treatment program.
The problem with nicotine replacement therapy
One important pillar of smoking cessation treatment is the provision of an alternative, safer way of taking nicotine.
When nicotine replacement therapy was introduced in the 1980s, it was thought that it would solve the problem of cigarette addiction because it was a safer way of providing what people were smoking cigarettes for (Rose, 2006). But, we all know that the results of nicotine replacement therapy alone are not great.
Let’s think about why that is. Perhaps because smoking cigarettes is associated with several characteristics that are not present with most nicotine replacement therapies. Cigarette smoking is associated with:
1. Repeated, quick spikes in the nicotine content of the blood that are very reinforcing (Rose, 2006).
2. Sensory cues–taste, smell, tracheobronchial sensations (Rose, 2006)
3. Motor cues–taking out the cigarette, handling it, lighting it, puffing on it, inhaling the smoke (Rose, 2006).
4. Other behavioral factors–taking a break from whatever the person was doing, smoking with someone else, etc.
Of course, nicotine is the most important reinforcing factor in cigarette smoking and these sensory, motor, and behavioral cues are reinforcing in part due to having become associated with nicotine (Rose, 2006).
But the fact is that if all we do is provide nicotine replacement of some kind, we are failing to realize that the sensory, motor, and behavioral cues associated with smoking are as important in addiction to cigarette smoking as nicotine is.
This is probably why electronic cigarettes (e-cigarettes) are appealing to patients–because they not only provide nicotine but also involve many of these other factors associated with smoking cigarettes. Some e-cigarettes even have a light at their end to simulate the glow of a cigarette!
Several million people are dying each year from cigarette smoking. Whether we like it or not, e-cigarette use has become widespread and huge numbers of people are seeking them out for smoking cessation. So, as mental health clinicians, we cannot avoid learning about them.
On another page on this website, we’ll discuss the potential risks of e-cigarettes including use by teenagers, potential toxicity of the liquids they use, etc. But on this page, let’s first look just at the question of whether or not cigarettes work for smoking cessation.
Do e-cigarettes work for smoking cessation?
A systematic review of the use of electronic cigarettes containing nicotine for facilitating smoking cessation (Hartmann-Boyce et al., 2016) included three randomized controlled clinical trials and 21 cohort studies.
In randomized controlled trials, when electronic cigarettes containing nicotine were compared to electronic cigarettes that did not contain nicotine as the control group, patients who received electronic cigarettes containing nicotine were more than twice as likely to quit smoking for six months or more.
But, the percentage of patients who completely stop smoking for six months or more was only 9% (versus 4% with the electronic cigarettes that did not contain nicotine).
Another meta-analysis included both randomized, controlled clinical trials and other studies, a total of 14 studies in which over 35,000 smokers participated (Liu et al., 2018). In this broader pool, the efficacy of e-cigarettes for smoking cessation varied from 13% to 23%, that is, higher than in the randomized controlled trials.
E-cigarettes versus nicotine replacement therapy
In the section above, we said that e-cigarettes with nicotine are more effective than a “placebo cigarette,” i.e., ones that don’t contain nicotine. But, for clinicians, a more important question is—how does the effectiveness of e-cigarettes for smoking cessation compare to that of conventional nicotine-replacement therapy?
A large randomized, controlled clinical trial to answer this question (Hajek et al., 2019) compared refillable e-cigarettes that used an e-liquid with a nicotine concentration of 18 mg/mL to conventional nicotine-replacement products. Participants randomized to conventional nicotine-replacement therapy to choose from various products (patch, gum, lozenge, nasal spray, inhalator, mouth spray, mouth strip, and microtabs). They were encouraged to use more than one product; a commonly used combination was that of a nicotine patch and a faster-acting oral product. All participants were also provided behavioral support.
The results of this study were made more generalizable to the real world by providing the participants with only an initial supply of product for about three months and then asking them to buy their own. Also, the main outcome measure was sustained abstinence for one year. As we all know, it is much easier to stop smoking for a shorter period than to be abstinent after one year.
This study found that a statistically significant difference in the rates of sustained abstinence for one year–18% in those randomized to e-cigarettes and 10% in those randomized to conventional nicotine-replacement products.
So, e-cigarettes not only work but they work better than conventional nicotine replacement products.
Note: This statement has nothing to do misuse of e-cigarettes, its marketing to teenagers, etc, etc. We are only talking here about the use of e-cigarettes for smoking cessation as part of a treatment program.
The randomized controlled clinical trial comparing the efficacy of e-cigarettes versus conventional nicotine-replacement products (Hajek et al., 2019) also had several relevant secondary findings.
Of those who had sustained abstinence for one year, 3% of those assigned to e-cigarettes switched on their own to nicotine-replacement products and 20% of those assigned to nicotine-replacement products switched on their own to e-cigarettes. When these participants who had switched to the other type of treatment were excluded from the analysis, the advantage of e-cigarettes was even greater–18% versus 8%.
What about those who reduced their smoking significantly but did not stop completely? The percentages of participants who reduced their smoking by 50% or more during the period between 6 months and one year after starting the study but were not abstinent were 13% for e-cigarettes and 7% for conventional nicotine-replacement products.
Participants reported that neither e-cigarettes nor nicotine-replacement products were as satisfying as regular cigarettes. But, e-cigarettes were reported to be more satisfying and as more helpful in staying abstinent from smoking.
Of those who were abstinent from smoking for one year, 80% were still using e-cigarettes while only 9% were still using nicotine-replacement products. The authors noted that this raises concern that some participants may end up using e-cigarettes longer-term.
Can e-cigarettes be a stepping stone to quitting cigarettes in the future?
What about reduction in cigarette smoking even if the person doesn’t stop completely?
Important! Cutting down on the number of cigarettes smoked per day is NOT an acceptable long-term strategy. There are many reasons for this. For example, people who cut down on the number of cigarettes they smoke, typically end up altering how they smoke–more frequent puffs, deeper inhalation, holding the smoke in, etc. It has not been clearly shown that reducing the number of cigarettes smoked per day significantly reduces the health risks of smoking.
BUT–if a person is not motivated to stop smoking right now but plans to quit in the future, reducing the number of cigarettes smoked has been shown to work in some patients as a stepping stone for quitting in the future (Begh et al., 2015).
The percentage of persons who reduced the number of cigarettes they smoked after e-cigarettes were given was 48% to 59% (Liu et al., 2018). But, it is very important to note the cutting down on cigarette smoking is only recommended as a stepping stone to eventually quitting.
There is some limited data that reducing the number of cigarettes smoked by adding electronic cigarettes may be helpful for longer-term smoking cessation in persons who are not motivated to completely stop smoking right now.
The data supporting the use of e-cigarettes as an effective, and perhaps the most effective form of pharmacological intervention for the treatment of tobacco dependence is strong and continues to grow.
E-cigarettes can be thought of as “smoking replacement” rather than just “nicotine replacement” (Hajek, 2015).
We need to remember that an incredible number of people die or are disabled every year due to smoking and that current smoking cessation treatments have limited efficacy. So, we probably need to use multiple interventions in combination.
Also, as in all addictive disorders, we need to be willing to accept “harm reduction” until complete abstinence can be achieved. Agree? Please post your thoughts and experiences under “Leave a Reply” at the bottom of this page.
Are varenicline (Chantix) and bupropion safe for smoking cessation in persons with mental disorders?
Begh R, Lindson-Hawley N, Aveyard P. Does reduced smoking if you can’t stop make any difference? BMC Med. 2015 Oct 12;13:257. PubMed PMID: 26456865; PubMed Central PMCID: PMC4601132.
Franks AS, Sando K, McBane S. Do Electronic Cigarettes Have a Role in Tobacco Cessation? Pharmacotherapy. 2018 May;38(5):555-568. Review. PubMed PMID: 29573440.
Hajek P. The development and testing of new nicotine replacement treatments: from ‘nicotine replacement’ to ‘smoking replacement’. Addiction. 2015 Jul;110 Suppl 2:19-22. PubMed PMID: 26042563.
Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, Li J, Parrott S, Sasieni P, Dawkins L, Ross L, Goniewicz M, Wu Q, McRobbie HJ. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019 Jan 30. [Epub ahead of print] PubMed PMID: 30699054.
Hartmann-Boyce J, Begh R, Aveyard P. Electronic cigarettes for smoking cessation. BMJ. 2018 Jan 17;360:j5543. Review. PubMed PMID: 29343486.
Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev. 2016 Sep 14;9:CD010216. Review. PubMed PMID: 27622384.
Hickling LM, Perez-Iglesias R, McNeill A, Dawkins L, Moxham J, Ruffell T, Sendt KV, McGuire P. A pre-post pilot study of electronic cigarettes to reduce smoking in people with severe mental illness. Psychol Med. 2018 Jul 10:1-8. [Epub ahead of print] PubMed PMID: 29986786.
Lindson-Hawley N, Hartmann-Boyce J, Fanshawe TR, Begh R, Farley A, Lancaster T. Interventions to reduce harm from continued tobacco use. Cochrane Database Syst Rev. 2016 Oct 13;10:CD005231. Review. PubMed PMID: 27734465.
Liu X, Lu W, Liao S, Deng Z, Zhang Z, Liu Y, Lu W. Efficiency and adverse events of electronic cigarettes: A systematic review and meta-analysis (PRISMA-compliant article). Medicine (Baltimore). 2018 May;97(19):e0324. Review. PubMed PMID: 29742683; PubMed Central PMCID: PMC5959444.
Rose JE. Nicotine and nonnicotine factors in cigarette addiction. Psychopharmacology (Berl). 2006 Mar;184(3-4):274-85. Review. PubMed PMID: 16362402.
Sharma R, Gartner CE, Castle DJ, Mendelsohn CP. Should we encourage smokers with severe mental illness to switch to electronic cigarettes? Aust N Z J Psychiatry. 2017 Jul;51(7):663-664. PubMed PMID: 28633573.
Last updated February 2019.
Copyright © 2018, 2019 Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.
Disclaimer: The content on this website is provided as general education for medical professionals. It is not intended or recommended for patients or other lay persons or as a substitute for medical advice, diagnosis, or treatment. Patients must always consult a qualified health care professional regarding their diagnosis and treatment. Healthcare professionals should always check this website for the most recently updated information.