Review of: Auer R et al, N Engl J Med 2024;390:601–610

Study type: Randomized open-label controlled trial

E-cigarettes, devices resembling cigarettes that mimic many aspects of cigarette smoking, are increasingly used as aids for smoking cessation. A recent study found that they are more effective compared to nicotine replacement therapy (NRT), but it is unclear how they compare to smoking-cessation counseling (Hajek P et al, N Engl J Med 2019;380(7):629–637). 

This study enrolled 1,246 adults who smoked 5 or more cigarettes per day. All participants received standard-of-care smoking-cessation counseling with cognitive behavioral therapy, motivational interviewing, and shared decision-making around smoking cessation medications (eg, NRT, varenicline, bupropion). In addition, participants were randomly assigned to one of two groups: an intervention group that received free e-cigarettes or a control group that received a cash voucher. The primary outcome was biochemically validated, continuous abstinence from tobacco smoking at six months. 

Interestingly, participants in the e-cigarette group were more likely to be abstinent from cigarette smoking than the control group, but less likely to be abstinent from nicotine altogether. At six months, 28.9% of the participants in the intervention group achieved continuous abstinence from smoking, compared to 16.3% of the control group (relative risk 1.77; 95% confidence interval 1.43–2.20). However, abstinence from nicotine products was 20.1% in the intervention group compared to 33.7% in the control group. Researchers noted that many participants in the intervention group continued to use e-cigarettes even after quitting smoking. 

Carlat Take
In this study, e-cigarettes helped people quit smoking tobacco cigarettes when added to standard-of-care ­smoking-cessation counseling, though some may end up using e-cigarettes as a smoking replacement rather than as a tool to quit nicotine altogether. However, since e-cigarettes are almost certainly less harmful than tobacco smoking, they are worth considering, especially for patients who do not find success with FDA-approved medications.