Study Says: E-Cigarette’s Don’t Help People Quit Smoking
New Study on Cancer Patients & E-Cigs
A study was released on Monday which followed cancer patients who had a desire to quit smoking over the course of one year. In this study, over 1,000 patients were enrolled in a tobacco treatment program. Patients were followed up at 6 months to one year to see if they had made any progress. During the course of the study, each patient was asked whether they were using e-cigarettes.
According to the study abstract, ‘E-cigarette users were more nicotine dependent than nonusers, had more prior quit attempts, and were more likely to be diagnosed with thoracic and head or neck cancers,’ and ‘E-cigarette users were as likely to be smoking at the time of follow-up as nonusers.’
Medical News Today picked up on the study, remarking that ‘No findings were made to support oncologists suggesting e-cigarettes as an option to cancer patients as a means to quitting smoking.’ One of the study’s authors, Dr. Jamie Ostroff, recommends that oncologists continue to urge patients to quit smoking using FDA-approved methods.
Yet, there is already controversy…
In the same article, two leading researchers of e-cigarettes and tobacco products in the UK, Professors Peter Hajek and Robert West, call into question the study’s methods, saying that many vapers dropped out of the study before it was completed and so were not counted in the final results.
They claim that, as a result, only those who tried to quit and failed were counted in the final results of the study – anyone who succeeded in quitting smoking, using e-cigarettes or otherwise, were not counted.
So what is really going on here?
According to the full text* of the study, over the course of two years all patients presenting for treatment at a cancer clinic were screened for tobacco use. Those who were identified as current smokers were referred to a tobacco cessation program, and those who wished to participate in the program were thus included as subjects in this study. Patients in the program were offered a variety of quit-smoking assistance methods, including therapy and suggestions for medications.
In addition to screening for smoking habits, the patients were also asked if they had used an e-cigarette in the last 30 days. Follow up information was collected from patients between 6 and 12 months after initiating treatment – these outcome assessments focused on detailing current smoking behavior and did not inquire about continued e-cigarette use.
Data fudging – er, ‘analysis’
As with all studies, many patients were lost to follow up. As it so happens, 66.3% of vapers dropped out of the study, while only 32.4% of nonvapers dropped out. This discrepancy is huge and unusual, yet the study authors make no attempt to explain exactly why that is. Instead, they resort to statistical fudging to make up for the loss:
‘Abstinence rates were calculated with 2 methods for handling missing data: 1) a modified intent-to-treat (ITT) analysis, assuming all participants lost to follow-up were smoking; and 2) complete case analysis (CCA), in which participants lost to follow-up were eliminated from the analysis.’
Now, to be fair, it is typical to consider those who dropped out of the study as simply non-existent for the purpose of statistical analysis. However, it is odd that for one of the two analyses they chose to assume that all who were lost to follow up were still smoking. In doing so, wouldn’t it make sense to run another analysis assuming that all who dropped from the study actually quit? Apparently the authors didn’t think so.
Could it be that they did not run a third analysis assuming that those lost to follow up (most of whom were vapers) had successfully quit because they knew that would make it look like e-cigarettes work, confusing their results and making it impossible to come to a clear conclusion? Hmm…
… and now, the results!
The authors state that almost all of the e-cigarette users in their study were dual users – this is consistent with the fact that they were studying patients who had elected to be part of a smoking cessation program, as not many non-smoking vapers would feel the need to do so. In addition, as noted previously, many who may have quit smoking simply dropped out of the study – this could be due to the fact that not many who have succeeded in quitting would feel the need to stay in a smoking cessation program.
As a result, at the outset of their study the majority of e-cigarette users were still smoking. The authors state that ‘E-cigarette users appeared to be smoking more cigarettes per day than nonusers.’ Yet the statistics they cite do not show a statistically significant difference.
In addition, they found that the dual users (who they are simply calling ‘e-cigarette users’) had higher rates of nicotine dependence and higher rates of thoracic, head and neck cancers. Both of these may be due to these patients having been heavier smokers before initiating e-cigarette use; yet, of course, they did not collect data on how much these patients smoked before they began vaping, so we will never know for sure.
The authors mention that some of the patients quit smoking by the end of the study, but fail to show how many.
So what does this study prove then??
This study proves that if someone enrolls in a smoking cessation program and stays in it for 6 to 12 months, they are unlikely to have quit smoking by then. That’s about it.
The study hints at the possibility that dual users may be more dependent on smoking and nicotine and thus more vulnerable to smoking related disease, but it does not prove that. More studies are needed to show a clear relationship here. If this is the case, as I stated earlier it may be simply because they were heavier smokers to begin with, i.e. it most likely has nothing to do with their e-cigarette use.
This study says absolutely nothing about people who vape exclusively, or those who eventually replaced smoking with vaping completely. Those patients were apparently lost to follow up.
The researchers state in their conclusion that, based on their results, there is no reason to believe that e-cigarettes can help people quit smoking. They say that from what they’ve seen, vaping is far more likely to lead to dual use with tobacco cigarettes than to complete smoking cessation.
This is consistent with recent, widely-touted concerns of the FDA and many public health officials that dual use is the norm for vapers, and that it can lead to a decreased likelihood for smoking cessation. Mitch Zeller, head of the Center for Tobacco Products at the FDA, has even stated publicly that dual use may lead to someone smoking for longer than they would have if they had simply made another quit attempt.
However, many have countered that dual use does lead to a reduction in the overall number of cigarettes smoked per day, and that it may eventually lead to smoking cessation.
Is there any evidence that vaping leads to a reduction in smoking rates?
Dr. Hajek, one of the critics of the study discussed above, conducted a comprehensive review along with his colleagues on all available e-cigarette research to date. In it he discussed a handful of studies which show clear evidence that vaping can lead to smoking cessation, including one where ‘in a large population sample, smokers attempting to stop smoking with the help of EC [e-cigarettes] were more likely to succeed than those using NRT bought from a store (without any professional supervision) or trying to quit unaided.’
He also noted that in this study, ‘Among ‘dual users’, 46% quit smoking altogether after 1 year.’
Also noteworthy is ‘In the United Kingdom, where the use of EC to assist smoking cessation has now overtaken use of NRT, and detailed figures are available on month-to-month changes in smoking behaviour, the rise in EC use has been accompanied by an increase in successful quit attempts and a continuing decrease in smoking prevalence.’
Many more studies have been conducted on the efficacy of vaping to reduce smoking rates. One comprehensive list of studies can be found here.
The available evidence suggests that dual use is not a significant problem, and that it can in fact lead to a significant reduction of smoking, even to complete cessation.
So why is there still so much debate?
The authorities (FDA, CDC, etc.) and public health officials are still claiming that there simply isn’t enough evidence to support the hypothesis that vaping reduces smoking.
Part of this is because of conflicting studies like the one discussed earlier. It is clear to me that the study was flawed, yet it would not have been so clear if all I had access to were the results. Similarly, many public health officials are not reading the full text of each and every study that crosses their desk looking for flaws in the research, so there is bound to be some confusion.
Also, for some it is a deeply ingrained belief that complete cessation of all tobacco and nicotine products is the only way to eliminate smoking related disease. For them, anything that does not lead to total abstinence is not good enough, and no amount of proof will suffice. As such, the debate rages on.
However, as much proof as we have that vaping can reduce smoking rates, more research is necessary to prove that widespread vaping will reduce smoking in the greater population, rather than simply supplement it. Many of the currently available studies on e-cigarettes show them to only be a little better at reducing smoking than nicotine replacement therapies, and nearly all of these studies use older, outdated e-cigarettes. There is some evidence that newer vapor products are far more effective at achieving and maintaining smoking abstinence, but there aren’t any studies to prove that yet.
In other words, while there is enough evidence to suggest that vaping can reduce smoking, there is still not enough evidence to prove that widespread vaping will decrease smoking significantly. We need more comprehensive research to clearly show the impact vaping will have on the average smoker.
Dr. Michael Siegel of Boston University announced Monday that he is planning to conduct one of the largest, most comprehensive studies on electronic cigarettes to date, and is seeking funding for his research. Click here to read more about his proposed study. UPDATE: This study has been canceled as of 9/27.* A link to the full text of this study can be found with the abstract, but in order to access it you need a Wiley account. If you are a college student or alumni, you may be able to access the full text through your university’s online library.