Supporting the Sustained Transition of Smokers of Conventional Cigarettes to Vaping Products

The Canadian Institutes of Health Research in collaboration with the Tobacco Control Directorate, Health Canada

Objectives

The Best Brains Exchange (BBE) will provide an opportunity for research and implementation experts, policy makers, health practitioners and other key stakeholders from across jurisdictions and sectors to collectively support the Government of Canada’s commitment to reduce tobacco use to less than 5% by 2035.

More specifically, the BBE will allow participants to address the following objectives:

  1. Translate current research and implementation evidence to identify key factors that could support the effective sustained transition of current tobacco smokers to vaping products. Relevant areas of expertise include: smoking cessation, addiction treatment, harm reduction and others.
  2. Begin to develop a framework which will act as the essence of an evidence-based strategy meant to support this sustained transition, including:
    1. the development of support and guidance material, and
    2. identifying potential areas needing further research and investigation.
  3. Identification of best practices to support Health Canada on how best to engage with, and disseminate evidence-based information and guidance to, tobacco smokers as well as health care professionals and social service and other providers, in support of this sustained transition.

This BBE is part of a series that Health Canada will be hosting over the next several months to address the risks and potential benefits of vaping products. Health Canada is also organizing a BBE addressing vaping products and youth prevention, currently scheduled for Spring 2019.

Policy Context

Tobacco use is the leading preventable cause of premature death in Canada,Footnote 1 playing a role in causing over 40 diseases and other serious negative health outcomesFootnote 2. In 2012, 45,000 Canadians died from a smoking-related disease,Footnote 1 and while the overall smoking rate in Canada has declined, this decline has stabilized over the last several years (approximately 15%).Footnote 3

The Government of Canada addresses the public health problem of tobacco use through Canada’s Tobacco Strategy (CTS), which was introduced as the Federal Tobacco Control Strategy (FTCS) in 2001. The CTS focuses on helping Canadians quit using tobacco, protecting youth and non-tobacco users from nicotine addiction, strengthening the foundations in science, surveillance and partnerships, and working with national and regional Indigenous organizations. The CTS uses broad population-based approaches to achieve the target tobacco use rate of 5% by 2035.

As part of the CTS, the Tobacco and Vaping Products Act (TVPA) was enacted in May 2018 to regulate both the manufacture, sale, labelling, and promotion of tobacco products and vaping products. The purpose of this legislation is to protect young persons and non-users of tobacco products from nicotine addiction and tobacco use, while allowing smokers access to vaping products as a less harmful alternative source of nicotine. Evidence suggests that transitioning completely from cigarettes to vaping products (e.g. e-cigarettes) will reduce a person’s exposure to many toxic and cancer-causing chemicals.Footnote 4

Smokers make quit attempts through a variety of methods, including quitting on their own, using nicotine replacement therapies (NRTs), medication, or counselling services. However, while a number of cessation approaches can be effective, they are not the only tools available to help Canadians transition away from cigarette smoking. While some evidence suggests that vaping product use may be linked to improved rates of success when quitting, the evidence is unclear regarding what factors contribute to the sustained transition of cigarette smokers to vaping products.

Need for Evidence

Although prevention strategies are central to achieving a smoking prevalence in Canada of less than 5% by 2035, to reach this goal, Canadian smokers would also benefit from evidence-based support to help quit or move away from cigarette smoking.

As indicated, current cessation services and programs include the use of NRTs, oral medication, behavioural counselling, and support through smoking cessation help lines. NRTs have been available since the 1970s and have proven to be effective and safe to use in comparison to placebo.Footnote 5 Some reviews indicate approximately 7% of all smokers receiving NRTs (gum/inhaler) were continuously abstinent for six months (within a range of 3%-10%).Footnote 6 Other cessation methods have also been shown to be effective compared to placebo,Footnote 7 although, to date, quitting without the use of any cessation aids or services remains the most common metho d.Footnote 8

Vaping products have become an increasingly popular choice among smokers. Many smokers of cigarettes report that they have tried vaping as a method to quit smoking or reduce their consumption. In the past two years, 32% of smokers in Canada used a vaping product to make a quit attempt.Footnote 9 Vaping products include features that allow for more efficient nicotine delivery and can resemble or simulate psycho-behavioural aspects of smoking, which may be factors in their popularity.

However, at present, the current evidence supports mixed or modest effects for vaping with regards to smoking cessation. The very limited number of randomized control trials (RCTs), using older generation vaping products is insufficient to make conclusions about cessation effectiveness.Footnote 10 At present, results from one RCT suggest that vaping products may be at least as effective as other NRTs. A somewhat larger number of observational/cohort studies provide mixed results. While 4 out of 5 US population studies observed a positive relationship between more frequent e-cigarette use and smoking cessationFootnote 11, recent population-level studies show that e-cigarettes can have noFootnote 12or modestFootnote 13,Footnote 14 effects on smoking cessation.

More research is needed to begin to identify potential factors, strategies or best practices to support the successful sustained transition of tobacco smokers to vaping products. Furthermore, effectively communicating evidence-informed information and guidelines to tobacco users, health care providers, and others is critical in a successful strategy. Evidence and expertise from a range of domains will provide valuable contributions to this public health issue, including experts in smoking cessation, addictiveness treatment, harm reduction (tobacco or other drugs of abuse), public and population health, and health communications.

At the BBE, points of discussion related to supporting the sustained transition of smokers of conventional cigarettes to vaping products may include, but are not limited to:

  • Type of support needed (e.g., behavioural support, combination treatments)
  • Feasibility of developing systematic transition programs (e.g., step-wise programs)
  • Individualized transition programs (e.g., for vulnerable population groups)
  • The role of environmental factors
  • The role of vaping products themselves (e.g., device type, flavours, nicotine levels)
  • How to engage the broader public health/medical community

Anticipated Outcomes

Insight from the BBE would provide a credible knowledge base, identify potential factors or strategies for success, as well as develop effective communication/dissemination strategies to support federal programs and policies addressing the effective sustained transition of smokers from conventional cigarettes to vaping products.

Presentation Summaries

The BBE was facilitated by Mr. James Van Loon, (Director General, Tobacco Control Directorate, Health Canada). Here is a summary of the evidence presented by each of the presenters:

Electronic Cigarettes as Cessation Aids: The U.S. National Academy Report and Subsequent Findings

Nancy Rigotti, Director, Tobacco Research and Treatment Center & Professor, Massachusetts General Hospital & Harvard Medical School

In January 2018, the U.S. National Academies of Science, Engineering, and Medicine (NASEM) released The Public Health Consequences of E-Cigarettes, a Consensus Study Report commissioned by the U.S. Food and Drug Administration to evaluate the available evidence about the health effects of e-cigarettes. The Report concluded that while e-cigarettes are not without health risks, they are likely to be far less harmful than combustible tobacco cigarettes, because e-cigarettes contain fewer numbers and lower levels of toxic substances than conventional cigarettes but cautioned that the long-term health effects of e-cigarettes are not yet clear. The Report articulated a framework for assessing the net public health effect of e-cigarettes as a balance of three factors: e-cigarettes’ ability to help current smokers quit combustible tobacco, their potential to increase the uptake of combustible tobacco product use among nonsmokers, and their inherent toxicity. Thus, the primary potential benefit of e-cigarettes depends on their ability to aid cessation at a population level. After reviewing the available evidence, the Report concluded that there was limited evidence that e-cigarettes are effective aids to promote smoking cessation overall and identified a pressing need for high-quality randomized controlled trials (RCTs) to examine this question. Since then, a new RCT has been published to address this question (Hajek et al., NEJM 2019) and others are underway. In the interim, the emergence of JUUL fueled a rapid rise in vaping among U.S. adolescents in 2018, shifting attention away from e-cigarettes as cessation aids. This presentation will review the NASEM Report’s findings about cessation and new trial, commenting on how its findings were received by the medical community and explore what new and old questions remain about e-cigarettes as cessation aids.

Synthesising evidence on electronic cigarettes for smoking cessation

Jamie Hartmann-Boyce, Senior Researcher, Nuffield Department of Primary Care Health Sciences, Oxford University

Cochrane reviews are often considered the gold-standard in terms of evidence synthesis. The first part of this session will summarise key findings from the most recent update of the Cochrane review of electronic cigarettes for smoking cessation, published in 2016. This review found 24 included studies, of which two were randomized controlled trials. Combined results from these two trials showed that electronic cigarettes with nicotine can help people quit smoking, but certainty in the evidence was limited because of the small number of studies and because the devices tested are no longer available on the market due to poor nicotine delivery. The one trial that compared electronic cigarettes to nicotine replacement therapy did not detect a difference between the two, but certainty in this finding was also low. None of the included studies (short‐ to mid‐term, up to two years) detected serious adverse events considered possibly related to electronic cigarette use. The second part of this session will focus on putting these findings in context by comparing findings from this review with other key reviews published on this topic, comparing findings from this review with Cochrane reviews evaluating other smoking cessation interventions, and exploring the possible impact of new studies on the review’s analyses and conclusions.

Characteristics of vaporized nicotine products that may influence their uptake among tobacco smokers leading to complete substitution for combustible cigarettes

Maciej L. Goniewicz, Associate Professor, Oncology Nicotine and Tobacco Product Assessment, Department of Health Behavior, Division of Cancer Prevention and Population Studies, Roswell Park Comprehensive Cancer Center      

Vaping products can vary in important characteristics including size, shape, flavor and nicotine yield and these devices have been shown to differ in nicotine delivery and reduction of nicotine withdrawal symptoms. Several studies indicate that there are differences in rates of smoking cessation among users of different vaping products (i.e. cigalike versus tank). Type of vaping products used also differs between daily and non-daily users. The initial perception of a vaping product may be an important facilitator or barrier to a tobacco cigarette smoker purchasing or trying a specific type of vaporizer for the first time. It is important to determine the characteristics of vaping products that could both facilitate and hinder a tobacco cigarette smoker attempting to transition to vaping for harm reduction purposes. In general, vaping products that deliver more nicotine also demonstrated higher mean urge relief; objective nicotine delivery and subjective amount of urge relief are strongly correlated. It has been shown that different flavors have the capacity to produce different ‘throat hit’ feelings, and this characteristic is similar to the effect of tobacco cigarette smoke. Cigarette smokers have stated a preference for devices that provide this feeling due to more satisfaction and fulfillment. Small vaping devices appear to be perceived by smokers as less harmful compared to larger devices. Small devices also appear to be less embarrassing to use and some smokers who tried vaping products and did not become regular uses gave embarrassment as a reason for non-regular use.

Clinical Pharmacology of JUUL and Risks of Long-term Nicotine Exposure

Neal Benowitz, Professor of Medicine and Bioengineering and Therapeutic Sciences & Chief, Division of Clinical Pharmacology, University of California San Francisco

The JUUL e-cigarette is a high-tech device that has characteristics that have substantially changed the e-cigarette device and liquid landscape. JUUL contains nicotine in high concentrations as the nicotine benzoate salt. The nicotine salt preparation has a low pH, such that almost all of the nicotine in unionized, which in turn results in less mouth and airway irritation and harshness. The low pH allows even a nicotine-naïve person to inhale large amounts of nicotine with a nicotine absorption profile similar to a cigarette. Electronic temperature control circuitry limits coil temperature heating and reduces generation of thermal degradation products. Small inhaled volumes due to high nicotine concentrations along with temperature control reduces toxicant exposure. JUUL is potentially the most effective and safest e-cigarette to aid smoking cessation in adults. However, reports of daily use and use for pharmacologic effects in youth suggest high abuse potential and raises concerns about primary nicotine addiction. The long-term health consequences of primary nicotine use are not well understood, but most likely include cardiovascular and reproductive risk, and possibly risks of increased susceptibility to infection and respiratory disease. Such risks are almost certainly much less than those of cigarette smoking, but do raise concerns about long-term primary nicotine use in today’s youth.

Recommended Readings

  1. Barrington-Trimis, J. L., Kong, G., Leventhal, A. M., Liu, F., Mayer, M., Cruz, T. B., Krishnan-Sarin, S., & McConnell, R. (2018). E-cigarette use and subsequent smoking frequency among adolescents. Pediatrics, 142(6), e20180486.
  2. Barrington-Trimis, J. L., & Leventhal, A. M. (2018). Adolescents’ use of “Pod Mod” e-cigarettes—urgent concerns. New England Journal of Medicine, 379(12), 1099-1102.
  3. Collins, L., Glasser, A. M., Abudayyeh, H., Pearson, J. L., & Villanti, A. C. (2018). E-cigarette marketing and communication: how e-cigarette companies market e-cigarettes and the public engages with e-cigarette information. Nicotine and Tobacco Research, 21(1), 14-24.
  4. Goldenson, N. I., Leventhal, A. M., Stone, M. D., McConnell, R. S., & Barrington-Trimis, J. L. (2017). Associations of electronic cigarette nicotine concentration with subsequent cigarette smoking and vaping levels in adolescents. JAMA pediatrics, 171(12), 1192-1199.
  5. Huang, J., Duan, Z., Kwok, J., Binns, S., Vera, L. E., Kim, Y., Szczypka, G., & Emery, S. L. (2019). Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tobacco control, 28(2), 146-151.
  6. Janzen, T. (2016). RESCUE The Behavior Change Agency [Using social branding to reduce young adult tobacco use: Evidence of a promising new approach].
  7. Jordan, J. W., Stalgaitis, C. A., Charles, J., Madden, P. A., Radhakrishnan, A. G., & Saggese, D. (2019). Peer crowd identification and adolescent health behaviors: results from a statewide representative study. Health Education & Behavior, 46(1), 40-52.
  8. Moran, M. B., Walker, M. W., Alexander, T. N., Jordan, J. W., & Wagner, D. E. (2017). Why peer crowds matter: Incorporating youth subcultures and values in health education campaigns. American journal of public health, 107(3), 389–395.
  9. Soneji, S., Barrington-Trimis, J., Wills, T. A., & Adam Leventhal, U. J. (2017). E-cigarette use and subsequent cigarette smoking among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatr, 17, 788-797.
  10. Villanti, A. C., Rath, J. M., Williams, V. F., Pearson, J. L., Richardson, A., Abrams, D. B., Niaura, R. S., & Vallone, D. M. (2015). Impact of exposure to electronic cigarette advertising on susceptibility and trial of electronic cigarettes and cigarettes in US young adults: a randomized controlled trial. Nicotine & Tobacco Research, 18(5), 1331-1339.
  11. Wagner, D. E., Fernandez, P., Jordan, J. W., & Saggese, D. J. (2019). Freedom from chew: Using social branding to reduce chewing tobacco use among country peer crowd teens. Health Education & Behavior, 46(2), 286–294.
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