E-cigarettes vs NRT - PowerPoint Presentation

E-cigarettes vs NRT within UK stop-smoking service: The TEC Trial Daniella LadmoreResearch Health Psychologist, Health & Lifestyle Research Unit, QMUL Wolfson Institute of Preventive Medicine

Overview Current practice in stop-smoking services Types of e-cigarettes Common Myths Evidence so far: Nicotine delivery Safety Can e- cigarettes help smokers quit? TEC Trial Use of e-cigarettes in stop-smoking services: case studies Implications for practice

Withdrawal-oriented TreatmentCombination of medication (NRT, Champix, Zyban) and weekly behavioural supportSome services now include e-cigarettes in their treatment packages free of charge, or provide information on how to use/where to buy e-cigarettes.But not all are ‘e-cig friendly’ Current Practice in SSS

1 st Generation or ‘Cig-a-like’ 2nd Generation or ‘re-fillable’ Tank system3rd Generation or ‘variable voltage’ 4th Generation or ‘pod’ deviceTypes of E-cigarettes

Media & Myths Misleading the public that e-cigarettes are just as harmful if not more harmful than smoking Fuelling misperceptions Ultimately, smokers might be put off switching to vaping…direct impact on smokers.Gateway to common myths…hard to change minds

Myth 1: Vaping is as harmful as smokingMyth 2: We don’t know what is in themMyth 3: E-cigarette vapour is harmful to bystanders (Passive Vaping)Myth 4: Harmful as they contain nicotineMyth 5: Dangerous as they can explodeMyth 6: Lead young people into smoking Common Myths

What is in e-liquid?Propylene glycol and/or vegetable glycerol, nicotine, flavouringsAlso impurities and potential toxicants Concentrations of these however are very small, much lower than in smoke, and unlikely to affect health Safety of E-cigarettes

Are E-cigs safer than cigarettes?No combustionNo tobacco chemicals other than nicotineE-cigs may not be entirely safe, but no serious risks have been documented so far There is little doubt that E-cigs are an order of magnitude safer than conventional cigarettes Safety of E-cigarettes

What adverse effects have been reported?Mostly mouth irritation and coughNo serious adverse effects in any study Cochrane review: No safety concerns emerged with use over short to mid-term (same as those of NRT and placebo) Safety of E-cigarettes

Cochrane Review:Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev2016;9Based on 2 randomised trials300 smokers not intending to quit, EC with or without nicotine (one arm reduced EC nicotine after 6w), 12M f-u Caponnetto P, Campagna D, Cibella F, et al. Efficiency and safety of an electronic cigarette (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One2013;8:e66317. 657 smokers wanting to quit, EC with or without nicotine or 21mg/24hr patches, minimal support, 6M f-uBullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet2013;382:1629-37Can E-cigarettes help smokers quit?

Results:Nicotine EC more effective than placebo (RR= 2.29, 95%CI 1.05-4.96)EC as good as nicotine patch (RR=1.26, 95%CI: 0.68-2.34) Early studies used 1st generation products. Can E-cigarettes help smokers quit?

886 smokers seeking help to quit, randomised to:EC starter pack with 18mg tobacco e-liquid (2nd generation EC); OR NRT (single or combination, of their choice)Both groups provided with weekly behavioural support within the SSS Can E-cigarettes help smokers quit? The TEC StudyHajek, P., Phillips-Waller, A., Przulj, D., Pesola, F., Myers Smith, K., Bisal, N., ... & Ross, L. (2019). A randomized trial of e-cigarettes versus nicotine-replacement therapy. New England Journal of Medicine, 380(7), 629-637.

Primary outcome: Sustained abstinence (1 year) validated by CO<8ppm; drop outs included as non-abstainersCO-validated smoking reduction of 50% or more from baselinePresence of adverse reactions Main outcome measures: Can E-cigarettes help smokers quit? The TEC Study

Effects on abstinence and reduction at 1 year EC (N=438) NRT (N=446) RR (95% CI)% abstinent for 52 weeks18.1%9.9%1.83 (1.30 to 2.58)Results similar for a range of sensitivity analyses and secondary outcomesCO validated reduction in non-abstainers12.8%7.4%1.75 (1.12 to 2.72) *biochemically validated Can E-cigarettes help smokers quit? The TEC Study

*biochemically validated Can E-cigarettes help smokers quit? The TEC Study Ecig users reported significantly less urges to smoke at 4 weeks compared to NRT armEcigs better at withdrawal relief and subjective effects

High on-going EC use in abstainers9% of one-year abstainers in NRT arm still on NRT, 80% in EC arm still vaped Good if it prevents relapse (like long-term NRT use), reduces withdrawal discomfort/cravings and weight gainBad if it poses health risks later on Vapers reduced nicotine content (18mg to 11mg) over 52 weeks Can E-cigarettes help smokers quit?The TEC Study

Respiratory symptoms EC (N=315) NRT (N=279) RR (95% CI) Baseline 52 weeks Baseline 52 weeks Shortness of breath 38% 21% 33% 23% NS Wheezing 32% 24% 31% 21% NS Cough 55% 31% 52% 40% 0.8 (0.6 to 0.9) Phlegm 44% 25% 43% 37% 0.7 (0.6 to 0.9) Can E-cigarettes help smokers quit? The TEC Study

Was it due to different quit rates?Controlling for smoking status did not change the resultsStudies of effects of vaping on lung health are needed Can E-cigarettes help smokers quit? The TEC Study

Study LimitationsCould not be blinded Negative expectations of NRT could lead to smokers not trying; but, NRT quit rates were similar to that of routine careMay not generalise to smokers using EC without support Unlikely to apply to ‘first generation’ EC Can E-cigarettes help smokers quit? The TEC Study

Examples from:Leicester Stop Smoking ServiceLeicestershire County Council: ‘Quit Ready’Salford City Council Use of E-cigarettes in SSS

The first ‘ecig-friendly’ Service- Leicester SSSSamples (basic 2nd generation refillable rechargeable) - initially donated then bought via NRT budgetMix of strengths, flavours, devicesAdvice to visit a reliable shop to get further suppliesOften combined with NRT or ChampixFurther decisions on what to use were shaped by service user feedback Use of E-cigarettes in SSS

Year on year increases in use of ecigs2014-15 total2,005 quits from 4,098: 49% success2015-16 total1,920 quits from 3,718: 52% success2016-17 total1,631 quits from 3,184: 51% success2017-18 total1,479 quits from 2,753: 54% success 180 EC quits from 293: 61% success487 EC quits from 752: 65% success512 EC quits from 851: 60% success573 EC quits from 917: 62% successUse of E-cigarettes in SSS

Stop-smoking support (12 weeks) via:TelephoneText Email Live ChatFace to Face- pregnant women, people with mental health problems, vulnerable peopleFull range of pharmacotherapy- sent via 1st class post Use of E-cigarettes in SSS

E-cig Provision Provided to anyone over 18 years old including pregnant womenStarter pack includes plug and USB chargerReplacement coil 12 weeks worth of follow-on liquid Flavours- tobacco flavoured liquidsStrengths- 3mg, 6mg, 12mg, 18mg Use of E-cigarettes in SSS

FeedbackOctober 2018 Very popular with service users, most popular in the R&M socio- economic groupE-Cigs an incentive for people to quitPositive feedback Use of E-cigarettes in SSS

Why Invest In E-Cigs?Combination NRT: £205 per 12 weeks E-Cigs starter pack and 12 e-liquid bottles over 12 weeks: £29.00Patch + Gum= £212.97  E-Cig+ Patch= £81.86 Difference in cost: £131.11 E-Cig vs. 20 a day smoking over a year £300 vs. £2800 Use of E-cigarettes in SSS

Swap to Stop pilot intervention 1,000 e-cigarettes for smokers in Salford Delivered in deprived areas of Salford, focus on people in social housingDelivered January to March 2018 Devices and liquid purchased centrally from Totally WickedDelivered via - Four community stop smoking servicesSeven pharmaciesClients received – 1 device5 bottles of liquid at baseline and 5 at week twoUSB wall adaptor2 spare atomisersFollow up incentive – 3x bottle of liquid or £10 voucherUse of E-cigarettes in SSS

E-cigarettes and liquidThree device options, one with longer battery life. Lots of colour options. Device selected by advisors in consultation with clientFour liquid flavours and two strengths(tobacco, rolling tobacco, menthol, mixed fruits)11mg and 16mg Use of E-cigarettes in SSS

Results1,022 smokers took up the offer over 10 weeks (January to March 2018)63% of those followed up at four weeks had quit smoking Stark difference in numbers ofquits compared to same quarterprevious year – 240 v 49 in mostdeprived quintileCost per quit cheaper for e-cig compared to NRT in pharmacy andin smoking cessation services Use of E-cigarettes in SSS

Evidence to date suggests E-cigs almost double quit rates compared to NRTMore cost-effective HCPs should encourage smokers to try E-cigs. SSS should include starter packs of E-cigs among treatment options to reduce treatment cost and increase its efficacy Some likely barriersNot licensed as medicine; product choice; media misinformation about E-cig safety Implications for Practice

Louise Ross, former Stop Smoking Service Manager for Leicester City CouncilZaheera Chatra, Stop Smoking Service Manager, Quit ReadyKuiama Thompson – Rochdale Borough Council, Swap to Stop Acknowledgements