The largest study conducted to date on the clinical effectiveness of vaping, Estxends included more than 1,200 people smoking five or more tobacco cigarettes per day, and volunteers to quit smoking (1).
Half of the participants received an electronic cigarette and e-liquids, to choose from six flavors in four nicotine dosages (0, 6, 11 or 19.6 mg/ml), and accompanying sessions, while he other half — the control group — received, in addition to the same support, a voucher (50 Swiss francs), which could be used as desired. This group may or may not have used cessation aids, such as nicotine substitutes, which was the case for two-thirds of the group.
At the end of a six-month follow-up, the smoking cessation rate was significantly higher in the vaping group: 28.9 vs. 16.3%; OR = 1.77; IC95 [1,43-2,20]. A result which is similar to that reported in a Cochrane review published in early 2024. Likewise, the percentage of people who abstained from smoking in the seven days preceding the six-month follow-up visit was 59.6% in the group e-cigarette, vs 38.5% in the control group.
On the other hand, the rate of people who abstained from any nicotine intake was 20.1% in the intervention group, compared to 33.7% in the control group.
A question that divides
It thus appears that vaping is more effective than nicotine substitutes for quitting smoking, undoubtedly thanks to better nicotine substitution in this study; but some people who stop smoking continue to consume nicotine via e-cigarettes. The medical community is divided regarding this situation, which raises a question of medical ethics. Can we advocate vaping to reduce the risks associated with cigarette consumption, when this approach does not allow, for some, to wean themselves off nicotine? For Professor Reto Auer, principal investigator of the Estxends study, “if stopping all tobacco and nicotine consumption remains the main objective, vaping is undoubtedly a good option for people who have not been able to quit smoking with pharmacological treatments. For those who want to stop smoking and, ultimately, no longer consume nicotine or vape, classic treatments — nicotine substitutes, bupropion — seem more appropriate. The choice must be made taking into account each person’s preferences, knowing that a majority of those who smoke do not consult a doctor and go directly to electronic cigarette stores. »
An option for those who have not been able to quit smoking with pharmacological treatments
Pr Reto Auer
At the same time, at the societal level, we must prevent young people who do not smoke from becoming addicted to nicotine via e-cigarettes. Because this is the subject of the debate which is agitating the media and health professionals. “There is no perfect solution,” recognizes Professor Auer, who advocates a pragmatic approach in clinical practice.
What about the side effects?
The study did not have the sample size necessary to conclude on the safety of e-cigarettes. Adverse effects of all grades were observed in 43.7 and 36.7% of participants respectively, and severe events were reported in 4% of people in the intervention group compared to 5% in the control group.
The six-month follow-up does not allow us to definitively conclude on the effect of vaping on cough and respiratory symptoms because it was a secondary clinical outcome, but trends are emerging, in particular with a reduction in cough. and sputum.
Favorable fruity aromas?
“Among the various secondary analyzes of the study, that on the choice of aromas provides interesting lessons”, reports Dr Isabelle Jacot Sadowski (Lausanne). At the start of the study, people who had received an e-cigarette had the choice between six flavors (two tobacco-flavored, three fruity and one menthol) and four nicotine concentrations (0, 6, 11 and 19, 6 mg/ml).
At inclusion, 25% had opted for a fruity aroma, as many for a tobacco flavor, 41% for several aromas and 9% for menthol. This distribution remained stable during follow-up. At the six-month visit, the authors found that people using e-cigarettes exclusively consumed fruity flavors more often than those using e-cigarettes dual-use while continuing to smoke. Among the latter, it was the tobacco flavor that was the most popular.
Second lesson: the nicotine concentration in e-liquids has tended to decrease over time, with ultimately a lower concentration in people weaned from cigarettes compared to those using dual use.
Interviews with Professor Reto Auer *,** and Dr Isabelle Jacot-Sadowski**
* Biham, Bern University Institute of Family Medicine. University of Bern, Switzerland
**Unisanté, University Center for General Medicine and Public Health, Lausanne, Switzerland
(1) Auer R et al. Electronic Nicotine-Delivery Systems for Smoking Cessation. New England Journal of Medicine 2024,390:601-10
