Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial

Pharmacological interventions for smoking cessation among people with schizophrenia spectrum disorders: a systematic review, meta-analysis, and network meta-analysis

BACKGROUND

People with schizophrenia have higher rates of smoking than the general population, and lower quit rates. Several randomised controlled trials have investigated the effectiveness of pharmacological interventions for smoking cessation over the past 20 years. We did a systematic review and pairwise and network meta-analysis of smoking abstinence to guide decision making in offering pharmacological interventions for smoking cessation for people with schizophrenia spectrum disorders.

METHODS

We systematically reviewed PubMed, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and China National Knowledge Infrastructure from inception to Sept 30, 2019, for randomised controlled trials of varenicline, bupropion, and nicotine replacement therapy for smoking cessation for people with schizophrenia spectrum disorders or psychotic disorders who were smokers at the time of study recruitment. Data were extracted from published studies on smoking abstinence outcomes and psychotic symptoms. We did pairwise and network meta-analyses for the primary outcome of smoking abstinence. Sensitivity analyses were done on study inclusion criteria, duration, quality, and location. This study is registered with the international prospective register of systematic reviews PROSPERO, CRD42018102343.

FINDINGS

A total of 15 111 records were identified by the database searches, and 163 full-text articles were assessed for eligibility. 145 articles were then excluded for several reasons including insufficient data, or abstracts published in later studies, and 18 studies were included in the meta-analysis. In the pairwise meta-analyses, four studies with 394 participants assessed varenicline (RR 3·75, 95% CI 1·96-7·19, p<0·0001; I²=0%), four studies with bupropion and 292 participants (RR 3·40, 95% CI 1·58-7·34, p=0·0002; I²=0%), and three studies with 561 participants assessed nicotine replacement therapy (RR 4·27, 95% CI 1·71-10·65, p=0·0002; I²=0%). All three treatments were deemed superior to placebo. In the network meta-analysis, varenicline was superior to bupropion (RR 2·02, 95% CI 1·04-3·93; p=0·038) but no significant difference was found between varenicline and nicotine replacement therapy, or bupropion and nicotine replacement therapy. No agents were associated with changes in psychiatric symptoms, but varenicline was associated with higher rates of nausea than was placebo.

INTERPRETATION

We found evidence to support use of pharmacological agents for smoking cessation for people with psychosis. Varenicline might be superior to bupropion; however, additional direct testing and combination trials of pharmacological agents for smoking cessation are required to inform clinical decision making for people with psychosis.

FUNDING

None.

Persistence targeted smoking cessation for smokers with schizophrenia or schizoaffective disorder: a feasibility study

Introduction

Individuals with schizophrenia are more likely to smoke and less likely to quit smoking than those without schizophrenia. Because task persistence is lower in smokers with than without schizophrenia, it is possible that lower levels of task persistence may contribute to greater difficulties in quitting smoking observed among smokers with schizophrenia.

Aims

To develop a feasible and acceptable intervention for smokers with schizophrenia.

Methods

Participants (N = 24) attended eight weekly individual cognitive behavioral therapy sessions for tobacco use disorder with a focus on increasing task persistence and received 10 weeks of nicotine patch.

Results

In total, 93.8% of participants rated the intervention as at least a 6 out of 7 regarding how ‘easy to understand’ it was and 81.3% rated the treatment as at least a 6 out of 7 regarding how helpful it was to them. A total of 62.5% attended at least six of the eight sessions and session attendance was positively related to nicotine dependence and age and negatively related to self-efficacy for quitting.

Discussion

This intervention was feasible and acceptable to smokers with schizophrenia. Future research will examine questions appropriate for later stages of therapy development such as initial efficacy of the intervention and task persistence as a mediator of treatment outcome.

Mental health, smoking, harm reduction and quit attempts - a population survey in England

BACKGROUND

Tobacco control strategies have engendered overall declines in smoking; however, a large gap remains between people with and without mental health problems, causing substantial health inequalities. Population-level information on barriers and opportunities for improvements is scarce. We aimed to assess mental health status of cigarette smokers and recent ex-smokers ('past-year smokers') in England, and smoking and harm reduction behaviour and quit attempts by mental health status.

METHODS

Data were collected from 5637 current and 434 recent ex-smokers in 2016/17 in household surveys of representative samples of adults. We calculated weighted prevalence of different indicators of mental health problem: a) ever diagnosis, b) none, moderate, serious past-month distress, c) past-year treatment. We compared weighted smoking status, cigarette type, dependence, motivation to stop smoking, cutting down, use of nicotine replacement therapy or e-cigarettes, short-term abstinence, and quit attempts according to mental health status.

RESULTS

Among past-year smokers: 35.9% ever had a diagnosis; 24.3% had experienced moderate, an additional 9.7% serious, past-month distress; 21.9% had had past-year treatment. Those with an indication of a mental health problem were more highly dependent and more likely to smoke roll-your-own cigarettes but also more likely to be motivated to stop smoking, to cut down, use nicotine replacement therapy or e-cigarettes and to have attempted to quit in the past year.

CONCLUSIONS

About a third of cigarette smokers in England have mental health problems. Interventions should address their increased dependence and leverage higher prevalence of harm reduction behaviours, motivation to stop and attempts to stop smoking.

Tobacco smoking in three “left behind” subgroups: indigenous, the rainbow community and people with mental health conditions

Purpose

This paper aims to investigate the extent to which three subgroups – people with mental health conditions, people belonging to sexual minority and gender groups and Indigenous peoples – have been “left behind” by countries implementing the World Health Organization’s Framework Convention on Tobacco Control.

Design/methodology/approach

A general review of electronic bibliographical databases to provide an overview of smoking prevalence among the three groups and interventions designed specifically to reduce their smoking rates.

Findings

Although explanations and specific rates differ, two trends are consistent across all three groups. First, information reported in the past two decades suggests that smoking prevalence is disproportionately high among people with mental health conditions, and in the rainbow and indigenous communities. Second, most cessation programmes are targeted at majority politically dominant groups, missing opportunities to reduce smoking rates in these minority communities.

Research limitations/implications

There is a general dearth of data preventing detailed analysis. Better data collection efforts are required. Trials to identify effective smoking reduction interventions for marginalised groups are needed.

Social implications

It is socially unjust that these groups are being systematically ignored by tobacco control initiatives. A failure to equitably reduce tobacco harms among all groups across society has contributed to the perceived concentration of smoking in some subgroups. The increasing stigmatisation of people who smoke then adds a marginality, compounding the negative effects associated with belonging to a marginalised group. Ongoing marginalisation of these groups is an important determinant of smoking.

Originality/value

Cross-case analysis of neglected subgroups with disproportionately high smoking rates suggests social marginalisation is a shared and important determinant of smoking prevalence.

'Quit During COVID-19'-staying smokefree in mental health in-patient settings

Cigarette smoking is one of the main preventable causes of cancers globally. At this time of global emergency, mental health professionals all over the world are joining hands with the public health and other healthcare communities to focus on acute measures to save lives from COVID-19. This has been particularly challenging in mental health hospital settings where numerous additional factors need to be considered, including difficulties of implementing social distancing, potential impacts of social isolation, increased stress levels and implications of all this on smoking. In this article, we will briefly discuss the prevalence of smoking in mental health patients, especially in those in mental health hospital settings and also what is the possible impact of COVID-19 pandemic in these people. Then we will go through the main reasons as to why encouraging smoking cessation in mental health patients is so important and measures we can take for supporting mental health patients quit smoking even during COVID-19 times. The smoking cessation interventions have a direct bearing on preventing future cancers and achieving smoking cessation among cancer patients in this already disadvantaged group.

Prevalence of smoking, quit attempts and access to cessation treatment among adults with mental illness in Brazil: a cross-sectional analysis of a National Health Survey

OBJECTIVES

Determine the national prevalence of smoking and factors related to smoking among adults with mental illness (PLWMI; people living with mental illness) in Brazil.

DESIGN

Cross-sectional study.

SETTING

We used data from the nationally representative general health survey Pesquisa Nacional de Saude of 2013, which included the Global Adult Tobacco Survey (GATS) module.

PARTICIPANTS

The survey used a complex probabilistic sample to collect data from 60 202 Brazilians 18 years or older. Primary and secondary outcomes: smoking prevalence and access to smoking cessation treatment. We also assessed past tobacco use, quit attempts and quit ratio among people with and without mental illness. Analyses were conducted in R and were weighted to account for the survey design and generate national estimates.

RESULTS

In Brazil, the 2013 smoking prevalence among PLWMI was 28.4% and among people with no mental illness was 12.8%. Both groups had high rates of past-year quit attempts (51.6% vs 55.3%) but the lifetime quit ratio among PLWMI was much lower than those with no mental illness (37% vs 54%). Adjusted odds showed PLWMI were more likely to be current smokers (OR (95% CI)=2.60 (2.40 to 2.82), less likely to be former smokers (OR (95% CI)=0.62 (0.55 to 0.70)) and as likely to have tried to quit in the past year (OR (95% CI)=0.90 (0.78 to 1.02)). Very few (3.7%) PLWMI and fewer with no mental illness (2.6%) received cessation treatment.

CONCLUSION

Smoking rates among PLWMI are roughly double the rate in the general population. Compared with Brazilian smokers without mental illness, those with mental illness were significantly less likely to quit even though as many tried to. Few Brazilians appear to be using publicly available cessation services. Expanding utilisation of treatment might be a good place to start for Brazil to further decrease the prevalence of smoking among PLWMI.

Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness

BACKGROUND

People with severe mental disorders (SMD) experience premature mortality mostly from preventable physical causes. The World Health Organization (WHO) have recently produced guidelines on the management of physical health conditions in SMD. This paper presents the evidence which led to the recommendations for tobacco cessation and management of substance use disorders in SMD.

METHODS

Scoping reviews informed 2 PICO (Population Intervention, Comparator, Outcome) questions relating to tobacco cessation and management of substance use disorders in SMD. Systematic searches led to the identification of systematic reviews with relevant evidence to address these questions. Retrieved evidence was assessed using GRADE methodology, informing the development of guidelines.

RESULTS

One thousand four hundred thirty-four records were identified through systematic searches for SMD and tobacco cessation, of which 4 reviews were included in GRADE tables and 18 reviews in narrative synthesis. For SMD and substance use disorders, 4268 records were identified, of which 4 studies from reviews were included in GRADE tables and 16 studies in narrative synthesis. People with SMD who use tobacco should be offered combined pharmacological (Varenicline, Bupropion or Nicotine Replacement Therapy) and non-pharmacological interventions such as tailored directive and supportive behavioural interventions. For people with SMD and substance use disorders (drug and/or alcohol), interventions should be considered in accordance with WHO mhGAP guidelines. Prescribers should note potential drug-drug interactions. Recommendation were conditional and based on low/very low certainty of evidence with a scarcity of evidence from low- and middle-income settings.

CONCLUSIONS

These guidelines mark an important step towards addressing premature mortality in people with SMD. The dearth of high-quality evidence and evidence from LMIC settings must inform the future research agenda.

GUIDELINES

https://www.who.int/mental_health/evidence/guidelines_physical_health_and_severe_mental_disorders/en https://www.who.int/publications-detail/mhgap-intervention-guide%2D%2D-version-2.0.

Tobacco smoking in young people seeking treatment for mental ill-health: what are their attitudes, knowledge and behaviours towards quitting?

INTRODUCTION

Tobacco smoking is a leading cause of preventable death and disease worldwide. Adults with mental ill-health smoke tobacco at substantially higher rates than other adults, with public health approaches effective in the population overall having less impact on those with mental ill-health. However, less is known about the tobacco smoking behaviours, attitudes and knowledge of young people with mental ill-health, despite this being the peak period of onset for both mental illness and cigarette smoking.

METHODS

Young people attending a youth mental health centre (providing both primary and specialist care) in Melbourne, Australia were approached by youth peer researchers and asked to complete a survey about smoking behaviours, attitudes and knowledge. We examined smoking and associated attitudes in the sample overall, and as a function of the services accessed.

RESULTS

In total, 114 young people completed the survey, with 56.3% reporting lifetime cigarette smoking, 42.0% smoking in the last 12 months and 28.6% in the past week. Of current regular smokers, 75.0% acknowledged they should quit in the future; however, only 23.5% planned to do so in the next month, with 44.4% confident that they could quit. Participants lacked knowledge about interactions between tobacco smoking, mental and physical health.

CONCLUSIONS

Youth presenting for mental ill-health had high rates of cigarette smoking relative to population rates. Presentation at youth mental health services may represent a critical window for early intervention to reduce the lifetime impacts of cigarette smoking in mental ill-health. Interventions to support smoking cessation in this group are urgently needed.

Exploring how health behaviours are supported and changed in people with severe mental illness: A qualitative study of a cardiovascular risk reducing intervention in Primary Care in England

Objectives This study explored how health behaviours were supported and changed in people with severe mental illness by primary health care professionals trained in delivering behaviour change techniques (BCTs) within a cardiovascular disease risk reducing intervention. Design Secondary qualitative analysis of 30 staff and patient interviews. Methods We mapped coded data to the BCT Taxonomy (version 1) to identify BCT application. Thematic analysis was conducted to explore the barriers and facilitators of supporting and changing health behaviours. Themes were then interpreted using the Capability, Opportunity, Motivation, and Behaviour model to gain greater explanation behind the processes. Results Twenty BCTs were identified. Staff and patients perceived that health behaviours were commonly affected by both automatic and reflective motivation, sometimes in turn affected by psychological capability, social, and physical opportunity. Staff and patients suggested that motivation was enhanced by both patient and staff ability to observe health benefits, in some cases patients' health knowledge, mental health status, and social support networks. It was suggested that engaging in/sustaining healthy behaviours was influenced by physical opportunities to engrain behaviours into routine. Conclusions According to staff and patients, health behaviour change in this population was driven by complex processes. It was suggested that capability, opportunity, and motivation were in some cases enhanced by BCTs, but variable. Behaviour change may be optimized by individualized behavioural assessments, identifying drivers of behaviour and applying a range of BCTs may help to target individual needs. Patient peer-led approaches, techniques to encourage awareness of visible success, and normalizing health behaviours may increase behaviour change. Statement of contribution What is already known on this subject? Poorer health behaviours may contribute to early mortality rates in people with severe mental illness. Health care professionals are encouraged to target the uptake of healthy behaviours, but there is limited guidance on how. The processes that cause or inhibit health behaviour change within interventions that use behaviour change techniques by health care practitioners are unclear. What does the study add? Staff and patients suggested that behaviour change techniques (BCTs) in some cases increased capability, opportunity, and motivation to engage in healthy behaviours, but in other cases had variable success. Staff and patients reported that in some cases, motivation impacted health behaviour change and was in turn affected by psychological capability, social, and physical opportunity. Individualized behavioural assessments, flexible approaches to BCT application, involvement from patient peer support and different ways of targeting patient motivation may help to increase healthy behaviour changes in this population.

Preconception care in mental health services: planning for a better future

It is increasingly recognised that the preconception period is a window of opportunity to intervene to improve outcomes for women and the next generation. The importance of preconception mental health and comorbidity problems has not traditionally been taken into account by policy makers or mental health service providers. We argue that by addressing preconception physical and mental health in men and women, medical health professionals could improve health outcomes across the whole life course.

Smoking amongst adults experiencing homelessness: a systematic review of prevalence rates, interventions and the barriers and facilitators to quitting and staying quit

Background

To date, there has been no review of the research evidence examining smoking cessation among homeless adults. The current review aimed to: (i) estimate smoking prevalence in homeless populations; (ii) explore the efficacy of smoking cessation and smoking reduction interventions for homeless individuals; and (iii) describe the barriers and facilitators to smoking cessation and smoking reduction.

Method

Systematic review of peer-reviewed research. Data sources included electronic academic databases. Search terms: ‘smoking’ AND ‘homeless’ AND ‘tobacco’, including adult (18+ years) smokers accessing homeless support services.

Results

Fifty-three studies met the inclusion criteria (n = 46 USA). Data could not be meta-analysed due to large methodological inconsistencies and the lack of randomised controlled trials. Smoking prevalence ranged from 57% to 82%. Although there was no clear evidence on which cessation methods work best, layered approaches with additions to usual care seemed to offer modest enhancements in quit rates. Key barriers to cessation exist around the priority of smoking, beliefs around negative impact on mental health and substance use, and environmental influences.

Conclusions

Homeless smokers will benefit from layered interventions which support many of their competing needs. To best understand what works, future recommendations include the need for consensus on the reporting of cessation outcomes.

Factors that influence participation in physical activity for anxiety or depression: a synthesis of qualitative evidence

This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows:

Main objective: To identify the factors that create barriers or facilitate physical activity for people with a diagnosis of anxiety or depression from the perspectives of service users, carers, service providers and practitioners to help inform the design and implementation of interventions that promote physical activity.

The overall aim of this review is to identify, appraise, and synthesise qualitative research evidence on the barriers and facilitators to engaging in physical activity in general lifestyle settings or as part of an intervention designed to increase physical activity for people with anxiety and depression. This will allow us to identify factors that create barriers and facilitators of physical activity in this population to inform the development, design, and implementation of future interventions. We will also integrate the findings from the QES with the two associated effectiveness reviews (Cooney 2014 ; Larun 2006 ). We will communicate our findings to public health commissioners and other stakeholders.

Lifestyle behaviors among 4,343 Brazilian adults with severe mental illness and 55,859 general population controls: data from the Brazilian National Health Survey

Objective:

To analyze the association between severe mental illnesses and health behaviors among Brazilian adults.

Methods:

We used data from the Brazilian National Health Survey, a large nationally representative cross-sectional study conducted in 2013 among 60,202 adults (≥ 18 years). Clinical diagnoses (major depressive disorder, bipolar disorder and schizophrenia), lifestyle behaviors (leisure-time physical activity, TV viewing, tobacco use and the consumption of alcohol, sweets, and soft drinks) and potential confounders (chronological age, race, educational and employment status) were self-reported. Logistic regression models were used to examine the associations between severe mental illness and lifestyle behaviors, adjusting for confounders.

Results:

Schizophrenia (n=41) was associated with lower odds of physical activity (OR 0.08 [95%CI 0.01-0.58]). Major depressive disorder (n=4,014) was associated with higher odds of TV viewing (OR 1.34 [95%CI 1.12-1.61]), tobacco use (OR 1.37 (95%CI 1.18-1.58]), consumption of sweets (OR 1.34 (95%CI 1.15-1.55]) and consumption of soft drinks (OR 1.24 (95%CI 1.06-1.45]). There were no significant associations between bipolar disorder (n=47) and any lifestyle behaviors.

Conclusions:

Schizophrenia was associated with lower physical activity, while major depressive disorder was associated with increased TV viewing, tobacco use, and consumption of sweets and soft drinks. These findings reinforce the need for prevention and treatment interventions that focus on people with severe mental illness in Brazil.

Interventions to Improve Metabolic Risk Screening Among Adult Patients Taking Antipsychotic Medication: A Systematic Review

OBJECTIVE

Antipsychotic use is associated with elevated cardiometabolic risk. Guidelines for metabolic risk screening of individuals taking antipsychotics have been issued, but with little uptake into clinical practice. This review systematically assessed interventions that address this guideline-to-practice gap and described their quality, improvement strategies, and effect on screening rates.

METHODS

Studies of interventions that addressed metabolic risk screening of adult patients taking antipsychotics, published from inception to July 2018, were selected from MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane Reviews databases. Information was extracted on study characteristics; improvement strategies at the provider, patient, and system levels; and screening rates in the intervention and comparison groups.

RESULTS

The review included 30 complex interventions that used between one and nine unique improvement strategies. Social influence to shift provider and health organization culture to encourage metabolic risk screening was a common strategy, as were clinical prompts and monitoring tools to capture provider attention. Most studies were deemed at high risk of bias. Relative to comparison groups, the interventions were associated with an increase in median screening rates for glucose (28% to 65%), lipids (22% to 61%), weight (19% to 67%), and blood pressure (22% to 80%).

CONCLUSIONS

This knowledge synthesis points to shortcomings of current interventions to improve antipsychotic metabolic risk screening, both in quality and in outcomes. Findings may be used to inform the design of future programs. Additional interventions are needed to address the current guideline-to-practice gap, in which approximately one-third of patients are unscreened for metabolic risk.

Should psychiatrists support the availability of nicotine e-cigarettes in Australia?

OBJECTIVE

To examine the position statement of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) regarding the availability of electronic cigarettes in Australia.

CONCLUSION

There is limited evidence supporting the efficacy of nicotine e-cigarettes as an effective tobacco harm-reduction or cessation strategy for people with mental illness. The recommendations to increase their availability under regulation must be balanced with the physical and mental health risks of vapour inhalation and nicotine use, particularly for youth. Future recommendations by the RANZCP in relation to e-cigarettes must consider both the available evidence for harm reduction and the potential risks associated with youth e-cigarette use.

Effect of lifestyle, medication and ethnicity on cardiometabolic risk in the year following the first episode of psychosis: prospective cohort study

BACKGROUND

The first episode of psychosis is a critical period in the emergence of cardiometabolic risk.

AIMS

We set out to explore the influence of individual and lifestyle factors on cardiometabolic outcomes in early psychosis.

METHOD

This was a prospective cohort study of 293 UK adults presenting with first-episode psychosis investigating the influence of sociodemographics, lifestyle (physical activity, sedentary behaviour, nutrition, smoking, alcohol, substance use) and medication on cardiometabolic outcomes over the following 12 months.

RESULTS

Rates of obesity and glucose dysregulation rose from 17.8% and 12%, respectively, at baseline to 23.7% and 23.7% at 1 year. Little change was seen over time in the 76.8% tobacco smoking rate or the quarter who were sedentary for over 10 h daily. We found no association between lifestyle at baseline or type of antipsychotic medication prescribed with either baseline or 1-year cardiometabolic outcomes. Median haemoglobin A1c (HbA1c) rose by 3.3 mmol/mol in participants from Black and minority ethnic (BME) groups, with little change observed in their White counterparts. At 12 months, one-third of those with BME heritage exceeded the threshold for prediabetes (HbA1c >39 mmol/mol).

CONCLUSIONS

Unhealthy lifestyle choices are prevalent in early psychosis and cardiometabolic risk worsens over the next year, creating an important window for prevention. We found no evidence, however, that preventative strategies should be preferentially directed based on lifestyle habits. Further work is needed to determine whether clinical strategies should allow for differential patterns of emergence of cardiometabolic risk in people of different ethnicities.

Electronic Cigarette Use During a Randomized Trial of Interventions for Smoking Cessation Among Medicaid Beneficiaries with Mental Illness

Objective: People with mental illness have high rates of cigarette smoking, but many wish to quit. Electronic cigarette (e-cigarette) use has become increasingly common, especially among smokers who wish to quit, but research on whether this facilitates quitting has been mixed, and little research has examined e-cigarette use among smokers with mental illness. This secondary analysis examined the associations between spontaneous e-cigarette use during cessation treatment and 6-month outcomes within a cessation trial among Medicaid beneficiaries with mental illness. Main outcomes were previously reported. Methods: Adult Medicaid beneficiaries receiving mental health services were recruited between 2012 and 2015. Eligible daily smokers were randomized, using equipoise stratification, to one of six cessation treatment conditions (combinations of prescriber visit for pharmacotherapy, behavioral interventions, and abstinence incentives; e-cigarette use was not a recommended intervention). Presence of any self-reported e-cigarette use, all tobacco product use, quit attempts, and biologically verified abstinence were assessed at 3, 6, 9, and 12 months. The 456 participants who completed the 6-month assessment were included in logistic regressions, adjusting for subject characteristics and treatment condition, examining associations between self-reported, spontaneous e-cigarette use and 6-month outcomes. We evaluated three outcomes: biologically verified abstinence at 6 months, quit attempts over the treatment period, and heavy smoking (≥20 cigarettes per day) at 6 months. Results: Any use of e-cigarettes was reported by 192 participants (42.1%) during the treatment period. Use of pharmacotherapy was not different between those who used e-cigarettes and those who did not use e-cigarettes. A total of 13.5% of participants (n = 61) had achieved biologically verified abstinence at the 6-month assessment. E-cigarettes were not significantly associated with biologically verified abstinence, use of cessation pharmacotherapy, self-reported quit attempts, or heavy smoking at the 6-month assessment. Conclusions: Spontaneous e-cigarette use during cessation treatment was common among smokers with mental illness and was not associated with positive or negative treatment outcomes. The high rate of naturalistic e-cigarette use in this group suggests that e-cigarettes are an appealing strategy to obtain nicotine during cessation treatment that could be harnessed as a smoking cessation tool or for harm reduction.