Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta-analyses

Electronic cigarette use, related health outcomes and policy interventions in the USA: a call for research to fill evidence gaps

The population-level health consequences of electronic cigarette (e-cigarette) use are heavily debated. This special communication provides updated evidence and identifies knowledge gaps across domains including: (1) health-related outcomes associated with e-cigarette use; (2) initiation and use of e-cigarettes among youth and young adults; (3) concurrent use of electronic and combustible cigarettes; (4) transitions from combustible cigarette use to exclusive e-cigarette use among adults who currently smoke cigarettes and (5) existing e-cigarette-related policy interventions. Literature was searched through PubMed and Medline for systematic reviews, scoping reviews, meta-analyses and primary research articles including emerging topics not covered in reviews published between 1 January 2017 and 1 January 2024. E-cigarette use is associated with several adverse acute health outcomes; there is currently insufficient longitudinal evidence to predict chronic health outcomes. Prevalence of e-cigarette use among youth is considerable and may be associated with subsequent combustible cigarette smoking. Evidence for the health and behavioural impact of dual use of e-cigarettes and combustible cigarettes is limited by imprecise measurement of exposure. Evidence on adults completely substituting combustible cigarettes for e-cigarettes is strong in clinical trials; observational studies do not show complete substitution. Finally, the effects of e-cigarette-related policy interventions to restrict e-cigarette consumption are currently limited in scope and too short-lived to draw causal inferences. Substantial evidence gaps related to the use, associated health impacts and regulation of e-cigarettes in the USA are identified, and we suggest key areas for future research to address that are crucial for informing the public health approach to e-cigarettes.

Interventions for smokeless tobacco use cessation

RATIONALE

While combustible tobacco has been the subject of a very large amount of research, smokeless tobacco products receive less attention. Most smokeless tobacco products are very harmful and cause global health inequality. It is therefore important to identify evidence-based cessation aids.

OBJECTIVES

To assess the effects of behavioural and pharmacological interventions for smokeless tobacco use cessation.

SEARCH METHODS

We searched the following databases from inception to 16 February 2024: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; PsycINFO; ClinicalTrials.gov (through CENTRAL); World Health Organisation International Clinical Trials Registry Platform (through CENTRAL). We also searched references of eligible studies.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) recruiting people of any age using smokeless tobacco, regardless of tobacco smoking status. Eligible studies could test any intervention designed to support people to quit smokeless tobacco use, and had to measure abstinence from either all tobacco use or smokeless tobacco use at six months or longer.

OUTCOMES

The outcome of interest was abstinence from all tobacco use or from smokeless tobacco use at six months or longer.

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess bias in included studies.

SYNTHESIS METHODS

We followed standard Cochrane methods for screening and data extraction. We grouped studies by comparisons of eligible interventions and comparators, reporting individual study and pooled effects as appropriate. We used a random-effects Mantel-Haenszel model for analyses of behavioural interventions and a fixed effect Mantel-Haenszel model for analyses of pharmacotherapies to calculate risk ratios (RR) with 95% confidence intervals (CI). We assessed the certainty of evidence using GRADE.

INCLUDED STUDIES

We included 43 trials of 20,346 people. Thirty-three trials were conducted in North America, five in India, two in Scandinavia, one in Pakistan and one in Turkey. One study was conducted across multiple sites in Bangladesh, India and Pakistan. Studies tested behavioural interventions (e.g. cessation counselling and brief advice) and pharmacotherapies (e.g. nicotine replacement therapy (NRT), varenicline, and bupropion). We judged five studies to be at low risk of bias overall, 22 at high risk of bias, and the remaining 16 at unclear risk of bias.

SYNTHESIS OF RESULTS

We found moderate-certainty evidence of increased quit rates from counselling compared with minimal support (RR 1.76, 95% CI 1.44 to 2.16; I2 = 69%; 21 studies, n = 7417; downgraded because of heterogeneity), brief advice compared with no support (RR 1.24, 95% CI 1.03 to 1.48; I2 = 49%; 7 studies, n = 6271; downgraded because of imprecision), and varenicline compared with placebo (RR 1.35, 95% CI 1.08 to 1.68; I2 = 0%; 2 studies, n = 508; downgraded because of imprecision). We found low-certainty evidence (downgraded because of imprecision and risk of bias) of increased quit rates from NRT compared with placebo or no medication (RR 1.18, 95% CI 1.05 to 1.33; I2 = 39%; 11 studies, n = 2826). Low-certainty evidence (downgraded because of imprecision) did not show benefit from bupropion compared with placebo (RR 0.89, 95% CI 0.54 to 1.44; I2 = 0%; 2 studies, n = 293). We planned subgroup analyses to explore whether smokeless tobacco type affects intervention efficacy, but found insufficient data.

AUTHORS' CONCLUSIONS

Cessation counselling, brief advice, and varenicline each probably help more people to quit smokeless tobacco use than minimal or no support, or placebo. NRT may help more people to quit smokeless tobacco use than placebo or no medication. Low-certainty evidence does not currently support bupropion as a smokeless tobacco cessation intervention. Despite the majority of smokeless tobacco users living in South and Southeast Asia, only a minority of trials are conducted in those regions. Future trials should address this imbalance.

FUNDING

None REGISTRATION: Protocol available via DOI: 10.1002/14651858.CD015314.

Trends and patterns of dual use of combustible tobacco and e-cigarettes among adults in England: A population study, 2016-2024

BACKGROUND/AIMS

E-cigarettes are frequently used by people who smoke. This study measured how the prevalence and patterns of smoking and vaping ('dual use') in England have changed as the vaping market has rapidly evolved.

DESIGN

Representative monthly cross-sectional survey, July 2016 to April 2024.

SETTING

England.

PARTICIPANTS

128 588 adults (≥18y).

MEASUREMENTS

Logistic regression estimated associations between survey wave and dual use. Descriptive statistics were used to analyse patterns of smoking and vaping, overall and by sociodemographic, smoking and vaping characteristics and harm perceptions of e-cigarettes vs. cigarettes.

FINDINGS

Across the period, the overall prevalence of dual use increased non-linearly from 3.5% to 5.2% of adults [prevalence ratio (PR) = 1.49 (1.25-1.76)]. Among adults who smoked, the proportion who also vaped was relatively stable up to mid-2021, at an average of 18.6% between July 2016 and May 2021, then increased rapidly to 34.2% by April 2024 [PR = 1.76 (1.48-2.09)]. This increase was greatest at younger ages [e.g. from 19.6% to 59.4% among 18- to 24-year-olds; PR = 3.04 (2.28-4.23)]. The most common pattern of dual use across the period was daily cigarette smoking with daily vaping [49.0% (47.3-50.8%)]. Over time, the proportion of dual users reporting daily cigarette smoking with non-daily vaping decreased [from 35.2% to 15.0%; PR = 0.43 (0.29-0.63)], offset primarily by an increase in the proportion reporting non-daily cigarette smoking with daily vaping [from 7.6% to 21.5%; PR = 2.84 (1.71-4.72)]. Daily cigarette smoking with daily vaping was more common (and non-daily cigarette smoking with daily vaping less common) among dual users who were older, less advantaged, mainly smoked hand-rolled cigarettes, had stronger urges to smoke and had been vaping for ≤6 months. Daily vaping was more common among dual users who thought e-cigarettes were less/equally harmful as cigarettes, or were unsure.

CONCLUSIONS

In England, vaping prevalence has increased rapidly among adults who smoke since 2021, which was when disposable e-cigarettes started to become popular. Since 2016, patterns of dual use have shifted away from more frequent smoking towards more frequent vaping. This may be the result of increasing prevalence of dual use among younger adults, who are more likely than older dual users to smoke non-daily and vape daily.

The budget impact analysis of nicotine replacement therapy among patients who smoke tobacco and have mental illness in South Africa and the implications

BACKGROUND

Tobacco use is the world's leading preventable cause of death, with the highest burden in low and middle-income countries (LMICs). Those who have mental illness are particularly vulnerable, with a smoking rate two to five times higher than that of the general population. Quitting smoking has demonstrated benefits for mental health, including reducing stress and improving the quality of life. However, the economic feasibility of introducing Nicotine Replacement Therapy (NRT) in the psychiatric medical environment in South Africa has not yet been explored. This study aims to address this gap by assessing the impact on the budget of implementing an NRT-based smoking cessation program in a psychiatric hospital.

METHODS

This retrospective and cross-sectional study followed a budget impact analysis framework. Data were retrieved between May 19 and Aug 18, 2023, from 214 patients' medical records. Using primary and secondary data, an ingredients costing approach was used to estimate direct treatment costs of NRT smoking cessation. All costs were expressed in ZAR (South African currency). The economic evaluation was conducted from the payer's perspective, and the results were reported at a 5% discount rate. A two-way 10% sensitivity analysis was conducted.

RESULTS

The study showed that study participants were primarily black, male, unemployed, diagnosed with schizophrenia and smoked lightly (69.16% ±3.46). Implementing the 3-month treatment period of NRT smoking cessation program would result in an expenditure of R1 478 915.42 for 214 patients. The hospital will require an additional 0.15% (±0.0095) of the total hospital budget and 6.09% (±0.31) of the hospital pharmacy budget.

CONCLUSION

Our findings indicate that while implementing a NRT is crucial for improving the overall health outcomes among patients with mental illnesses, substantial investment would be required. The budgetary allocation for NRT smoking cessation interventions would vary by treatment settings and program duration. Consequently, careful consideration of budget allocation and resource distribution is necessary to ensure the program's sustainability within the broader healthcare framework in South Africa.

Use of low-dose varenicline in patients who do not tolerate standard-dose varenicline: A longitudinal case series

INTRODUCTION

Although varenicline tartrate is the most effective monotherapy for smoking cessation, the standard-dose (1 mg twice daily) is associated with adverse events: gastrointestinal, sleep-related, and mood-related. Lower doses have demonstrated similar efficacy with lower adverse event incidence. The purpose of this study was to determine whether patients who previously discontinued standard-dose varenicline due to adverse events could tolerate and benefit from low-dose varenicline.

METHODS

We conducted a prospective longitudinal pilot study of 22 adult daily smokers in Durham NC, USA, in 2022. All participants previously discontinued standard-dose varenicline due to adverse events. These patients were prescribed either 0.5 mg twice daily for varenicline-related nausea or 1 mg in the morning for sleep problems. The primary outcome was change in self-reported adverse event severity (scale: 0-7). Secondary outcomes were smoking abstinence at 6-week follow-up and tolerance of the lower dose.

RESULTS

Patients with intolerable nausea reported significant severity reduction (6.00 to 0.00; p<0.001) as did patients with intolerable vivid dreams (3.27 to 0.27; p=0.001). Smoking abstinence rates were 28.6% for 0.5 mg twice daily and 26.7% for 1 mg once daily. Low-dose varenicline tolerance was 81.8%.

CONCLUSIONS

Patients who experience significant nausea with standard-dose varenicline may successfully make transition to a 0.5 mg low dose twice daily and those who experience vivid dreams to 1 mg varenicline in the morning. Treatment efficacy rates remained relatively high. This suggests a need for a future randomized controlled trial to establish low-dose varenicline as an approach for patients who do not tolerate the standard-dose varenicline.

Utilization and Experiences of Using Quit Now, a Nicotine and Tobacco Smoking Cessation Website: Thematic Analysis

BACKGROUND

British Columbia residents have access to a program called QuitNow that provides behavioral support and information about pharmacotherapy to nicotine and tobacco users. Web- or computer-based smoking cessation programs have been shown to yield an abstinence rate about 1.5 times higher when compared to a control. Although quantitative evidence reveals significant promise for web-based services like QuitNow, there is very little qualitative evidence available. Understanding website utilization and the experiences of end users is key to contextualizing the effectiveness of web-based cessation services and providing directions for enhancing these services.

OBJECTIVE

This qualitative interview study aims to delve into users' utilization and experiences of QuitNow, which is supplemented by Google Analytics data.

METHODS

We interviewed 10 QuitNow users using semistructured interviews to understand what they liked the most and the least about QuitNow. We transcribed these interviews and conducted an inductive thematic analysis using NVivo (QSR International) software to extract common themes about user experiences. We also gathered utilization metrics via Google Analytics (n=13,856 users) to understand which aspects of QuitNow were used the most and which were used the least during the study period.

RESULTS

Thematic analysis yielded four major themes: (1) barriers to information access reduce opportunities to take action, (2) lack of clarity around pharmacological options is discouraging, (3) hearing from others is an important part of the journey, and (4) recognizing own agency throughout the quit process. These themes provided context and support for the Google Analytics data, which showed that end user activity, measured by indicators such as page views and average time spent on each page, was highest on pages about how to quit (10,393 page views), pharmacology information (1999 page views), and the community forum (11,560 page views).

CONCLUSIONS

Results of this study point to several important implications for improving the website, as well as directions for enhancing cessation support services in general.

Nicotine replacement therapy as a smoking cessation tool for adolescents: an update

Background

Adolescent smoking is a significant public health concern, as early nicotine addiction leads to more severe addiction and reduced cessation success during adulthood. While nicotine replacement therapy (NRT) is an effective smoking cessation tool in adults, its efficacy in adolescents is less clear.

Objective

This systematic review evaluates the effectiveness and safety of NRT for smoking cessation in adolescents.

Methods

A comprehensive search of PubMed and Cochrane Library databases identified 12 studies (randomized controlled trials and observational) examining NRT in adolescents. Outcomes included smoking cessation rates, withdrawal symptom relief, smoking reduction, and adverse events.

Results

NRT demonstrated limited success in long-term smoking cessation among adolescents, with low cessation rates that often declined post-treatment. However, NRT was effective in reducing smoking frequency and in managing withdrawal symptoms in some cases. The safety profile was generally favourable, with mild side effects such as skin irritation, headaches, and nausea.

Conclusion

While NRT can reduce smoking and alleviate withdrawal symptoms, its effectiveness in sustaining long-term cessation in adolescents is limited. Adherence challenges and side effects suggest a need for complementary behavioural support and further research into tailored NRT strategies for this population.

Smoking Cessation Strategies After Acute Coronary Syndrome

Smoking is one of the strongest modifiable risk factors for coronary artery disease. It is the cause of approximately 10-30% of deaths due to cardiovascular disease around the world. There is a 50% reduction in the risk of myocardial infarction by one year for people who successfully quit smoking. Considering the risk associated with smoking and the benefits of smoking cessation, it is important to identify and implement effective smoking cessation strategies. There are pharmacological as well as non-pharmacological interventions to assist in smoking cessation. Pharmacological therapies including nicotine replacement therapy; bupropion and varenicline have generally been studied more in patients with cardiovascular disease than the non-pharmacological interventions. Non-pharmacological strategies for smoking cessation include behavioural interventions such as counselling sessions and cognitive behavioural therapy. Studies and randomised controlled trials have demonstrated the safety of most of the pharmacological interventions. Nonetheless, the success rates are variable for the different pharmacological options. Data suggest that greater success can be achieved in smoking cessation with a combination of pharmacological and non-pharmacological treatment. However, more studies are needed to explore the best therapeutic options to improve the success of smoking cessation.

Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: Primary objectives To evaluate the benefits and harms of oral nicotine pouches when used to help people transition away from combustible tobacco use (smoking) To evaluate the impact of oral nicotine products on the prevalence of combustible tobacco use Secondary objectives To evaluate the benefits and harms of oral nicotine pouches when used to help people transition away from other non-combustible tobacco/commercial nicotine product use To evaluate the impact of oral nicotine products on the prevalence of use of other non-combustible tobacco/commercial nicotine products.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices that produce an aerosol by heating an e-liquid. People who smoke, healthcare providers, and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the safety, tolerability, and effectiveness of using EC to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments, and no treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 February 2024 and the Cochrane Tobacco Addiction Group's Specialized Register to 1 February 2023, reference-checked, and contacted study authors.

SELECTION CRITERIA

We included trials randomizing people who smoke to an EC or control condition. We included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report an eligible outcome.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. We used the risk of bias tool (RoB 1) and GRADE to assess the certainty of evidence. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). Important outcomes were biomarkers, toxicants/carcinogens, and longer-term EC use. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA).

MAIN RESULTS

We included 90 completed studies (two new to this update), representing 29,044 participants, of which 49 were randomized controlled trials (RCTs). Of the included studies, we rated 10 (all but one contributing to our main comparisons) at low risk of bias overall, 61 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. Nicotine EC results in increased quit rates compared to nicotine replacement therapy (NRT) (high-certainty evidence) (RR 1.59, 95% CI 1.30 to 1.93; I2 = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more). The rate of occurrence of AEs is probably similar between groups (moderate-certainty evidence (limited by imprecision)) (RR 1.03, 95% CI 0.91 to 1.17; I2 = 0%; 5 studies, 2052 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.20, 95% CI 0.90 to 1.60; I2 = 32%; 6 studies, 2761 participants; low-certainty evidence). Nicotine EC probably results in increased quit rates compared to non-nicotine EC (moderate-certainty evidence, limited by imprecision) (RR 1.46, 95% CI 1.09 to 1.96; I2 = 4%; 6 studies, 1613 participants). In absolute terms, this might lead to an additional three quitters per 100 (95% CI 1 to 7 more). There is probably little to no difference in the rate of AEs between these groups (moderate-certainty evidence) (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 9 studies, 1412 participants; low-certainty evidence). Compared to behavioural support only/no support, quit rates may be higher for participants randomized to nicotine EC (low-certainty evidence due to issues with risk of bias) (RR 1.96, 95% CI 1.66 to 2.32; I2 = 0%; 11 studies, 6819 participants). In absolute terms, this represents an additional four quitters per 100 (95% CI 3 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC (RR 1.18, 95% CI 1.10 to 1.27; I2 = 6%; low-certainty evidence; 6 studies, 2351 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.93, 95% CI 0.68 to 1.28; I2 = 0%; 12 studies, 4561 participants; very low-certainty evidence). Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes. There was inconsistency in the AE network, which was explained by a single outlying study contributing the only direct evidence for one of the nodes. Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons; hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care or no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were, for the most part, wide for data on AEs, SAEs, and other safety markers, with no evidence for a difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT, but low-certainty evidence for increased AEs compared with behavioural support/no support. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longer, larger studies are needed to fully evaluate EC safety. Our included studies tested regulated nicotine-containing EC; illicit products and/or products containing other active substances (e.g. tetrahydrocannabinol (THC)) may have different harm profiles. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Differences in the effectiveness of individual-level smoking cessation interventions by socioeconomic status

BACKGROUND

People from lower socioeconomic groups are more likely to smoke and less likely to succeed in achieving abstinence, making tobacco smoking a leading driver of health inequalities. Contextual factors affecting subpopulations may moderate the efficacy of individual-level smoking cessation interventions. It is not known whether any intervention performs differently across socioeconomically-diverse populations and contexts.

OBJECTIVES

To assess whether the effects of individual-level smoking cessation interventions on combustible tobacco cigarette use differ by socioeconomic groups, and their potential impact on health equalities.

SEARCH METHODS

We searched the Cochrane Database of Systematic Reviews from inception to 1 May 2023 for Cochrane reviews investigating individual-level smoking cessation interventions. We selected studies included in these reviews that met our criteria. We contacted study authors to identify further eligible studies.

SELECTION CRITERIA

We included parallel, cluster or factorial randomised controlled trials (RCTs) investigating any individual-level smoking cessation intervention which encouraged complete cessation of combustible tobacco cigarette use compared to no intervention, placebo, or another intervention in adults. Studies must have assessed or reported smoking quit rates, split by any measure of socioeconomic status (SES) at longest follow-up (≥ six months), and been published in 2000 or later.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening, data extraction, and risk of bias assessment. We assessed the availability of smoking abstinence data by SES in lieu of selective reporting. The primary outcome was smoking cessation quit rates, split by lower and higher SES, at the longest follow-up (≥ six months). Where possible, we calculated ratios of odds ratios (ROR) with 95% confidence intervals (CIs) for each study, comparing lower to higher SES. We pooled RORs by intervention type in random-effects meta-analyses, using the generic inverse-variance method. We subgrouped by type of SES indicator and economic classification of the study country. We summarised all evidence in effect direction plots and categorised the intervention impact on health equality as: positive (evidence that the relative effect of the intervention on quit rates was greater in lower rather than higher SES groups), possibly positive, neutral, possibly neutral, possibly negative, negative, no reported statistically significant difference, or unclear. We evaluated certainty using GRADE.

MAIN RESULTS

We included 77 studies (73 from high-income countries), representing 127,791 participants. We deemed 12 studies at low overall risk of bias, 13 at unclear risk, and the remaining 52 at high risk. Included studies investigated a range of pharmacological interventions, behavioural support, or combinations of these. Pharmacological interventions We found very low-certainty evidence for all the main pharmacological interventions compared to control. Evidence on cytisine (ROR 1.13, 95% CI 0.73 to 1.74; 1 study, 2472 participants) and nicotine electronic cigarettes (ROR 4.57, 95% CI 0.88 to 23.72; 1 study, 989 participants) compared to control indicated a greater relative effect of these interventions on quit rates in lower compared to higher SES groups, suggesting a possibly positive impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring higher SES groups. There was a lower relative effect of bupropion versus placebo on quit rates in lower compared to higher SES groups, indicating a possibly negative impact on health equality (ROR 0.05, 95% CI 0.00 to 1.00; from 1 of 2 studies, 354 participants; 1 study reported no difference); however, the CI included the possibility of no clinically important difference. We could not determine the intervention impact of combination or single-form nicotine replacement therapy on relative quit rates by SES. No studies on varenicline versus control were included. Behavioural interventions We found low-certainty evidence of lower quit rates in lower compared to higher SES groups for print-based self-help (ROR 0.85, 95% CI 0.52 to 1.38; 3 studies, 4440 participants) and text-messaging (ROR 0.76, 95% CI 0.47 to 1.23; from 3 of 4 studies, 5339 participants; 1 study reported no difference) versus control, indicating a possibly negative impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring lower SES groups. There was very low-certainty evidence of quit rates favouring higher SES groups for financial incentives compared to balanced intervention components. However, the CI included the possibility of no clinically important difference and of favouring lower SES groups (ROR 0.91, 95% CI 0.45 to 1.85; from 5 of 6 studies, 3018 participants; 1 study reported no difference). This indicates a possibly negative impact on health equality. There was very low-certainty evidence of no difference in quit rates by SES for face-to-face counselling compared to less intensive counselling, balanced components, or usual care. However, the CI included the possibility of favouring lower and higher SES groups (ROR 1.26, 95% CI 0.18 to 8.93; from 1 of 6 studies, 294 participants; 5 studies reported no difference), indicating a possibly neutral impact. We found very low-certainty evidence of a greater relative effect of telephone counselling (ROR 4.31, 95% CI 1.28 to 14.51; from 1 of 7 studies, 903 participants; 5 studies reported no difference, 1 unclear) and internet interventions (ROR 1.49, 95% CI 0.99 to 2.25; from 1 of 5 studies, 4613 participants; 4 studies reported no difference) versus control on quit rates in lower versus higher SES groups, suggesting a possibly positive impact on health equality. The CI for the internet intervention estimate included the possibility of no difference. Although the CI for the telephone counselling estimate only favoured lower SES groups, most studies narratively reported no clear evidence of interaction effects.

AUTHORS' CONCLUSIONS

Currently, there is no clear evidence to support the use of differential individual-level smoking cessation interventions for people from lower or higher SES groups, or that any one intervention would have an effect on health inequalities. This conclusion may change as further data become available. Many studies did not report sufficient data to be included in a meta-analysis, despite having tested the association of interest. Further RCTs should collect, analyse, and report quit rates by measures of SES, to inform intervention development and ensure recommended interventions do not exacerbate but help reduce health inequalities caused by smoking.

Interventions for quitting vaping

RATIONALE

There is limited guidance on the best ways to stop using nicotine-containing vapes (otherwise known as e-cigarettes) and ensure long-term abstinence, whilst minimising the risk of tobacco smoking and other unintended consequences. Treatments could include pharmacological interventions, behavioural interventions, or both.

OBJECTIVES

To conduct a living systematic review assessing the benefits and harms of interventions to help people stop vaping compared to each other or to placebo or no intervention. To also assess how these interventions affect the use of combustible tobacco, and whether the effects vary based on participant characteristics.

SEARCH METHODS

We searched the following databases from 1 January 2004 to 24 April 2024: CENTRAL; MEDLINE; Embase; PsycINFO; ClinicalTrials.gov (through CENTRAL); World Health Organization International Clinical Trials Registry Platform (through CENTRAL). We also searched the references of eligible studies and abstracts from the Society for Research on Nicotine and Tobacco 2024 conference, and contacted study authors.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) recruiting people of any age using nicotine-containing vapes, regardless of tobacco smoking status. Studies had to test an intervention designed to support people to quit vaping, and plan to measure at least one of our outcomes.

OUTCOMES

Critical outcomes: vaping cessation; change in combustible tobacco use at six months or longer; number of participants reporting serious adverse events (SAEs) at one week or longer.

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess bias in the included studies.

SYNTHESIS METHODS

We followed standard Cochrane methods for screening and data extraction. We grouped studies by comparisons and outcomes reported, and calculated individual study and pooled effects, as appropriate. We used random-effects Mantel-Haenszel methods to calculate risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes. We used random-effects inverse variance methods to calculate mean differences and 95% CI for continuous outcomes. We assessed the certainty of the evidence using the GRADE approach.

INCLUDED STUDIES

Nine RCTs, representing 5209 participants motivated to stop using nicotine-containing vapes at baseline, are included. In six studies, participants were abstinent from smoking tobacco cigarettes at baseline, although most studies included some participants who had previously smoked. Eight studies included participants aged 18 or older, three included only young adults (18 to 24 years), and one included 13- to 17-year-olds only. We judged three studies at low risk, three at high risk, and three at unclear risk of bias.

SYNTHESIS OF RESULTS

Pharmacological interventions for quitting nicotine vaping Studies assessed combination nicotine replacement therapy (NRT), cytisine, and varenicline as pharmacological interventions for quitting vaping in comparison to placebo or no/minimal support (control). The point estimate for combination NRT indicated possible benefit, but the CI incorporated the possibility of no benefit and a potential benefit of control (very low-certainty evidence due to imprecision and risk of bias; RR 2.57, 95% CI 0.29 to 22.93; 1 study, 16 participants). The one study investigating cytisine did not report vaping cessation rates at six months or longer. Varenicline increased vaping cessation rates at six months, but the evidence was low certainty due to imprecision (RR 2.00, 95% CI 1.09 to 3.68; 1 study, 140 participants). Zero participants reported SAEs in the studies of combination NRT versus no/minimal support (1 study, 508 participants; low-certainty evidence due to imprecision) and cytisine versus placebo (1 study, 159 participants; low-certainty evidence due to imprecision). Three studies investigating varenicline measured the number of participants reporting SAEs. However, only one study reported an SAE (in the intervention arm); therefore, the effect estimate was calculated based on that single study (RR 2.60, 95% CI 0.11 to 62.16; 95 participants; low-certainty evidence due to imprecision). Behavioural interventions for quitting nicotine vaping Studies assessed reducing nicotine concentration and vaping behaviour (1 study) and text message-based interventions (3 studies) as behavioural interventions for stopping vaping in comparison to no/minimal support (control). In one study, the point estimate suggested nicotine/vaping reduction increased vaping cessation compared to minimal support at six-month follow-up, but the CI incorporated the possibility of no intervention effect and higher cessation rates in the control arm (RR 3.38, 95% CI 0.43 to 26.30; 17 participants; very low-certainty due to imprecision and risk of bias). There was low-certainty evidence (downgraded two levels due to indirectness) that text message-based interventions may have increased vaping cessation rates compared to control in 13- to 24-year-olds (RR 1.32, 95% CI 1.19 to 1.47; I2 = 0%; 2 studies, 4091 participants). The one study investigating nicotine/vaping behaviour reduction did not report on SAEs. One of the studies investigating text message-based interventions did report on SAEs; however, zero events were reported in both study arms (508 participants; low-certainty evidence due to imprecision). No studies reported change in combustible tobacco smoking at six-month follow-up or longer.

AUTHORS' CONCLUSIONS

There is low-certainty evidence that text message-based interventions designed to help people stop nicotine vaping may help more youth and young adults to successfully stop than no/minimal support, and low-certainty evidence that varenicline may also help people quit vaping. Data exploring the effectiveness of combination NRT, cytisine, and nicotine/vaping behaviour reduction are inconclusive due to risk of bias and imprecision. Most studies that measured SAEs reported none; however, more data are needed to draw clear conclusions. Of note, data from studies investigating these interventions for quitting smoking have not demonstrated serious concerns about SAEs. No studies assessed the change in combustible tobacco smoking, including relapse to or uptake of tobacco smoking, at six-month follow-up or longer. It is important that future studies measure this so the complete risk profile of relevant interventions can be considered. We identified 20 ongoing RCTs. Their incorporation into the evidence base and the continued identification of new studies is imperative to inform clinical and policy guidance on the best ways to stop vaping. Therefore, we will continue to update this review as a living systematic review by running searches monthly and updating the review when relevant new evidence that will strengthen or change our conclusions emerges.

FUNDING

Cancer Research UK (PRCPJT-Nov22/100012). National Institute of Health Research (NIHR206123) REGISTRATION: Protocol available via DOI: 10.1002/14651858.CD016058.

Effect of nicotine mouth spray on urges to vape: A randomized, placebo-controlled, pharmacodynamic clinical trial in exclusive e-cigarette users

AIMS

To determine whether nicotine mouth spray provides rapid and prolonged relief of urges to vape and measure the steady-state plasma nicotine levels during vaping and ad libitum mouth spray usage in e-cigarette users.

DESIGN

Randomized, parallel group, double-blind trial.

SETTING

Single site at Hammersmith Medicines Research Ltd (HMR), London, UK.

PARTICIPANTS

216 (25.9% females, average age 27.6 ± 7.63 [standard deviation, SD]) exclusive vapers who used their e-cigarette within 30 minutes of waking up and had vaped about 2 years on average.

INTERVENTIONS

Two sprays of 1 mg nicotine mouth spray (Nicorette QuickMist Freshmint, n = 109), or placebo (identical in appearance and presentation, n = 107).

MEASUREMENTS

Urge to vape was rated on a 100 mm visual analogue scale before and repeatedly for 2 hours after administration. The primary outcome measured average change from baseline in urges to vape ratings during the first hour.

FINDINGS

Nicotine mouth spray achieved statistically significantly greater reductions in urges to vape than placebo from the first assessment point at 30 seconds to 1 hour, when the estimated mean treatment difference was 11.90 mm (95% confidence interval [CI] = 6.86-16.95, P < 0.001). The integrated urge to vape over 11 hours ad libitum usage showed a statistically significant benefit compared with placebo (2.00 [0.88 SD] vs 2.51 [0.84 SD], P < 0.001). Mean steady-state plasma nicotine concentrations were lower after nicotine mouth spray usage compared with vaping (6.22 [4.70 SD] ng/ml vs 9.91 [7.59 SD] ng/ml, respectively). Adverse events were more commonly reported in the nicotine mouth spray group and were mostly mild.

CONCLUSIONS

Among regular e-cigarette users, nicotine mouth spray provided statistically significant and fast relief of urges to vape one hour after dosing. Nicotine mouth spray showed statistically significant reductions in urges to vape as soon as 30 seconds and up to 2 hours after dosing compared with placebo, and nicotine mouth spray was well-tolerated and safe.

The Saudi Thoracic Society Evidence-based guidelines for the diagnosis and management of chronic obstructive pulmonary disease

The Saudi Thoracic Society (STS) developed an updated evidence-based guideline for diagnosing and managing chronic obstructive pulmonary disease (COPD) in Saudi Arabia. This guideline aims to provide a comprehensive and unbiased review of current evidence for assessing, diagnosing, and treating COPD. While epidemiological data on COPD in Saudi Arabia are limited, the STS panel believes that the prevalence is increasing due to rising rates of tobacco smoking. The key objectives of the guidelines are to facilitate accurate diagnosis of COPD, identify the risk for COPD exacerbations, and provide recommendations for relieving and reducing COPD symptoms in stable patients and during exacerbations. A unique aspect of this guideline is its simplified, practical approach to classifying patients into three classes based on symptom severity using the COPD Assessment Test and the risk of exacerbations and hospitalizations. The guideline provides the reader with an executive summary of recommended COPD treatments based on the best available evidence and also addresses other major aspects of COPD management and comorbidities. This guideline is primarily intended for use by internists and general practitioners in Saudi Arabia.

Smoking cessation and harm reduction: a systematic overview of ongoing, randomized controlled trials

BACKGROUND

Smoking remains one of the major public health threats, necessitating substantial scientific and societal interest in further developing and implementing systematic, smoking cessation trials. This review examines ongoing randomized controlled trials (RCTs) on smoking cessation and harm reduction, focusing on adherence to German S3 guidelines for tobacco dependence and identifying areas needing further research and neglected aspects in the implementation of treatment guidelines for tobacco dependence.

METHODS

A systematic search was conducted on the International Clinical Trials Registry Platform, comprising multiple trial registries worldwide, to identify ongoing RCTs focusing on smoking cessation and harm reduction. Utilizing the PICOS-scheme, we focused on trials targeting the general population, with biochemical verification, psychological counseling, telemedicine, and nicotine replacement therapy /smoking cessation medication or electronic nicotine delivery systems. Exclusion criteria included trials marked as "completed," "terminated," "unknown," or "withdrawn.".

RESULTS

The review identified 30 ongoing RCTs, with a majority located in North America. A significant number of trials focus on socioeconomically disadvantaged or uninsured populations, while few address cancer survivors or individuals with smoking-related diseases. Nicotine replacement therapy or smoking cessation medication is consistently used across trials, but with varying regimens. Psychotherapeutic interventions are employed in 22 trials, with motivational interviewing being the most common method. Only four trials utilize electronic nicotine delivery systems as a harm reduction strategy. The lack of standardized reporting in trial registries was a significant barrier to synthesizing and categorizing information. Geographic representation is predominantly in North America, suggesting a need for more diverse trial locations.

CONCLUSIONS

There is a critical need for more RCTs involving electronic nicotine delivery systems and tailored psychotherapeutic interventions. Expanding trial locations beyond North America and standardizing trial reporting could enhance the global applicability of smoking cessation strategies. Future research should focus on the long-term risks and benefits of electronic nicotine delivery systems, particularly in high-risk populations. This approach will aid in developing more effective and culturally relevant smoking cessation guidelines.

Potential Policy Targets to Reduce Vaping Among Youths

This cross-sectional study uses Population Assessment of Tobacco and Health study data to estimate the association between different policy targets and electronic nicotine delivery system use among US youths compared with adults.

The impact of voluntary wheel-running exercise on hippocampal neurogenesis and behaviours in response to nicotine cessation in rats

RATIONALE

The literature indicates that nicotine exposure or its discontinuation impair adult hippocampal neurogenesis in rats, though the impact of exercise on this process remains unclear. We have previously shown that disturbances in the number of doublecortin (DCX, a marker of immature neurons)-positive (DCX+) cells in the dentate gyrus (DG) of the hippocampus during nicotine deprivation may contribute to a depression-like state in rats.

OBJECTIVES

This study aimed to investigate the effect of running on hippocampal neurogenesis, depression-like symptoms, and drug-seeking behaviour during nicotine deprivation.

METHODS

The rats were subjected to nicotine (0.03 mg/kg/inf) self-administration via an increasing schedule of reinforcement. After 21 sessions, the animals entered a 14-day abstinence phase during which they were housed in either standard home cages without wheels, cages equipped with running wheels, or cages with locked wheels.

RESULTS

Wheel running increased the number of Ki-67+ and DCX+ cells in the DG of both nicotine-deprived and nicotine-naive rats. Wheel-running exercise evoked an antidepressant effect on abstinence Day 14 but had no effect on nicotine-seeking behaviour on abstinence Day 15 compared to rats with locked-wheel access.

CONCLUSIONS

In summary, long-term wheel running positively affected the number of immature neurons in the hippocampus, which corresponded with an antidepressant response in nicotine-weaned rats. One possible mechanism underlying the positive effect of running on the affective state during nicotine cessation may be the reduction in deficits in DCX+ cells in the hippocampus.

E-cigarettes and vaping, new spotlight on smoking as an old cardiovascular risk factor?

Smoking is one of the leading causes of chronic non-communicable diseases and a significant risk factor for cardiovascular and respiratory diseases. While global tobacco consumption has decreased over the past two decades, the use of e‑cigarettes and water pipes (shisha) has surged at an alarming rate, particularly among younger individuals. E‑cigarettes do not offer a completely risk-free alternative to traditional cigarettes, as the vast array of flavors and ease of use contribute to a growing number of dependent users. Furthermore, they are not necessarily effective in overcoming nicotine addiction. This contribution provides an overview of the cardiovascular health impacts associated with shisha smoking and e‑cigarette vaping, with a particular emphasis on the detrimental effects on endothelial function. The harmful biological effects of the toxic substances in these products, especially oxidative stress and inflammatory responses, are also discussed. Finally, the current state of recommendations, legal regulations, and commercial advertising are summarized.

Smokers' Characteristics Associated with Successful Smoking Cessation Undergoing Pharmacotherapy in Slovenia

Introduction

Tobacco use is a major global health problem, contributing to premature death and disability. In Slovenia, the prevalence of smoking is higher than the EU average, emphasizing the need for effective tobacco control measures. The aim of this study was to identify the characteristics of patients most likely to benefit from pharmacotherapy for smoking cessation.

Methods

We performed cross-sectional analysis of factors associated with successful smoking cessation using pharmacotherapy for Slovenian smokers. A total of 176 (24.6%) smokers with an average age of 50 years agreed to receive pharmacotherapy for their smoking cessation attempt and were enrolled in the study. Participants were followed up at 4-week intervals during treatment and for 24 weeks after completion of pharmacotherapy.

Results

Attempts to quit smoking with prescription medications were successful in 24.4% of those willing to try. Female smokers, older persons, those with more children, with a lower self-perception of health, a higher number of cigarettes per day and a higher nicotine dependence were more likely to attempt to quit smoking. However, the strongest predictors of smoking cessation success were lower nicotine dependence, which was tested using the Fagerström test for nicotine dependence, and higher adherence to pharmacotherapy.

Conclusion

Nicotine dependence and adherence to pharmacotherapy are the strongest predictors of a successful smoking cessation attempt. Identification of potential responders, prescription of pharmacotherapy and follow-up are applicable in the primary healthcare setting.

Use, perceptions, and effectiveness of e-cigarettes for smoking cessation among older adults in England: a population study, 2014-2024

BACKGROUND

This study aimed to characterise patterns of tobacco smoking and vaping among older adults (≥ 65 years) in England, to explore harm perceptions of e-cigarettes among those who smoke, and to estimate the real-world effectiveness of e-cigarettes for helping older adults to stop smoking.

METHODS

Data were collected as part of a representative monthly cross-sectional household survey in England between April 2014 and April 2024 (n = 197,219). We analysed differences between older (≥ 65 years) and younger/middle-aged adults (18-64 years) in (a) time trends in tobacco smoking and vaping, (b) harm perceptions of e-cigarettes vs. cigarettes (adjusting for gender, socioeconomic position, and vaping status), and (c) the real-world effectiveness of e-cigarettes for smoking cessation (adjusting for gender, socioeconomic position, characteristics of the quit attempt, and use of other evidence-based cessation aids).

RESULTS

Tobacco smoking prevalence remained relatively unchanged over time among older adults (at ~ 9%; 9.5% [8.5-10.6%] in April 2014 and 8.7% [7.7-9.8%] in April 2024) but vaping prevalence increased (from 2.1% [1.6-2.7%] to 3.7% [3.0-4.6%], respectively). These trends differed from those observed among younger/middle-aged adults, among whom there was a clear decline in smoking (from 21.8% [21.0-22.7%] to 18.2% [17.3-19.0%]) and a larger increase in vaping (from 5.6% [5.2-6.1%] to 16.2% [15.3-17.0%]). Older adults were consistently less likely than younger/middle-aged adults to use e-cigarettes to support attempts to quit smoking (26.8% [17.2-39.3%] vs. 43.7% [39.6-48.0%] in April 2024). Older smokers reported greater uncertainty about the harms of e-cigarettes compared with cigarettes (ORadj = 2.48 [2.28-2.69]). E-cigarettes appeared to be effective for helping older adults to stop smoking (ORadj = 1.50 [0.96-2.34]); whether effectiveness was lower than for younger/middle-aged adults was inconclusive.

CONCLUSIONS

Over the past decade, smoking prevalence has remained stable among older adults while decreasing among the rest of the adult population in England. Older adults are more unsure about the relative harms of e-cigarettes and less likely to use them to support attempts to quit smoking, despite evidence that they are effective for smoking cessation in this population.

Long-Term Effectiveness of a Quitline for Smoking Cessation: Results of a Randomized Controlled Trial

INTRODUCTION

Smoking remains a significant global public health issue, leading to numerous preventable deaths and disabilities annually. Telephone counselling is a recommended intervention for smoking cessation, offering accessible support to a wide range of people who smoke. This study aimed to evaluate the long-term effectiveness of the German quitline for smoking cessation.

METHODS

A parallel-group, two-arm, superiority, randomized controlled trial was conducted between October 2021 and November 2023. People who smoked daily and were willing to quit received either up to six telephone counselling calls (intervention group) or a self-help brochure (control group). Seven-day point prevalence abstinence from cigarettes and tobacco at 12 months and prolonged cigarette and tobacco abstinence from 3 to 12 months after the start of the intervention were assessed. Further, the use of additional cessation aids was assessed.

RESULTS

A total of n = 905 participants were randomized (intention-to-treat sample). The intervention group (n = 477) exhibited higher rates of prolonged cigarette abstinence (31.7% vs. 17.8%) and prolonged tobacco abstinence (30.8% vs. 15.2%) compared to the control group (n = 428) at 12-month follow-up with corresponding odds ratios of 2.2 (95% CI [1.6, 3.0]) and 2.5 (95% CI [1.8, 3.5]). Seven-day point-prevalence cigarette abstinence was not statistically significant (OR = 1.3, 95% CI [1.0, 1.7]). E-cigarettes were the most commonly used additional cessation aid (46.0%), followed by electronic media (31.0%) and nicotine replacement therapy (26.2%).

CONCLUSIONS

Telephone counselling provided by the national German quitline for smoking cessation demonstrates effectiveness in promoting long-term abstinence from cigarettes and tobacco. Increased awareness and use of the quitline could promote cessation rates in Germany. Given the rising popularity of novel nicotine consumer products, counselling protocols should incorporate information on their risks and potential as cessation tools.

Interventions for tobacco use cessation in people living with HIV

BACKGROUND

The prevalence of tobacco use among people living with HIV (PLWH) is up to four times higher than in the general population. Unfortunately, tobacco use increases the risk of progression to AIDS and death. Individual- and group-level interventions, and system-change interventions that are effective in helping PLWH stop using tobacco can markedly improve the health and quality of life of this population. However, clear evidence to guide policy and practice is lacking, which hinders the integration of tobacco use cessation interventions into routine HIV care. This is an update of a review that was published in 2016. We include 11 new studies.

OBJECTIVES

To assess the benefits, harms and tolerability of interventions for tobacco use cessation among people living with HIV. To compare the benefits, harms and tolerability of interventions for tobacco use cessation that are tailored to the needs of people living with HIV with that of non-tailored cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, and PsycINFO in December 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of individual-/group-level behavioural or pharmacological interventions, or both, for tobacco use cessation, delivered directly to PLWH aged 18 years and over, who use tobacco. We also included RCTs, quasi-RCTs, other non-randomised controlled studies (e.g. controlled before and after studies), and interrupted time series studies of system-change interventions for tobacco use cessation among PLWH. For system-change interventions, participants could be PLWH receiving care, or staff working in healthcare settings and providing care to PLWH; but studies where intervention delivery was by research personnel were excluded. For both individual-/group-level interventions, and system-change interventions, any comparator was eligible.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods, and used GRADE to assess certainty of the evidence. The primary measure of benefit was tobacco use cessation at a minimum of six months. Primary measures for harm were adverse events (AEs) and serious adverse events (SAEs). We also measured quit attempts or quit episodes, the receipt of a tobacco use cessation intervention, quality of life, HIV viral load, CD4 count, and the incidence of opportunistic infections.

MAIN RESULTS

We identified 17 studies (16 RCTs and one non-randomised study) with a total of 9959 participants; 11 studies are new to this update. Nine studies contributed to meta-analyses (2741 participants). Fifteen studies evaluated individual-/group-level interventions, and two evaluated system-change interventions. Twelve studies were from the USA, two from Switzerland, and there were single studies for France, Russia and South Africa. All studies focused on cigarette smoking cessation. All studies received funding from independent national- or institutional-level funding. Three studies received study medication free of charge from a pharmaceutical company. Of the 16 RCTs, three were at low risk of bias overall, five were at high risk, and eight were at unclear risk. Behavioural support or system-change interventions versus no or less intensive behavioural support Low-certainty evidence (7 studies, 2314 participants) did not demonstrate a clear benefit for tobacco use cessation rates in PLWH randomised to receive behavioural support compared with brief advice or no intervention: risk ratio (RR) 1.11, 95% confidence interval (CI) 0.87 to 1.42, with no evidence of heterogeneity. Abstinence at six months or more was 10% (n = 108/1121) in the control group and 11% (n = 127/1193) in the intervention group. There was no evidence of an effect on tobacco use cessation on system-change interventions: calling the quitline and transferring the call to the patient whilst they are still in hospital ('warm handoff') versus fax referral (RR 3.18, 95% CI 0.76 to 13.99; 1 study, 25 participants; very low-certainty evidence). None of the studies in this comparison assessed SAE. Pharmacological interventions versus placebo, no intervention, or another pharmacotherapy Moderate-certainty evidence (2 studies, 427 participants) suggested that varenicline may help more PLWH to quit smoking than placebo (RR 1.95, 95% CI 1.05 to 3.62) with no evidence of heterogeneity. Abstinence at six months or more was 7% (n = 14/215) in the placebo control group and 13% (n = 27/212) in the varenicline group. There was no evidence of intervention effects from individual studies on behavioural support plus nicotine replacement therapy (NRT) versus brief advice (RR 8.00, 95% CI 0.51 to 126.67; 15 participants; very low-certainty evidence), behavioural support plus NRT versus behavioural support alone (RR 1.47, 95% CI 0.92 to 2.36; 560 participants; low-certainty evidence), varenicline versus NRT (RR 0.93, 95% CI 0.48 to 1.83; 200 participants; very low-certainty evidence), and cytisine versus NRT (RR 1.18, 95% CI 0.66 to 2.11; 200 participants; very low-certainty evidence). Low-certainty evidence (2 studies, 427 participants) did not detect a difference between varenicline and placebo in the proportion of participants experiencing SAEs (8% (n = 17/212) versus 7% (n = 15/215), respectively; RR 1.14, 95% CI 0.58 to 2.22) with no evidence of heterogeneity. Low-certainty evidence from one study indicated similar SAE rates between behavioural support plus NRT and behavioural support only (1.8% (n = 5/279) versus 1.4% (n = 4/281), respectively; RR 1.26, 95% CI 0.34 to 4.64). No studies assessed SAEs for the following: behavioural support plus NRT versus brief advice; varenicline versus NRT and cytisine versus NRT.

AUTHORS' CONCLUSIONS

There is no clear evidence to support or refute the use of behavioural support over brief advice, one type of behavioural support over another, behavioural support plus NRT over behavioural support alone or brief advice, varenicline over NRT, or cytisine over NRT for tobacco use cessation for six months or more among PLWH. Nor is there clear evidence to support or refute the use of system-change interventions such as warm handoff over fax referral, to increase tobacco use cessation or receipt of cessation interventions among PLWH who use tobacco. However, the results must be considered in the context of the small number of studies included. Varenicline likely helps PLWH to quit smoking for six months or more compared to control. We did not find evidence of difference in SAE rates between varenicline and placebo, although the certainty of the evidence is low.

[Intended and unintended effects of e-cigarettes in clinical studies: a plea for (more) transparency]

E-cigarettes are used in clinical trials to facilitate smoking cessation. Due to the health risks associated with the use of e-cigarettes, the results of clinical trials should be fully reported, including continued exclusive use and dual use of tobacco and e-cigarettes. Nicotine cessation outcomes should be reported as the primary endpoint as well as the analysis of tobacco cessation alone. As there is currently no robust evidence that reducing cigarette consumption provides substantial health benefits, cigarette consumption reduction should not be used as a health outcome in clinical trials. Continued nicotine dependence should be included as an "adverse event" in the reporting of trial results.

Effectiveness of smoking cessation interventions among adults: an overview of systematic reviews

BACKGROUND

This overview of reviews aims to identify evidence on the benefits (i.e. tobacco use abstinence and reduction in smoking frequency) and harms (i.e. possible adverse events/outcomes) of smoking cessation interventions among adults aged 18 years and older.

METHODS

We searched Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, the CADTH Health Technology Assessment Database and several other websites for grey literature. Searches were conducted on November 12, 2018, updated on September 24, 2020, with publication years 2008 to 2020. Two reviewers independently performed title-abstract and full-text screening considering pre-determined inclusion criteria. Data extraction and quality assessments were initially completed by two reviewers independently (i.e. 73% of included studies (n = 22)) using A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR 2), and the remainder done by one reviewer and verified by another due to resources and feasibility. The application of Grading of Recommendations Assessment, Development and Evaluation (GRADE) was performed by one independent reviewer and verified by another.

RESULTS

A total of 22 Cochrane systematic reviews evaluating the impact of smoking cessation interventions on outcomes such as tobacco use abstinence, reduction in smoking frequency, quality of life and possible adverse events were included. Pharmaceutical (i.e. varenicline, cytisine, nicotine replacement therapy (NRT), bupropion) and behavioural interventions (i.e. physician advice, non-tailored print-based self-help materials, stage-based individual counselling, etc.) showed to have increased smoking cessation; whereas, data for mobile phone-based interventions including text messaging, hypnotherapy, acupuncture, continuous auricular stimulation, laser therapy, electrostimulation, acupressure, St John's wort, S-adenosyl-L-methionine (SAMe), interactive voice response systems and other combination treatments were unclear. Considering harms related to smoking cessation interventions, small/mild harms (i.e. increased palpitations, chest pain, nausea, insomnia, headache) were observed following NRT, varenicline and cytisine use. There were no data on harms related to behavioural therapies (i.e. individual or group counselling self-help materials, internet interventions), combination therapies or other therapies (i.e. laser therapy, electrostimulation, acupressure, St John's wort, SAMe).

CONCLUSION

Results suggest that pharmacological and behavioural interventions may help the general smoking population quit smoking with observed small/mild harms following NRT or varenicline. Consequently, evidence regarding ideal intervention strategies and the long-term impact of these interventions for preventing smoking was unclear.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018099691.

Combining app-based behavioral therapy with electronic cigarettes for smoking cessation: a study protocol for a single-arm mixed-methods pilot trial

BACKGROUND

Cigarette smoking remains a leading cause of preventable illness and death, underscoring the need for effective evidence-based smoking cessation interventions. Nuumi, a novel smoking cessation program integrating a digital behavioral therapy and an electronic cigarette, may provide a solution.

OBJECTIVE

To investigate the initial efficacy, acceptability and psychological outcomes of an evidence-based smoking cessation intervention comprised of a mobile phone app and an electronic cigarette among adults who smoke and who are motivated to quit.

METHODS

A prospective 6-month single-arm mixed-methods pilot study will be conducted. Seventy adults who smoke and who are motivated to quit will be recruited via web-based advertisements and flyers. Participants receive access to an app and an electronic cigarette with pods containing nicotine for temporary use of at least 3 months. The electronic cigarette is coupled with the app via Bluetooth, allowing for tracking of patterns of use. The behavioral therapy leverages evidence-based content informed by cognitive behavioral therapy and mindfulness-informed principles. Web-based self-report surveys will be conducted at baseline, at 4 weeks, at 8 weeks, at 12 weeks, and at 24 weeks post-baseline. Semi-structured interviews will be conducted at baseline and at 12 weeks post-baseline. Primary outcomes will be self-reported 7-day point prevalence abstinence from smoking at 12 weeks and 24 weeks. Secondary outcomes will include other smoking cessation-related outcomes, psychological outcomes, and acceptability of the nuumi intervention. Descriptive analyses and within-group comparisons will be performed on the quantitative data, and content analyses will be performed on the qualitative data. Recruitment for this study started in October 2023.

DISCUSSION

As tobacco smoking is a leading cause of preventable morbidity and mortality, this research addresses one of the largest health burdens of our time. The results will provide insights into the initial efficacy, acceptability, and psychological outcomes of a novel mobile health intervention for smoking cessation. If successful, this pilot may generate an effective intervention supporting adults who smoke to quit smoking. The results will inform feasibility of a future randomized controlled trial. Trial Registration German Clinical Trials Register DRKS00032652, registered 09/15/2023, https://drks.de/search/de/trial/DRKS00032652 .

Has learning gone to waste?-Health-promoting behaviors of seniors

Objective

Regardless of the fact that Universities of Third Age (UTA's) are becoming more and more popular among seniors there are not many available studies examining the impact of conducted educational activities on seniors' adherence to health-promoting activities. The aim of the study was to compare health behaviors (e.g.,: physical activity, eating habits, alcohol consumption, tobacco smoking, preventive tests performance) between seniors attending and not attending UTA's classes.

Methods

The study involved 631 (100%) seniors aged 60-92 years (x =70.28 ± 6.09 years). The majority of the study group were women (475; 75.28%). To conduct the study, a proprietary questionnaire was used, consisting of questions regarding the discussed topic and basic questions including: age, gender, place of residence and education. Polish versions of standardized questionnaire-"My eating behaviors" examine eating behaviors of the respondents. The Chi2 test was used for qualitative data, and for quantitative data-the Mann-Whitney U test (No normal distribution: T S-W < 0.001). Linear and logistic regression models were used to check whether the associations would remain after adjustments for potential cofounders. The level of statistical significance was set at α < 0.05.

Results

Number of seniors participating in UTA's activities was higher in terms of engaging in: actively spending free time (261; 73.73% vs. 93; 26.27%; p < 0.001), regular physical activity (270; 76.27% vs. 133; 48.01%; p < 0.001), self-assessment of physical activity (259; 73.16% vs. 95; 26.84%; p = 0.004), duration of physical activity (< 0.001), past tobacco smoking (133; 37.57 vs. 76; 27.44%; p = 0.007) and alcohol consumption depending on the habit frequency (p < 0.001). Number of seniors not participating in UTA's classes was lower in terms of: regular annual dental controls (161; 58.12%; vs. 265; 74.86%; p < 0.001), regular self-examination of breasts/testicles (148; 53.43% vs. 218; 61.58%; p = 0.04) and regular laboratory tests (232; 83.75% vs. 318; 89.83%; p = 0.02).

Conclusions

Health-promoting behaviors of seniors attending classes at the UTA's were more correct in terms of physical activity, adequate attendance with preventive test and worst in terms of alcohol consumption. Overall picture allows to conclude that participation in UTA's classes seems to have a positive impact on the examined health-promoting behaviors of the surveyed seniors.

Brain Glucose Metabolism as a Readout of the Central Nervous System Impact of Cigarette Smoke Exposure and Withdrawal and the Effects of NFL-101, as an Immune-Based Drug Candidate for Smoking Cessation Therapy

Neuroimaging biomarkers are needed to investigate the impact of smoking withdrawal on brain function. NFL-101 is a denicotinized aqueous extract of tobacco leaves currently investigated as an immune-based smoking cessation therapy in humans. However, the immune response to NFL-101 and its ability to induce significant changes in brain function remain to be demonstrated. Brain glucose metabolism was investigated using [18F]fluoro-deoxy-glucose ([18F]FDG) PET imaging in a mouse model of cigarette smoke exposure (CSE, 4-week whole-body inhalation, twice daily). Compared with control animals, the relative uptake of [18F]FDG in CSE mice was decreased in the thalamus and brain stem (p < 0.001, n = 14 per group) and increased in the hippocampus, cortex, cerebellum, and olfactory bulb (p < 0.001). NFL-101 induced a humoral immune response (specific IgGs) in mice and activated human natural-killer lymphocytes in vitro. In CSE mice, but not in control mice, single-dose NFL-101 significantly increased [18F]FDG uptake in the thalamus (p < 0.01), thus restoring normal brain glucose metabolism after 2-day withdrawal in this nicotinic receptor-rich region. In tobacco research, [18F]FDG PET imaging provides a quantitative method to evaluate changes in the brain function associated with the withdrawal phase. This method also showed the CNS effects of NFL-101, with translational perspectives for future clinical evaluation in smokers.

Smoking Cessation After Initial Treatment Failure With Varenicline or Nicotine Replacement: A Randomized Clinical Trial

Importance

Most people who smoke do not quit on their initial attempt.

Objective

To determine the best subsequent strategy for nonabstinence following initial treatment with varenicline or combined nicotine replacement therapy (CNRT).

Design, Setting, and Participants

Using a double-blind, placebo-controlled, sequential multiple assignment randomized trial, 490 volunteers were randomized to receive 6 weeks of varenicline or CNRT. After 6 weeks, nonabstainers were rerandomized to continue, switch, or increase medication dosage for 6 additional weeks. The study was conducted from June 2015 through October 2019 in a Texas tobacco treatment clinic.

Interventions

The initial treatment was 2 mg/d of varenicline or the combined replacement therapy of a 21-mg patch plus 2-mg lozenge. The rerandomized participants either continued with their initial therapies, switched between varenicline and CNRT, or increased dosages either to 3-mg or more of varenicline or to a 42-mg patch and lozenges. All received weekly brief counseling.

Main Outcomes and Measures

Biochemically verified 7-day point prevalence abstinence at the end of treatment at 12 weeks.

Results

The 490 randomized participants (210 female [43%], 287 non-Hispanic White [58%], mean age, 48.1 years) smoked an average of 20 cigarettes per day. After the first phase, 54 participants in the CNRT group were abstinent and continued their therapy; of the 191 who were not abstinent, 151 were rerandomized, and the 40 who did not return for rerandomization were assigned to continue their initial CNRT condition in phase 2. The end-of-treatment abstinence rate for the 191 phase 1 nonabstainers was 8% (95% credible interval [CrI], 6% to 10%) for the 90 (47%) who continued at the dosage condition, 14% (CrI, 10% to 18%) for the 50 (33%) who increased their dosage, and 14% (95% CrI, 10% to 18%) for the 51 (34%) who switched to varenicline (absolute risk difference [RD], 6%; 95% CrI, 6% to 11%) with more than 99% posterior probability that either strategy conferred benefit over continuing the initial dosage. After the first phase, 88 participants in the varenicline group were abstinent and continued their therapy; of the 157 who were not abstinent, 122 were rerandomized and 35 who did not return for rerandomization were assigned to continue with the varenicline condition. The end-of-treatment abstinence rate for the 157 phase 1 nonabstainers was 20% (95% CrI, 16% to 26%) for the 39 (32%) who increased their varenicline dosage, 0 (95% CrI, 0 to 0) for the 41 (34%) who switched CNRT, and 3% (95% CrI, 1% to 4%) for the 77 (49%) who were assigned to the continued varenicline condition (absolute RD, -3%; 95% CrI, -4% to -1%) with more than 99% posterior probability that continuing varenicline at the initial dosage was worse than switching to a higher dosage. Furthermore, increasing the varenicline dosage had an absolute RD of 18% (95% CrI, 13% to 24%) and a more than 99% posterior probability of conferring benefit. The secondary outcome of continuous abstinence at 6 months indicated that only increased dosages of the CNRT and varenicline provided benefit over continuation of the initial treatment dosages.

Conclusions and Relevance

For individuals who smoked but did not achieve abstinence after treatment with varenicline, increasing the dosage enhanced abstinence vs continuing, whereas for nonabstainers initially treated with CNRT, a dosage increase or switch to varenicline enhanced abstinence and may be viable rescue strategies.

Trial Registration

ClinicalTrials.gov Identifier: NCT02271919.

Interventions for smoking cessation in hospitalised patients

BACKGROUND

In 2020, 32.6% of the world's population used tobacco. Smoking contributes to many illnesses that require hospitalisation. A hospital admission may prompt a quit attempt. Initiating smoking cessation treatment, such as pharmacotherapy and/or counselling, in hospitals may be an effective preventive health strategy. Pharmacotherapies work to reduce withdrawal/craving and counselling provides behavioural skills for quitting smoking. This review updates the evidence on interventions for smoking cessation in hospitalised patients, to understand the most effective smoking cessation treatment methods for hospitalised smokers.

OBJECTIVES

To assess the effects of any type of smoking cessation programme for patients admitted to an acute care hospital.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 7 September 2022.

SELECTION CRITERIA

We included randomised and quasi-randomised studies of behavioural, pharmacological or multicomponent interventions to help patients admitted to hospital quit. Interventions had to start in the hospital (including at discharge), and people had to have smoked within the last month. We excluded studies in psychiatric, substance and rehabilitation centres, as well as studies that did not measure abstinence at six months or longer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was abstinence from smoking assessed at least six months after discharge or the start of the intervention. We used the most rigorous definition of abstinence, preferring biochemically-validated rates where reported. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 82 studies (74 RCTs) that included 42,273 participants in the review (71 studies, 37,237 participants included in the meta-analyses); 36 studies are new to this update. We rated 10 studies as being at low risk of bias overall (low risk in all domains assessed), 48 at high risk of bias overall (high risk in at least one domain), and the remaining 24 at unclear risk. Cessation counselling versus no counselling, grouped by intensity of intervention Hospitalised patients who received smoking cessation counselling that began in the hospital and continued for more than a month after discharge had higher quit rates than patients who received no counselling in the hospital or following hospitalisation (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.24 to 1.49; 28 studies, 8234 participants; high-certainty evidence). In absolute terms, this might account for an additional 76 quitters in every 1000 participants (95% CI 51 to 103). The evidence was uncertain (very low-certainty) about the effects of counselling interventions of less intensity or shorter duration (in-hospital only counselling ≤ 15 minutes: RR 1.52, 95% CI 0.80 to 2.89; 2 studies, 1417 participants; and in-hospital contact plus follow-up counselling support for ≤ 1 month: RR 1.04, 95% CI 0.90 to 1.20; 7 studies, 4627 participants) versus no counselling. There was moderate-certainty evidence, limited by imprecision, that smoking cessation counselling for at least 15 minutes in the hospital without post-discharge support led to higher quit rates than no counselling in the hospital (RR 1.27, 95% CI 1.02 to 1.58; 12 studies, 4432 participants). Pharmacotherapy versus placebo or no pharmacotherapy Nicotine replacement therapy helped more patients to quit than placebo or no pharmacotherapy (RR 1.33, 95% CI 1.05 to 1.67; 8 studies, 3838 participants; high-certainty evidence). In absolute terms, this might equate to an additional 62 quitters per 1000 participants (95% CI 9 to 126). There was moderate-certainty evidence, limited by imprecision (as CI encompassed the possibility of no difference), that varenicline helped more hospitalised patients to quit than placebo or no pharmacotherapy (RR 1.29, 95% CI 0.96 to 1.75; 4 studies, 829 participants). Evidence for bupropion was low-certainty; the point estimate indicated a modest benefit at best, but CIs were wide and incorporated clinically significant harm and clinically significant benefit (RR 1.11, 95% CI 0.86 to 1.43, 4 studies, 872 participants). Hospital-only intervention versus intervention that continues after hospital discharge Patients offered both smoking cessation counselling and pharmacotherapy after discharge had higher quit rates than patients offered counselling in hospital but not offered post-discharge support (RR 1.23, 95% CI 1.09 to 1.38; 7 studies, 5610 participants; high-certainty evidence). In absolute terms, this might equate to an additional 34 quitters per 1000 participants (95% CI 13 to 55). Post-discharge interventions offering real-time counselling without pharmacotherapy (RR 1.23, 95% CI 0.95 to 1.60, 8 studies, 2299 participants; low certainty-evidence) and those offering unscheduled counselling without pharmacotherapy (RR 0.97, 95% CI 0.83 to 1.14; 2 studies, 1598 participants; very low-certainty evidence) may have little to no effect on quit rates compared to control. Telephone quitlines versus control To provide post-discharge support, hospitals may refer patients to community-based telephone quitlines. Both comparisons relating to these interventions had wide CIs encompassing both possible harm and possible benefit, and were judged to be of very low certainty due to imprecision, inconsistency, and risk of bias (post-discharge telephone counselling versus quitline referral: RR 1.23, 95% CI 1.00 to 1.51; 3 studies, 3260 participants; quitline referral versus control: RR 1.17, 95% CI 0.70 to 1.96; 2 studies, 1870 participants).

AUTHORS' CONCLUSIONS

Offering hospitalised patients smoking cessation counselling beginning in hospital and continuing for over one month after discharge increases quit rates, compared to no hospital intervention. Counselling provided only in hospital, without post-discharge support, may have a modest impact on quit rates, but evidence is less certain. When all patients receive counselling in the hospital, high-certainty evidence indicates that providing both counselling and pharmacotherapy after discharge increases quit rates compared to no post-discharge intervention. Starting nicotine replacement or varenicline in hospitalised patients helps more patients to quit smoking than a placebo or no medication, though evidence for varenicline is only moderate-certainty due to imprecision. There is less evidence of benefit for bupropion in this setting. Some of our evidence was limited by imprecision (bupropion versus placebo and varenicline versus placebo), risk of bias, and inconsistency related to heterogeneity. Future research is needed to identify effective strategies to implement, disseminate, and sustain interventions, and to ensure cessation counselling and pharmacotherapy initiated in the hospital is sustained after discharge.

Interpersonal communication and perceived norms as social influence mechanisms of e-cigarette use among adults: a systematic review

Background: Given the increasing popularity of e-cigarette use among adults and the ongoing debate about the benefits and the potential adverse health risks associated with e-cigarette use, it is critical to identify the correlates of e-cigarette use. Prior research has found associations between interpersonal communication, perceived norms, and adults' e-cigarette use, but the evidence has yet to be summarized and synthesized.Objectives: This paper reviewed empirical studies examining the relationship between interpersonal communication, perceived norms, and e-cigarette use among adults.Methods: Following PRISMA guidelines, articles were searched on DOAJ, EMBASE, Europe PubMed Central, Google Scholar, PsychINFO, PubMed, Web of Science, and the reference list of the retrieved studies for studies that examined social influence on e-cigarette use. Three reviewers independently screened 1,713 non-duplicate papers and further screened the full text of 195 articles for inclusion.Results: Thirty studies (30), consisting of quantitative (n = 25) and qualitative (n = 5) data, were included in this review. The twenty-five (25) quantitative studies consisted of both cross-sectional (n = 20) and longitudinal (n = 5) studies. Interpersonal communication portraying e-cigarettes as beneficial or harmful was found to increase e-cigarette use and quit attempts, respectively. Across study designs, greater perceptions of others' e-cigarette use or approval were related to more frequent e-cigarette use.Conclusions: The findings highlight that e-cigarette-related interpersonal communication and perceived norms are associated with e-cigarette use. These factors may be useful targets in brief interventions. However, most of the included studies were cross-sectional, limiting the ability to establish clear cause-and-effect relationships; therefore, more longitudinal studies are needed.

[Tobacco cessation: one of the most effective medical measures]

Tobacco smoking is widespread in Germany. An increase in the number of teenagers and young adults that smoke has recently been a cause for concern. The high prevalence in Germany is contrasted by inadequate preventive measures compared to international standards. Smoking behavior should always be inquired about and documented in the same way as vital signs. All smokers, regardless of the reason for contact and motivation, should receive short, low-threshold advice, e.g. using the ABC approach (ask, brief advice, cessation). In addition to repeated advice and referral to further services, the use of nicotine replacement or drug therapy is essential for the success of quitting. The combination of long- and short-acting nicotine replacement products doubles the success rate. Electronic nicotine delivery systems are not recommended for smoking cessation.

A Global Health Survey of People Who Vape but Never Smoked: Protocol for the VERITAS (Vaping Effects: Real-World International Surveillance) Study

BACKGROUND

There is only limited information about the health effects of regular vaping. Research on the health status of people who used to smoke faces the challenge that previous smoking may have caused unknown health effects. Only studies of people who vape but have never smoked combustible cigarettes can enable the detection of harms attributable to vaping. Large prospective studies of well-characterized electronic cigarette users with and without a history of combustible cigarette smoking are warranted to establish the long-term effects of regular vaping on respiratory health.

OBJECTIVE

We will conduct a global cross-sectional survey of individuals from 6 world regions. Respiratory symptoms will be assessed using a validated questionnaire-the Respiratory Symptom Experience Scale (RSES). Current vapers who are nonusers of other tobacco or nicotine products will be compared with matched controls who are nonusers of vapes and other tobacco or nicotine products.

METHODS

This will be a multicountry, cross-sectional internet-based survey of 750 adults aged ≥18 years who satisfy the criteria for inclusion in either a cohort of people who exclusively vape and who are nonusers of other tobacco or nicotine products ("vapers cohort"; target N=500) or a cohort of nonvapers who are also nonusers of other tobacco or nicotine products ("controls cohort"; target N=250). The primary end point of the study is the RSES score. RSES scores of people in the "vapers cohort" will be compared with those of people in the "controls cohort." Additionally, the study will collect data to characterize patterns of vaping product use among the vapers cohort. Data collection will include information about the age initiation of using vape products, reasons for starting and continuing the use of vape products, specific types of products used, flavors and nicotine strengths of recently used products, as well as the frequency and intensity of product use in the past 30 days.

RESULTS

Participant recruitment started in April 2023, and enrollment was completed by November 2023 with 748 participants. Results will be reported in 2024.

CONCLUSIONS

This will be the first study providing key insights into respiratory health effects associated with using electronic cigarettes in people who vape with no established use of combustible cigarettes or other tobacco or nicotine products.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54236.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the safety, tolerability and effectiveness of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments and no treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register to 1 February 2023, and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2023, and reference-checked and contacted study authors.

SELECTION CRITERIA

We included trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention as these studies have the potential to provide further information on harms and longer-term use. Studies had to report an eligible outcome.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA).

MAIN RESULTS

We included 88 completed studies (10 new to this update), representing 27,235 participants, of which 47 were randomized controlled trials (RCTs). Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 58 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There is high certainty that nicotine EC increases quit rates compared to nicotine replacement therapy (NRT) (RR 1.59, 95% CI 1.29 to 1.93; I2 = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more). There is moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs is similar between groups (RR 1.03, 95% CI 0.91 to 1.17; I2 = 0%; 5 studies, 2052 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.20, 95% CI 0.90 to 1.60; I2 = 32%; 6 studies, 2761 participants; low-certainty evidence). There is moderate-certainty evidence, limited by imprecision, that nicotine EC increases quit rates compared to non-nicotine EC (RR 1.46, 95% CI 1.09 to 1.96; I2 = 4%; 6 studies, 1613 participants). In absolute terms, this might lead to an additional three quitters per 100 (95% CI 1 to 7 more). There is moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 9 studies, 1412 participants; low-certainty evidence). Due to issues with risk of bias, there is low-certainty evidence that, compared to behavioural support only/no support, quit rates may be higher for participants randomized to nicotine EC (RR 1.88, 95% CI 1.56 to 2.25; I2 = 0%; 9 studies, 5024 participants). In absolute terms, this represents an additional four quitters per 100 (95% CI 2 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low-certainty evidence; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.89, 95% CI 0.59 to 1.34; I2 = 23%; 10 studies, 3263 participants; very low-certainty evidence). Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes, and there was no indication of inconsistency within the networks. Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but the longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Does e-cigarette use affect response to non-surgical periodontal therapy?

DESIGN

Cross-sectional study CASE SELECTION: Consecutive patient charts (n = 220) at Guy's Dental Hospital between April 2018 and April 2020 were included. The inclusion criteria were adults ≥18 years with a diagnosis of periodontitis (localized or generalized, all stages and grades) and who have received professional mechanical plaque removal (PMPR) by periodontology graduate students. Data of periodontal indices before and after PMPR (6-20 weeks) were also needed to be available. Exclusion criteria included uncontrolled diabetes, pregnancy, medications attributed to drug induced overgrowth, among others.

DATA ANALYSIS

This retrospective study evaluated the response to periodontal treatment in e-cigarette users and they compared the outcomes to non-smokers, former and current smokers. The primary outcome to evaluate the response to periodontal therapy was 'need for surgery'. This was defined by the authors as the number of sextants with ≥2 non-adjacent sites with probing depth (PD) ≥ 5 mm after PMPR. Secondary outcomes included periodontal parameters such as number of sextants with ≥1 site with PD ≥ 5 mm, PD, clinical attachment level (CAL), bleeding on probing, recession, and plaque scores.

RESULTS

E-cigarette users and current smokers had similar poorer clinical response to periodontal therapy. Analysis revealed e-cigarette users had more sextants with 'need for surgery' as the primary outcome. Pocket closure outcome (PD ≤ 4 mm with no bleeding on probing) were highest in nonsmokers (77.1%), followed by former smokers (74.9%), current smokers (69.4%), and e-cigarette users (66.6%).

CONCLUSIONS

E-cigarette users showed less than beneficial response to periodontal therapy compared to non-smokers, who had the best outcome overall.