A Rush to the Evidence: Programs Urged to Promote Proven Tobacco Treatments Over Vaping

As new headlines related to the outbreak of lung illnesses associated with vaping emerge every day, the topic of e-cigarettes' role in smoking cessation swirls across the community of addiction treatment centers. Leaders from the academic and public service sectors tell Addiction Professional that treatment programs will be on firm ground in advising patients if they focus on recommending evidence-based treatments for smoking cessation.

E-cigs do not qualify under that research-based standard, these experts say.

“We never should stray from evidence-based practices when making recommendations,” says Phil McCabe, health educator at the Rutgers University School of Public Health, where training in tobacco control is one of his focus areas.

Similar comments are being echoed at the state government level, given the gravity of the now two-month-old federal health investigation into what is causing the sudden outbreak of serious lung illnesses among users of vaping products. In Mississippi, which this week confirmed the state's first death associated with e-cig use, State Health Officer Thomas Dobbs, MD, said, “We are just now starting to see some of the dangerous health outcomes of vaping. There is still so much we don't know. It's uncharted territory.”

The week's developments

The news cycle around e-cigs has churned incessantly in recent weeks. This week's developments included:

• Updated data released Thursday by the Centers for Disease Control and Prevention (CDC), stating that the numbers of confirmed cases of lung illnesses and deaths nationwide have reached 805 and 12, respectively. Earlier in the week, a CDC official told members of Congress that around half of the illness victims have been ages 25 and younger, adding that many of the vaping products that the affected individuals used contained THC. But the agency has not been able to pinpoint one cause of all of the illnesses.

• More actions at the state level to restrict sales of e-cigs, including a dramatic four-month ban on all sales announced by Massachusetts Gov. Charlie Baker.

• A leadership shakeup at leading e-cig maker Juul, which included an announcement that the company is suspending its U.S. advertising of e-cigs.

• An early release of data from the 2019 Monitoring the Future Survey, showing steep increases in youth use of e-cigarettes over the past two years. The survey found that the prevalence of past-month use of e-cigs in 2019 was 25% among high school seniors, 20% among high school sophomores, and 9% among students in 8th grade.

Even in states that have not taken formal action regarding the sale of vaping products, the message from leaders has been one of using extreme caution on e-cig use and recommending smoking cessation treatments with the strongest evidence base.

“We have a long way to go to integrate evidence-based tobacco use treatments as a field,” Stephanie Gans, tobacco treatment specialist at the North Carolina Department of Health and Human Services' Tobacco Prevention and Control Branch, tells Addiction Professional.

Rutgers' McCabe says treatment programs should be focused on recommending the approved medication treatments varenicline (Chantix) or bupropion (Zyban) and/or the various forms of nicotine replacement therapy (patches, gum, lozenges, etc.) for patients in addiction treatment programs who express a desire to quit smoking.

Gans points out that a 2013 Cochrane review of meta-analyses of smoking cessation treatments found that varenicline and combination replacement therapies were two interventions that showed particularly strong results for patients.

McCabe says that when he encounters people who tell him they have used e-cigs to help them quit smoking conventional cigarettes, he offers positive reinforcement on their move to stop tobacco use. However, while the evidence points to e-cigs being safer than combustible cigarettes, “Safer doesn't necessarily mean safe,” McCabe says.

How programs should respond

Gans says all state-operated behavioral health centers in North Carolina have gone smoke-free, and several other health facilities in the state have done the same. She believes that in addiction treatment centers that work toward eliminating nicotine use in their patient population, patients' e-cig use should be looked at in the same way as use of any tobacco products as part of addressing tobacco use disorder.

A patient entering substance use treatment who is using e-cigs should be evaluated to determine if he/she meets criteria for tobacco use disorder, Gans says.

McCabe adds, however, that if a patient has been using e-cigs as a smoking cessation tool, programs should not simply advise them to stop vaping immediately, but should work toward helping them titrate down and then pursue another smoking cessation strategy.

Moreover, “Anyone who is not a current smoker shouldn't start vaping,” McCabe says. It is clear from the latest youth data that “there is a novelty to using [e-cigs],” he says. “Many young people get drawn into whatever is popular at the time.”

Young people recently have been receiving additional options for help in the effort to steer away from the attraction of vaping products. The Truth initiative, which historically has been active in efforts to reduce youth use of tobacco products, now is also promoting a “This Is Quitting” text message-based program to help young people quit e-cig use.