February 12, 2018

Stanton A. Glantz, PhD

E-cigarette users in Europe (including England) are less likely to quit smoking conventional cigarettes: Results challenge PHE recommendation that e-cigarettes be used in hospitals

A new paper based on a large sample of smokers across the European Union, E-cigarettes Associated with Depressed Smoking Cessation: A Cross-sectional Study of 28 European Union Countries was just published in the American Journal of Preventive Medicine. University of California researchers Margarete Kulik, Nadra Lisha and Stanton Glantz found that in the European Union smokers who use e-cigarettes are less, not more, likely to quit smoking.

An additional analysis pulling out the data from Great Britain alone showed the same thing: smokers who use e-cigarettes are less likely to quit smoking than smokers who do not use e-cigarettes.

This paper is the first large scale study of the relationship between e-cigarette use and quitting smoking compared to people who do not use e-cigarettes in the EU.

The results based on a cross-sectional survey of 12,608 ever smokers conducted by Eurobarometer are consistent with most other studies of real-world e-cigarette use.

This new result particularly calls into question recent  suggestions from Public Health England that hospitals in Britain begin selling e-cigarettes and provide patients with vaping lounges.  The new study suggests that implementing Public Health England’s recommendations will keep most people smoking cigarettes.  Results from our study strongly indicate that implementing these policies that promote e-cigarette use will substantially worsen the tobacco epidemic.

In a statement we distributed before the paper was published, my co-author Margarete Kulik observed, “We expect a skeptical response from e-cigarette enthusiasts, especially in England” because study is based on cross-sectional data observed at a single point in time.  “Cross-sectional data can only be used to measure associations, not causal links,” she continued, “but they are a well-established epidemiological method.” 

It will be interesting to see how vigorously e-cigarette enthusiasts attack our paper based on the dataset we used and the fact that we did a cross-sectional analysis because these same people heralded a paper using the same Eurobarometer data set in a cross-sectional analysis by Farsalinos et al (Electronic cigarette use in the European Union: analysis of a representative sample of 27460 Europeans from 28 countries. Addiction. 2016;111(11):2032–2040. https://doi.org/10.1111/add.13506 ) that concluded that heavier e-cigarette users quit smoking more often than occasional e-cigarette users.  (Our analysis found the same thing.)  The big problem with the Farsalinos et al study was that they left out the control group, smokers who did not use e-cigarettes.

Our analysis including all the smokers, including those who did not use e-cigarettes and compares quitting among all three groups.  What we find is that heavy e-cigarette users quit smoking more than intermittent e-cigarette uses, but both quit less than people smokers who don’t use e-cigarettes.

We certainly hope that the same e-cigarette enthusiasts who touted the earlier paper will accept ours.  The data and methods are the same as the earlier study; we just did a more complete analysis.

But, I expect that they will find some way to continue to love the Farsalinos paper  while trashing ours.  It will be interesting to see how they do it.

In the meantime, one can only hope that the health authorities in Great Britain will abandon their irresponsible and dangerous policies of promoting e-cigarettes for smoking cessation, especially in hospitals and health facilities.

Here is the abstract:

Introduction: Electronic cigarettes (e-cigarettes) are often promoted to assist with cigarette smoking cessation. In 2016–2017, the relationship between e-cigarette use and having stopped smoking among ever (current and former) smokers was assessed in the European Union and Great Britain by itself.

Methods: Cross-sectional logistic regression of the association between being a former smoker and e-cigarette use was applied to the 2014 Eurobarometer survey of 28 European Union countries controlling for demographics.

Results: Among all ever smokers, any regular ever use of nicotine e-cigarettes was associated with lower odds of being a former smoker (unadjusted OR=0.34, 95% CI=0.26, 0.43, AOR=0.43, 95% CI=0.32, 0.58) compared with smokers who had never used e-cigarettes. In unadjusted models, daily use (OR=0.42, 95% CI=0.31, 0.56); occasional use (OR=0.25, 95% CI=0.18, 0.35); and experimentation (OR=0.24, 95% CI=0.19, 0.30) of nicotine e-cigarettes were associated with lower odds of being a former smoker compared with having never used nicotine-containing e-cigarettes. Comparable results were found in adjusted models. Results were similar in Great Britain alone. Among current smokers, daily cigarette consumption was 15.6 cigarettes/day (95% CI=14.5, 16.7) among those who also used e-cigarettes versus 14.4 cigarettes/day (95% CI=13.4, 15.4) for those who did not use them (p<0.05).

Conclusions: These results suggest that e-cigarettes are associated with inhibiting rather than assisting in smoking cessation. On the population level, the net effect of the entry of e-cigarettes into the European Union (and Great Britain) is associated with depressed smoking cessation of conventional cigarettes.

The full citation is: Kulik et al. E-cigarettes Associated With Depressed Smoking Cessation: A Cross-sectional Study of 28 European Union Countries. American Journal of Preventive Medicine. Epub ahead of print 12 Feb 2018 DOI: https://doi.org/10.1016/j.amepre.2017.12.017 . It is available here.



PHE continues to use the same ‘independent experts’ for all their former and current released studies.
Yet the same ’independent experts’ have issued previous reports that have confirmed the UCSF study on e-cig users’ lack of cessation.

Brose, McNeil, Brown, West, Hitchman
Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with a 1-year follow-up.
CONCLUSIONS: Daily use of e-cigarettes while smoking appears to be associated with subsequent increases in rates of attempting to stop smoking and reducing smoking, BUT NOT WITH SMOKING CESSATION

McRobbie et al
“Achievement of abstinence was substantially LOWER THAN WE ANTICIPATED for the power calculation, thus we had insufficient statistical power to conclude superiority of nicotine e-cigarettes to patches or to placebo e-cigarettes. We identified no significant differences in adverse events, with 137 events in the nicotine e-cigarettes group, 119 events in the patches group, and 36 events in the placebo e-cigarettes group.
Interpretation E-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence AS WITH NICOTINE PATCHES, and few adverse events.
Uncertainty exists about the place of e-cigarettes in tobacco control”


"An important concern with this analysis is that the survey does not contain information on when smokers quit smoking and hence the sample includes people who quit before e-cigarettes were available."

A crucial limitation, indeed.


As the paper discusses, the fact that some of the smokers quit before e-cigarettes became available biases the results toward the null.   This bias means that if using e-cigarettes depresses quitting, we will underestimate how much it depresses quitting and if using e-cigarettes facilitates quitting, we will understimate the benefit.  The fact that we found depressed quitting despite this bias increases the confidence that we can have in the conclusion that use of e-cigarettes is associated with less quitting.  The paper discusses this issue in detail.

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