E-cigarettes aren’t better at helping smokers quit than other strategies


May 23, 2018

E-cigarettes don’t help smokers quit more than other interventions, though financial incentives do, a new study in the New England Journal of Medicine finds.

The electronic vaporizers have skyrocketed in popularity in recent years. Between 2014 and 2015, for example, sales jumped over 14 percent nationwide, according to research published in the American Journal of Preventative Medicine. The authors write that e-cigarettes present a potential public health benefit, but only if smokers “completely quit combusted tobacco.” This is because smoking even one cigarette a day puts people at a much higher risk of cardiovascular disease than those who abstain entirely.

But the New England Journal of Medicine’s new findings present evidence that the highly touted technology is not a panacea for smokers trying to quit. A team led by researchers at the University of Pennsylvania looked at the outcomes of five different strategies for workplace smoking-cessation programs.

They invited 6,131 smokers at 54 United States companies to join the study, which was designed with an opt-out enrollment policy. In other words, unless those invited decided not to participate, they were enrolled. There were 125 people who opted out, so just over 6,000 were included in the study group.

The participants were randomized into five groups. The groups received either usual care (informational materials and text messages with advice and encouragement); free cessation aids (including nicotine-replacement therapy, prescription medications to help quit and, in the event that those strategies failed, e-cigarettes); free e-cigarettes; a reward of up to $600 plus the free cessation aids detailed above; or a redeemable deposit account of up to $600 plus the free cessation aids. The deposit group differed from the reward group in that money was removed from the deposit account if abstinence goals were not met. This framed the deposit account in terms of potential losses, in contrast to the incentive framing of the reward group, in which additional money was added to the reward for each goal met.

The researchers were interested in determining which strategies were most effective, as measured by the number of participants who refrained from smoking for six months following the target quit date. They confirmed participants’ self-reported claims with urine or blood tests. Then they analyzed the data to determine overall quit rates and compare the success of the differing strategies. They found:

  • Eighty participants, or 1.3 percent of the study population, successfully kept from smoking for 6 months past the target quit date.
  • The success rates of the five strategies, ranked from highest to lowest, are as follows: redeemable deposit (2.9 percent); reward (2 percent); e-cigarettes (1 percent); free cessation aids (0.5 percent); usual care (0.1 percent).
  • Between-group comparisons indicate that there were not statistically significant differences between quit rates in the free e-cigarettes group, the free cessation aids group, and the usual care group. In other words, none of these strategies were much more effective than the others.
  • Money talks. There were statistically significant differences between the redeemable deposit strategy as compared with free cessation aids and e-cigarettes — the deposits had higher abstinence rates.
  • The opt-out study design highlighted low engagement rates. Only 1,191 participants — less than 20 percent — remained engaged with the study (that is, they logged onto the trial website at least once).
  • The participants in the “engaged cohort” were more educated, more motivated to quit, more likely to be women and more commonly past or current users of e-cigarettes.
  • The success rates of each of the strategies among engaged participants, ranked from highest to lowest, are as follows: redeemable deposit (12.7 percent); reward (9.5 percent); e-cigarettes (4.8 percent); free cessation aids (2.9 percent); usual care (0.7 percent).
  • The findings from between-group comparisons for the general study population held within the engaged subset; there were not significant differences in abstinence rates between the three strategies that did not involve cash.
  • Though the monetary incentive strategies might seem pricey, the researchers calculated the average cost per successful quit was actually lower for these programs than for the free cessation aids and e-cigarettes. “Programs that offered financial incentives tripled the rates of smoking cessation, reduced employers’ costs per successful quit as compared with programs that offered cessation aids alone, and yielded total costs that compared favorably with the costs of employing smokers,” they write.

The authors note that actual quit rates might have been higher than reflected in the results, because those who did not report responses were assumed to be ongoing smokers. Further, the monetary incentives might have increased the likelihood that participants reported their success as compared with other groups, because the responses were necessary for the disbursement of rewards.

The paper’s findings contrast with prior workplace smoking-cessation studies, which had higher overall cessation rates that might be explained in part by their opt-in approach. One might expect that those who choose to enroll in an opt-in study are more motivated to quit. The low engagement in this study, the authors write, demonstrates the “real-world effects employers can expect when offering these programs to all employees who smoke.”


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Citation: Halpern, Scott D.; et al. "A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation," The New England Journal of Medicine, May 2018. DOI: 10.1056/NEJMsa1715757.