By Denise Williams | News & Views

For cardiopulmonary rehabilitation participants who use tobacco, smoking cessation is an important, necessary and very often elusive goal. The lucky ones are able to quit ‘cold turkey,’ through sheer willpower and determination. For everyone else, the chase is on to find the right intervention that will help liberate them from the clutches of nicotine addiction. The Federal Drug Administration (FDA) has approved seven products designed to assist in quit attempts: varenicline, nicotine patch, buproprion, nicotine gum, nicotine nasal spray, nicotine inhaler, and nicotine lozenge. Evidence now suggests that using vapes to wean adults off combustible cigarettes might represent an additional treatment option. But does it, really? Maybe. That’s the “quick and dirty” answer, according to Quinn Pack, MD, chair of AACVPR’s Quality of Care Committee.

The Good, the Bad and the Unknown

Dr. Pack, who has special expertise in smoking cessation, notes the short-term evidence collected over the past 8 years or so looks promising. Using data from lung function and cardiovascular tests as a barometer, for example, the general consensus is that e-cigarettes are “healthier” in some respect than conventional ones. The research also shows conclusively that vaping actually does increase the quit rate in smokers – by as much as double, based on one large study. Nonetheless, the quit rate remains dismally low overall. And although the current data seems to supports e-cigarettes as a harm-reduction technique, Dr. Pack estimates it will take another 10-20 years to understand the long-term effects. “Everything looks like it’s heading in the right direction,” he says, “but we still don’t know if it’s going to make people live longer.”

What scientists do know already, Dr. Pack continues, is that smokers who switch to the electronic format are more likely to relapse and take up combusted tobacco again. Importantly, he adds, substituting e-cigarettes for combustible ones also doesn’t resolve the problem of nicotine addiction. Yes, he acknowledges, it will increase the likelihood of the smoker quitting tobacco; however, the nicotine addiction will persist. “You’re not really treating the addiction, you’re just reducing the harm of the addiction,” he explains. “But you’re still basically exchanging one type of addiction (combusted tobacco) for another (inhaled nicotine).” To punctuate that point, he reports that even as vaping boosts the cessation rate, most patients continue to use vaping long term. In other words, they never really get off e-cigarettes.

Not a First-Line Method

Given the totality of the evidence to date, Dr. Pack believes vaping can be a reasonable cessation approach for some patients; but at this point, it shouldn’t be at the top of the list. Rather, he says the starting point for smokers should be FDA-approved interventions, which in his experience are used neither enough nor appropriately. “There’s a lot of misinformation about how to use these medications,” Dr. Pack ruefully acknowledges, pointing out that users typically need to take them for 3-6 months to see results. People also may not realize that they can be used in combination. Too often, he says, patients conclude that a treatment “didn’t work,” but the reality is they stopped taking the medication prematurely or were sidelined by a treatable adverse effect that was never resolved. Although he’s counseled an estimated 1,000 patients to quit smoking, Dr. Pack says he’s recommended vaping for only two or three. Overwhelmingly, he’s identified a combination of medicines to effectively deliver withdrawal relief. FDA-approved medications are proven to improve smoking cessation – ideally, he notes, when “taken under the supervision of a doctor or tobacco treatment specialist who can assess for and help manage side effects.”

Admittedly, even in the best scenario, it’s true that most smokers will fail even when using cessation agents – which he emphasizes are a tool, but not a magic bullet. “No medication is powerful enough to overcome an addiction without a lot of willpower, counseling and effort on the patient’s part,” Dr. Pack explains. “But the medications do double to triple quit rates.”

Prepping for Provider-Patient Conversation

If a cardiopulmonary rehab patient has given at least two or three FDA-approved cessation techniques a strong, honest try and is interested in exploring the vaping approach, Dr. Pack underscores a few points that providers should be sure to communicate:

• Although the long-term implications of vaping are far from certain, the evidence suggests e-cigarettes will help you quit smoking and, relative to traditional tobacco products, are less likely to cause heart and lung problems.
• However, you will still be addicted to nicotine – just the vaporized variety instead of the kind from combusted tobacco.
• Because of the ongoing nicotine addiction, you should be prepared for the financial burden of purchasing vapes and cartridges for the long haul.
• Most importantly, you MUST commit to switching fully from conventional cigarettes to e-cigarettes! “Dual use” – smoking a regular cigarette while in your personal home or vehicle while using a vaping device in places where conventional cigarettes are banned, for example – is confirmed to have zero health benefit or harm-reduction value.

Should a patient ever feel ready to take the next step and get off e-cigarettes, and nicotine, completely, Dr. Pack says providers are equipped to help them accomplish that, too.