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Original Investigation
July 15, 2019

Association Between Electronic Cigarette Use and Smoking Reduction in France

Author Affiliations
  • 1Inserm, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Sorbonne Université, Paris, France
  • 2Inserm, Unité Mixte de Service 011, Population-based Epidemiological Cohorts, Villejuif, France
  • 3Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
  • 4Inserm, Unité Mixte de Recherche 1168, VIeillissement et Maladies chroniques–Approches épidémiologiques et de santé publique, Villejuif, France
  • 5Assistance publique–Hôpitaux de Paris, Hôpitaux Universitaires Paris Ouest, Service de Psychiatrie de l’adulte et du sujet âgé, Paris, France
  • 6Inserm, U894, Centre Psychiatrie et Neurosciences, Paris, France
  • 7BioStatistique, Traitement et Modélisation des données biologiques–Équipe d’Accueil 7537, Faculté de Pharmacie de Paris, Université Paris Descartes, Paris 75006
JAMA Intern Med. 2019;179(9):1193-1200. doi:10.1001/jamainternmed.2019.1483
Key Points

Question  Is electronic cigarette use associated with smoking reduction in the general population?

Findings  This cohort study found that, among daily smokers in France, regular (daily) electronic cigarette use is associated with a significantly higher decrease in the number of cigarettes smoked per day as well as an increase in smoking cessation attempts. However, among former smokers, electronic cigarette use is associated with an increase in the rate of smoking relapse.

Meaning  Daily electronic cigarette use appears to be helpful in initiating smoking cessation among persons who intend to quit tobacco; however, in the general population, its efficacy with regard to smoking abstinence in the long term is uncertain.


Importance  The electronic cigarette (EC) has become popular among smokers who wish to reduce their tobacco use levels or quit smoking, but its effectiveness as a cessation aid is uncertain.

Objective  To examine the association of regular EC use with the number of cigarettes smoked per day, smoking cessation among current smokers, and smoking relapse among former smokers.

Design, Setting, and Participants  The CONSTANCES (Consultants des Centres d’Examens de Santé) cohort study, based in France, began recruiting participants January 6, 2012, and is currently ongoing. Participants were enrolled in CONSTANCES through 2015, and included 5400 smokers (mean [SD] follow-up of 23.4 [9.3] months) and 2025 former smokers (mean [SD] follow-up of 22.1 [8.6] months) at baseline who quit smoking in 2010, the year in which ECs were introduced in France, or afterward. Analyses were performed from February 8, 2017, to October 15, 2018.

Main Outcomes and Measures  The association between EC use and the number of cigarettes smoked during follow-up was studied using mixed regression models. The likelihood of smoking cessation was studied using Poisson regression models with robust sandwich variance estimators. The association between EC use and smoking relapse among former smokers was studied using Cox proportional hazards regression models. All statistical analyses were adjusted for sociodemographic characteristics, duration of follow-up, and smoking characteristics.

Results  Among the 5400 daily smokers (2906 women and 2494 men; mean [SD] age, 44.9 [12.4] years), regular EC use was associated with a significantly higher decrease in the number of cigarettes smoked per day compared with daily smokers who did not use ECs (–4.4 [95% CI, –4.8 to –3.9] vs –2.7 [95% CI, –3.1 to –2.4]), as well as a higher adjusted relative risk of smoking cessation (1.67; 95% CI, 1.51-1.84]). At the same time, among the 2025 former smokers (1004 women and 1021 men; mean [SD] age, 43.6 [12.1] years), EC use was associated with an increase in the rate of smoking relapse among former smokers (adjusted hazard ratio, 1.70; 95% CI, 1.25-2.30).

Conclusions and Relevance  This study’s findings suggest that, among adult smokers, EC use appears to be associated with a decrease in smoking level and an increase in smoking cessation attempts but also with an increase in the level of smoking relapse in the general population after approximately 2 years of follow-up.

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    2 Comments for this article
    RE: Association Between Electronic Cigarette Use and Smoking Reduction.
    Rajiv Kumar, MBBS, MD . | Faculty, Dept. of Pharmacology, Government Medical College & Hospital, Chandigarh, 160030. India.
    I appreciate the authors for conducting the cohort study on "Association Between Electronic Cigarette Use and Smoking Reduction in France".
    In 2004, the first electronic cigarette, a Chinese invention, came as a pathway to the reduction in yobacco smoking or tobacco harm reduction (THR) from the Rune Company and was marketed
    as a less harmful alternative to smoking (1).
    The use of electronic cigarettes have become a fashion statement among young tobacco users and  use has spread to almost all corners of the world.
    The Oxford Dictionary named "vape" the 2014 word of the year, which marks the rise of a billion dollars electronic cigarette industry.

    It would not be wrong to say that peoples and politicians are confused and wrongly informed on the use of electronic cigarettes; only the manufacturers  are taking advantage of the situations.

    The Indian Council of Medical Research (ICMR) on  "No Tobacco day" released a white paper on electronic cigarettes. The ICMR recommends a complete prohibition on electronic cigarettes in India for the protection of public health. The ICMR on the basis of available scientific data has claimed that "adverse effects of the use of electronic cigarettes" are documented, including DNA damage, carcinogenesis, respiratory, heart and nervous disorders (2).

    Research continues on the use of electronic cigarettes, but conclusive and valid results are not there yet;  the dispute about electronic cigarettes persists.

    Dr.Rajiv Kumar, Faculty, Dept. of Pharmacology, Government Medical College & Hospital, Chandigarh, 160030. India.

    1. Backgrounder on WHO report on regulation of e-cigarettes and similar products. Geneva: World Health Organization (WHO), 26 Aug 2014.http://www.who.int/nmh/events/2014/backgrounder-e-cigarettes/en/

    2. https://www.bmj.com/content/365/bmj.l4030
    Potential adverse health effects from nicotine itself is often absent from public health debates
    Aki Nilanga Ediriweera Bandara | Department of Emergency Medicine-UBC-Founding Chair-Global coalition to increase awareness for potential harmful therapies for adolescents’ unique tobacco addictions related issues
    A recent study found that the electronic cigarette is effective in reducing combustible tobacco use in France. However, the major limitation of this study is a lack of discussion on the accumulating strong evidence of adverse effects and potential injury risks of electronic cigarette (1).

    A recent randomized controlled trial (RCT) published by Hajek and his colleagues in the NEJM showed comparative efficacy of electronic cigarettes in helping smokers quit (2). Further, study authors have suggested that the health care professionals should widely recommend its’ use for clinical care decision making on smoking cessation (3). However, to date
    two RCTs, compared electronic cigarettes with standard smoking cessation therapies such as nicotine replacement therapy (NRT), pharmacotherapy (e.g., bupropion and varenicline) (2, 4). The RCT by Halpern colleagues did not find electronic cigarettes significantly better than financial incentives and pharmacological therapies (4). Moreover, the findings of 1-year abstinence rates in the 10% to 20% range in the study by Hajek et al are typical for FDA approved safer pharmacologic smoking-cessation therapies (2, 5).

    Could this emerging evidence  be used to recommend electronic cigarettes as a smoking cessation tool? I strongly believe that the physicians could potentially use National Academies of Sciences, Engineering and Medicines’ (NASEM) recommendations on electronic cigarette in their clinical practice (6, 7):
    (a). “In summary, the existing systematic reviews consistently agreed that the available evidence base was insufficient to definitively answer the question of whether e-cigarettes helped smokers to quit. They uniformly identified the urgent need for additional studies of high scientific quality, especially RCTs” (Pp. 576).

    According to the best evidence available, it is too premature to categorize electronic cigarette as either beneficial or harmful. Medical community is so divided on their opinion on the efficacy as a therapeutic tool or potential harm of electronic cigarettes (8, 9). According to available literature, many physicians do not feel comfortable discussing the health effects of electronic cigarettes, obviously, due to limited knowledge and contradictory scientific information available on this topic (1, 2, 4, 5, 8, 9). Therefore,  physicians need evidence-based information (in straight forward simple language) to help them appropriately address electronic cigarettes in primary care (8, 9). Similarly, evidence based information on electronic cigarettes should be communicated appropriately using lay language in order to assist patients’ informed decision making.

    I am concerned that the emerging evidence in France (1) will be used for the tobacco industries’ aggressive online marketing efforts to encourage more adolescents to use electronic cigarettes. Electronic cigarettes contain nicotine that is highly addictive (10). Unfortunately, careful consideration of the potential adverse health effects from nicotine itself is often absent from public health debates (10) and available position statements of reputable medical organizations.

    Adolescent electronic cigarette use has increased rapidly in recent years to an epidemic level. Adolescents are more likely to use electronic cigarettes because of unique factors of electronic cigarettes, such as e-cigarette liquid flavors, easy online access and perceptions that electronic cigarettes are less harmful and a tobacco cessation tool.

    (1). Gomajee R, El-Khoury F, Goldberg M, Zins M, Lemogne C, Wiernik E, Lequy-Flahault E, Romanello L, Kousignian I, Melchior M. Association Between Electronic Cigarette Use and Smoking Reduction in France. JAMA Intern Med. 2019 Jul 15. doi: 10.1001/jamainternmed.2019.1483. [Epub ahead of print]
    (2). Hajek P, Phillips-Waller A, Przulj D, Pesola F, Myers Smith K, Bisal N, Li J, Parrott S, Sasieni P, Dawkins L, Ross L, Goniewicz M, Wu Q, McRobbie HJ. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy.N Engl J Med. 2019;14;380(7):629-637. 
    (3). Brown T.-e-Cigs Beat Nicotine Patch, Gum for Smoking Cessation in RCT. Medscape - Jan 30, 2019. https://www.medscape.com/viewarticle/908429#vp_1
    (4). Halpern SD, Harhay MO, Saulsgiver K, Brophy C, Troxel AB, Volpp KG. A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation. N Engl J Med. 2018;14;378(24):2302-2310.
    (5). Brett AS. E-Cigarettes vs. Nicotine-Replacement Therapy for Smoking Cessation-NEJM Journal Watch. 2019-https://www.jwatch.org/na48449/2019/02/07/e-cigarettes-vs-nicotine-replacement-therapy-smoking
    (6). Gideon ST, Eaton DL. Public Health Consequences of e-Cigarette Use. JAMA Intern Med. 2018; doi: 10.1001/jamainternmed.2018.1600
    (7). National Academies of Sciences and Engineering and Medicine (NASEM). Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems. Public health consequences of e-cigarettes. The National Academies Press, Washington, DC; 2018.
    (8). Doescher MP, Wu M, Rainwater E, Khan AS, Rhoades DA. Patient Perspectives on Discussions of Electronic Cigarettes in Primary Care. J Am Board Fam Med. 2018;31(1):73-82. doi: 10.3122/jabfm.2018.01.170206.
    (9). Pepper JK, Gilkey MB, Brewer NT. Physicians' Counseling of Adolescents Regarding E-Cigarette Use. J Adolesc Health. 2015 Dec;57(6):580-6. doi: 10.1016/j.jadohealth.2015.06.017. Epub 2015 Aug 19.
    (10). England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the Developing Human: A Neglected Element in the Electronic Cigarette Debate. Am J Prev Med. 2015;49(2):286-93.