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Figure.  Time to Smoking Relapse According to Current Regular Electronic Cigarette (EC) Use Among Former Smokers (n = 2025), CONSTANCES Cohort Study, 2012-2017
Time to Smoking Relapse According to Current Regular Electronic Cigarette (EC) Use Among Former Smokers (n = 2025), CONSTANCES Cohort Study, 2012-2017

The shaded area indicates 95% CIs. CONSTANCES indicates Consultants des Centres d’Examens de Santé.

Table 1.  Characteristics of Smokers and Former Smokers According to EC Use Status, CONSTANCES Cohort Study, 2012-2017
Characteristics of Smokers and Former Smokers According to EC Use Status, CONSTANCES Cohort Study, 2012-2017
Table 2.  Longitudinal Changes in Cigarette Smoking as a Function of EC Use CONSTANCES Cohort Study, 2012-2017a
Longitudinal Changes in Cigarette Smoking as a Function of EC Use CONSTANCES Cohort Study, 2012-2017a
Table 3.  Models for Smoking Relapse as a Function of EC Use Among Former Smokers Who Stopped Smoking From 2010, CONSTANCES Cohort Study, 2012-2017
Models for Smoking Relapse as a Function of EC Use Among Former Smokers Who Stopped Smoking From 2010, CONSTANCES Cohort Study, 2012-2017
1.
Doll  R, Hill  AB.  Smoking and carcinoma of the lung; preliminary report.  BMJ. 1950;2(4682):739-748. doi:10.1136/bmj.2.4682.739PubMedGoogle ScholarCrossref
2.
Schiller  WJ. Ashes to ashes: America’s hundred-year cigarette war, the public health, and the unabashed triumph of Philip Morris. Political Science Quarterly. http://link.galegroup.com/apps/doc/A19791857/AONE?sid=googlescholar. Published June 22, 1997. Accessed December 27, 2018.
3.
Douglas  CE, Henson  R, Drope  J, Wender  RC.  The American Cancer Society public health statement on eliminating combustible tobacco use in the United States.  CA Cancer J Clin. 2018;68(4):240-245. doi:10.3322/caac.21455PubMedGoogle ScholarCrossref
4.
Elders  MJ, Perry  CL, Eriksen  MP, Giovino  GA.  The report of the Surgeon General: preventing tobacco use among young people.  Am J Public Health. 1994;84(4):543-547. doi:10.2105/AJPH.84.4.543PubMedGoogle ScholarCrossref
5.
Fidler  J, Ferguson  SG, Brown  J, Stapleton  J, West  R.  How does rate of smoking cessation vary by age, gender and social grade? findings from a population survey in England.  Addiction. 2013;108(9):1680-1685. doi:10.1111/add.12241PubMedGoogle ScholarCrossref
6.
Hartmann-Boyce  J, Chepkin  SC, Ye  W, Bullen  C, Lancaster  T.  Nicotine replacement therapy versus control for smoking cessation.  Cochrane Database Syst Rev. 2018;5:CD000146. doi:10.1002/14651858.CD000146.pub5PubMedGoogle Scholar
7.
Cahill  K, Stevens  S, Perera  R, Lancaster  T.  Pharmacological interventions for smoking cessation: an overview and network meta-analysis.  Cochrane Database Syst Rev. 2013;(5):CD009329. doi:10.1002/14651858.CD009329.pub2PubMedGoogle Scholar
8.
Stead  LF, Koilpillai  P, Fanshawe  TR, Lancaster  T.  Combined pharmacotherapy and behavioural interventions for smoking cessation.  Cochrane Database Syst Rev. 2016;3:CD008286. doi:10.1002/14651858.CD008286.pub3PubMedGoogle Scholar
9.
Rahman  MA, Hann  N, Wilson  A, Mnatzaganian  G, Worrall-Carter  L.  E-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis.  PLoS One. 2015;10(3):e0122544. doi:10.1371/journal.pone.0122544PubMedGoogle ScholarCrossref
10.
Smith  AL, Carter  SM, Chapman  S, Dunlop  SM, Freeman  B.  Why do smokers try to quit without medication or counselling? a qualitative study with ex-smokers.  BMJ Open. 2015;5(4):e007301. doi:10.1136/bmjopen-2014-007301PubMedGoogle ScholarCrossref
11.
Babb  S, Malarcher  A, Schauer  G, Asman  K, Jamal  A.  Quitting smoking among adults—United States, 2000-2015.  MMWR Morb Mortal Wkly Rep. 2017;65(52):1457-1464. doi:10.15585/mmwr.mm6552a1PubMedGoogle ScholarCrossref
12.
Guignard  R, Richard  J-B, Pasquereau  A,  et al. Quit attempts in the last quarter of 2016 and relation with Mois sans tabac: first results from the 2017 Health Barometer [in French]. Bulletin épidémiologique hebdomadaire. http://invs.santepubliquefrance.fr/beh/2018/14-15/2018_14-15_6.html. Accessed March 8, 2019.
13.
Hung  WT, Dunlop  SM, Perez  D, Cotter  T.  Use and perceived helpfulness of smoking cessation methods: results from a population survey of recent quitters.  BMC Public Health. 2011;11:592. doi:10.1186/1471-2458-11-592PubMedGoogle ScholarCrossref
14.
Kotz  D, Brown  J, West  R.  ‘Real-world’ effectiveness of smoking cessation treatments: a population study.  Addiction. 2014;109(3):491-499. doi:10.1111/add.12429PubMedGoogle ScholarCrossref
15.
Bao  W, Xu  G, Lu  J, Snetselaar  LG, Wallace  RB.  Changes in electronic cigarette use among adults in the United States, 2014-2016.  JAMA. 2018;319(19):2039-2041. doi:10.1001/jama.2018.4658PubMedGoogle ScholarCrossref
16.
Laverty  AA, Filippidis  FT, Vardavas  CI.  Patterns, trends and determinants of e-cigarette use in 28 European Union member states 2014-2017.  Prev Med. 2018;116:13-18. doi:10.1016/j.ypmed.2018.08.028PubMedGoogle ScholarCrossref
17.
Pasquereau  A, Andler  R, Guignard  R, Richard  J-B, Arwidson  P, Nguyen-Thanh  V. Tobacco consumption in France: preliminary results from the 2017 Health Barometer [in French]. http://invs.santepubliquefrance.fr/beh/2018/14-15/2018_14-15_1.html. Accessed June 7, 2019.
18.
McNeill  A, Brose  LS, Calder  R, Bauld  L, Robson  D. Evidence review of e-cigarettes and heated tobacco products 2018: a report commissioned by Public Health England. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf. Published February 2018. Accessed June 7, 2019.
19.
Etter  J-F, Bullen  C.  Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy.  Addiction. 2011;106(11):2017-2028. doi:10.1111/j.1360-0443.2011.03505.xPubMedGoogle ScholarCrossref
20.
Kalkhoran  S, Glantz  SA.  E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis.  Lancet Respir Med. 2016;4(2):116-128. doi:10.1016/S2213-2600(15)00521-4PubMedGoogle ScholarCrossref
21.
Bullen  C, Howe  C, Laugesen  M,  et al.  Electronic cigarettes for smoking cessation: a randomised controlled trial.  Lancet. 2013;382(9905):1629-1637. doi:10.1016/S0140-6736(13)61842-5PubMedGoogle ScholarCrossref
22.
Pasquereau  A, Guignard  R, Andler  R, Nguyen-Thanh  V.  Electronic cigarettes, quit attempts and smoking cessation: a 6-month follow-up.  Addiction. 2017;112(9):1620-1628. doi:10.1111/add.13869PubMedGoogle ScholarCrossref
23.
Brown  J, Beard  E, Kotz  D, Michie  S, West  R.  Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study.  Addiction. 2014;109(9):1531-1540. doi:10.1111/add.12623PubMedGoogle ScholarCrossref
24.
Brose  LS, Hitchman  SC, Brown  J, West  R, McNeill  A.  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.  Addiction. 2015;110(7):1160-1168. doi:10.1111/add.12917PubMedGoogle ScholarCrossref
25.
Hajek  P, Phillips-Waller  A, Przulj  D,  et al.  A randomized trial of e-cigarettes versus nicotine-replacement therapy.  N Engl J Med. 2019;380(7):629-637. doi:10.1056/NEJMoa1808779PubMedGoogle ScholarCrossref
26.
Zawertailo  L, Pavlov  D, Ivanova  A, Ng  G, Baliunas  D, Selby  P.  Concurrent e-cigarette use during tobacco dependence treatment in primary care settings: association with smoking cessation at three and six months.  Nicotine Tob Res. 2017;19(2):183-189. doi:10.1093/ntr/ntw218PubMedGoogle ScholarCrossref
27.
Biener  L, Hargraves  JL.  A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit.  Nicotine Tob Res. 2015;17(2):127-133. doi:10.1093/ntr/ntu200PubMedGoogle ScholarCrossref
28.
Maloney  EK, Cappella  JN.  Does vaping in e-cigarette advertisements affect tobacco smoking urge, intentions, and perceptions in daily, intermittent, and former smokers?  Health Commun. 2016;31(1):129-138. doi:10.1080/10410236.2014.993496PubMedGoogle ScholarCrossref
29.
Yong  H-H, Borland  R, Cummings  KM, Partos  T.  Do predictors of smoking relapse change as a function of duration of abstinence? findings from the United States, Canada, United Kingdom and Australia.  Addiction. 2018;113(7):1295-1304. doi:10.1111/add.14182PubMedGoogle ScholarCrossref
30.
Rutten  LJF, Blake  KD, Agunwamba  AA,  et al.  Use of e-cigarettes among current smokers: associations among reasons for use, quit intentions, and current tobacco use.  Nicotine Tob Res. 2015;17(10):1228-1234. doi:10.1093/ntr/ntv003PubMedGoogle ScholarCrossref
31.
Kong  G, Morean  ME, Cavallo  DA, Camenga  DR, Krishnan-Sarin  S.  Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults.  Nicotine Tob Res. 2015;17(7):847-854. doi:10.1093/ntr/ntu257PubMedGoogle ScholarCrossref
32.
Berry  KM, Reynolds  LM, Collins  JM,  et al.  E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of Tobacco and Health Study, 2013-2015.  Tob Control. 2019;28(1):42-49. doi:10.1136/tobaccocontrol-2017-054108PubMedGoogle Scholar
33.
Zins  M, Goldberg  M; CONSTANCES team.  The French CONSTANCES population-based cohort: design, inclusion and follow-up.  Eur J Epidemiol. 2015;30(12):1317-1328. doi:10.1007/s10654-015-0096-4PubMedGoogle ScholarCrossref
34.
Goldberg  M, Carton  M, Descatha  A,  et al; CONSTANCES team.  CONSTANCES: a general prospective population-based cohort for occupational and environmental epidemiology: cohort profile.  Occup Environ Med. 2017;74(1):66-71. doi:10.1136/oemed-2016-103678PubMedGoogle ScholarCrossref
35.
Zhuang  Y-L, Cummins  SE, Sun  JY, Zhu  S-H.  Long-term e-cigarette use and smoking cessation: a longitudinal study with US population.  Tob Control. 2016;25(suppl 1):i90-i95. doi:10.1136/tobaccocontrol-2016-053096PubMedGoogle ScholarCrossref
36.
Marti  J.  Successful smoking cessation and duration of abstinence—an analysis of socioeconomic determinants.  Int J Environ Res Public Health. 2010;7(7):2789-2799. doi:10.3390/ijerph7072789PubMedGoogle ScholarCrossref
37.
Farsalinos  KE, Poulas  K, Voudris  V, Le Houezec  J.  Electronic cigarette use in the European Union: analysis of a representative sample of 27 460 Europeans from 28 countries.  Addiction. 2016;111(11):2032-2040. doi:10.1111/add.13506PubMedGoogle ScholarCrossref
38.
Tibshirani  R.  Regression Shrinkage and Selection via the Lasso.  J R Stat Soc Series B Stat Methodol. 1996;58(1):267-288.Google Scholar
39.
McNutt  L-A, Wu  C, Xue  X, Hafner  JP.  Estimating the relative risk in cohort studies and clinical trials of common outcomes.  Am J Epidemiol. 2003;157(10):940-943. doi:10.1093/aje/kwg074PubMedGoogle ScholarCrossref
40.
Bartlett  JW, Seaman  SR, White  IR, Carpenter  JR; Alzheimer’s Disease Neuroimaging Initiative.  Multiple imputation of covariates by fully conditional specification: Accommodating the substantive model.  Stat Methods Med Res. 2015;24(4):462-487. doi:10.1177/0962280214521348PubMedGoogle ScholarCrossref
41.
de Leon  J, Diaz  FJ, Becoña  E, Gurpegui  M, Jurado  D, Gonzalez-Pinto  A.  Exploring brief measures of nicotine dependence for epidemiological surveys.  Addict Behav. 2003;28(8):1481-1486. doi:10.1016/S0306-4603(02)00264-2PubMedGoogle ScholarCrossref
42.
Wong  SL, Shields  M, Leatherdale  S, Malaison  E, Hammond  D.  Assessment of validity of self-reported smoking status.  Health Rep. 2012;23(1):47-53.PubMedGoogle Scholar
43.
Chaiton  M, Diemert  L, Cohen  JE,  et al.  Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers.  BMJ Open. 2016;6(6):e011045. doi:10.1136/bmjopen-2016-011045PubMedGoogle ScholarCrossref
44.
Andler  R, Guignard  R, Wilquin  J-L, Beck  F, Richard  J-B, Nguyen-Thanh  V.  Electronic cigarette use in France in 2014.  Int J Public Health. 2016;61(2):159-165. doi:10.1007/s00038-015-0773-9PubMedGoogle ScholarCrossref
45.
Zhu  S-H, Zhuang  Y-L, Wong  S, Cummins  SE, Tedeschi  GJ.  E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys.  BMJ. 2017;358:j3262. doi:10.1136/bmj.j3262PubMedGoogle ScholarCrossref
46.
Andler  R, Guignard  R, Wilquin  J-L, Beck  F, Nguyen-Thanh  V. L’usage de la cigarette électronique en France en 2014. http://inpes.santepubliquefrance.fr/CFESBases/catalogue/pdf/1689.pdf. Accessed June 7, 2019.
47.
Jarvis  MJ, Cohen  JE, Delnevo  CD, Giovino  GA.  Dispelling myths about gender differences in smoking cessation: population data from the USA, Canada and Britain.  Tob Control. 2013;22(5):356-360. doi:10.1136/tobaccocontrol-2011-050279PubMedGoogle ScholarCrossref
48.
Piper  ME, Cook  JW, Schlam  TR,  et al.  Gender, race, and education differences in abstinence rates among participants in two randomized smoking cessation trials.  Nicotine Tob Res. 2010;12(6):647-657. doi:10.1093/ntr/ntq067PubMedGoogle ScholarCrossref
49.
Piñeiro  B, Correa  JB, Simmons  VN,  et al.  Gender differences in use and expectancies of e-cigarettes: online survey results.  Addict Behav. 2016;52:91-97. doi:10.1016/j.addbeh.2015.09.006PubMedGoogle ScholarCrossref
50.
Simonavicius  E, McNeill  A, Arnott  D, Brose  LS.  What factors are associated with current smokers using or stopping e-cigarette use?  Drug Alcohol Depend. 2017;173:139-143. doi:10.1016/j.drugalcdep.2017.01.002PubMedGoogle ScholarCrossref
51.
Dawkins  L, Corcoran  O.  Acute electronic cigarette use: nicotine delivery and subjective effects in regular users.  Psychopharmacology (Berl). 2014;231(2):401-407. doi:10.1007/s00213-013-3249-8PubMedGoogle ScholarCrossref
52.
Hiler  M, Breland  A, Spindle  T,  et al.  Electronic cigarette user plasma nicotine concentration, puff topography, heart rate, and subjective effects: influence of liquid nicotine concentration and user experience.  Exp Clin Psychopharmacol. 2017;25(5):380-392. doi:10.1037/pha0000140PubMedGoogle ScholarCrossref
53.
Farsalinos  KE, Spyrou  A, Tsimopoulou  K, Stefopoulos  C, Romagna  G, Voudris  V.  Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices.  Sci Rep. 2014;4:4133. doi:10.1038/srep04133PubMedGoogle ScholarCrossref
54.
Yan  XS, D’Ruiz  C.  Effects of using electronic cigarettes on nicotine delivery and cardiovascular function in comparison with regular cigarettes.  Regul Toxicol Pharmacol. 2015;71(1):24-34. doi:10.1016/j.yrtph.2014.11.004PubMedGoogle ScholarCrossref
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    2 Comments for this article
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    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.

    Regards,
    Dr.Rajiv Kumar, Faculty, Dept. of Pharmacology, Government Medical College & Hospital, Chandigarh, 160030. India.
    DRrajiv.08@gmail.com

    References:
    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
    CONFLICT OF INTEREST: None Reported
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    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.

    References:
    (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.
    CONFLICT OF INTEREST: None Reported
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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.

    Abstract

    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.

    Introduction

    Cigarette smoking has been identified as a cause of cancer incidence and mortality since the end of World War II1 and remains a major public health problem today.2,3 Most smokers initiate tobacco use in adolescence4 and attempt to quit at around 30 years of age (especially women) or after 50 years of age.5 Pharmacotherapies (nicotine replacement therapy [NRT], bupropion hydrochloride, and varenicline tartrate) and behavioral therapies have been shown to be effective in helping smokers quit.6-8 However, the appeal of smoking cessation aids is relatively low,9 and most quit attempts are done “cold turkey” (ie, stopping nicotine consumption all at once), without professional assistance or treatment,10-13 which may be because smoking cessation aids have a financial cost or because smokers lack knowledge about their effectiveness and safety. There are also other reasons for not using smoking cessation aids; for example, some smokers believe that quitting without help gives them greater satisfaction and a feeling of self-control, strength, and autonomy.10 However, studies show that smokers who use smoking cessation aids are more likely to remain abstinent.14

    Electronic cigarettes (ECs), sometimes also referred to as electronic nicotine delivery systems, have become popular in recent years. In the United States, approximately 15.3% of adults have used ECs,15 as have 14.6% of adults in Europe16 (41.7% of adults in France17). Approximately 3.2% of persons in the United States use ECs regularly,15 as do 1.8% of persons in Europe16 (3.8% of persons in France17). Electronic cigarettes are generally used by smokers who consider them to be less harmful than conventional cigarettes18,19 and try to reduce or quit their cigarette consumption.12 In some countries, such as France, ECs have become the leading smoking cessation method (27% of smokers who try to quit use ECs), ahead of NRT (18%).12 However, the effectiveness of ECs as a smoking reduction and cessation aid is still a subject of controversy.20-24 Randomized clinical trials have shown that ECs are as effective as21 or more effective than25 NRT with regard to smoking reduction or cessation. On the other hand, there is also evidence that concurrent use of ECs and NRT may hamper smoking cessation.26 However, prior studies have been based on relatively small samples or were conducted for short follow-up periods and have limited external validity.

    One of the major concerns regarding the consequences of EC use is that it might reduce smokers’ motivation to quit27 by providing a cue for smoking relapse.28 Thus, paradoxically, EC users might need a larger number of quit attempts to achieve successful smoking cessation. Because former smokers may relapse at different rates, some after only a few days and others after several months,29 it is necessary to follow the consequences of EC use over extended periods of time. To date, population-based evidence of long-term smoking trajectories after EC use is limited.

    Moreover, most studies have focused on the association between EC use and smoking cessation among smokers who are trying to stop smoking21,22 (ie, among those most motivated to quit). However, in the general population, smokers use ECs for various reasons—to reduce smoking level, to “smoke” indoors, to reduce tobacco-related expenses, to reduce health risks, or simply out of curiosity.30,31 Recent studies have examined the effect of EC use in the general population,23,32 but they have mostly been cross-sectional or short-term.

    The aim of our study, based on the French CONSTANCES (Consultants des Centres d’Examens de Santé) cohort, was to investigate whether, in a community sample with prospective follow-up, EC use is associated with changes in the number of cigarettes smoked, with smoking cessation rates among smokers, and with smoking relapse among former smokers.

    Methods
    Study Design, Settings, and Participants

    The CONSTANCES cohort was designed as a randomly selected sample of 200 000 adults drawn from France’s compulsory health insurance scheme (Caisse nationale d’assurance maladie), which covers about 85% of persons living in France (excluding farmers and self-employed workers). Recruitment started January 6, 2012, and is currently ongoing, among persons 18 to 69 years of age who live throughout France; the sociodemographic and economic characteristics of participants’ districts of residence are very similar to the French average. The sampling base at inclusion is composed of all persons meeting eligibility criteria; to obtain a sample comparable to the French population, an unequal probability sampling scheme overrepresenting men, younger participants, and those belonging to socioeconomically disadvantaged groups, who generally tend to have low participation levels in epidemiologic surveys, was implemented.33,34 Every year, participants are invited to complete a paper and pencil or web-based questionnaire and additionally undergo a medical examination every 4 years.33,34 Participants involved in the first wave of recruitment had more follow-up questionnaires than those recruited at later stages. The CONSTANCES cohort received the approval of the French legal authorities (Commission nationale de l’informatique et des libertés) that ensure ethical review, including an evaluation of participants’ written informed consent, data confidentiality, and safety.33

    Our investigation is based on CONSTANCES cohort participants included in the study through 2015, and who had at least 1 completed follow-up questionnaire (n = 40 311). A total of 19 912 participants (49.4%) were nonsmokers, 6423 (15.9%) were current smokers (at least 1 cigarette per day), and 13 976 (34.7%) were former smokers at the time of inclusion in CONSTANCES (eFigure in the Supplement).

    We focused on current smokers and former smokers who reported having quit smoking from 2010 onward (the year that ECs were commercially introduced in France; n = 2046). After excluding participants with no data on EC use (1023 current smokers and 21 former smokers), our final analytical sample comprised 5400 current smokers and 2025 former smokers with at least 1 year of follow-up (mean [SD] follow-up of 2.6 [0.7] years for current smokers and 2.5 [0.6] years for). First, among current smokers, we studied the association between EC use and the number of cigarettes smoked as well as smoking cessation. Second, among former smokers, we studied the association between EC use and smoking relapse.

    Variables
    Outcomes

    The 4 study outcomes examined are (1) the number of cigarettes smoked per day, (2) the difference between the number of cigarettes smoked per day at baseline and the number of cigarettes smoked per day at follow-up, (3) smoking cessation among smokers (ie, 0 cigarettes per day in any year of follow-up), and (4) cigarette smoking relapse among former smokers (≥1 cigarette per day reported on any follow-up questionnaire).

    Exposure: EC Use

    Participants reported current regular (daily) EC use (yes or no) (822 [15.2%] smokers and 176 [8.7%] former smokers) and the date of initiation of regular EC use, which made it possible to calculate the duration of regular EC use. For each participant, we evaluated EC use prospectively, irrespective of the type of device (rechargeable vs disposable; data on device type were not usable because of missing data). Because data on motives for using EC were not collected, EC use in our study is not restricted to only those who want to stop smoking. Among the 822 smokers who used an EC during the study, 194 (23.6%) had started using ECs prior to study baseline.

    The duration of EC use has been shown to be associated with smoking cessation.35 In secondary analyses, we studied the association between the duration of EC use (<1 year vs ≥1 year) and smoking patterns.

    Covariates

    Our statistical analyses controlled for covariates previously shown to be associated with either tobacco cessation or EC use: sex, age,33 marital status (single vs cohabiting or married), educational level36 (≤high school vs higher education), employment status (employed, unemployed, or retired), citizenship (non-French vs French), household income36 (<€1500 [$1694.50], €1500-€2799 [$1694.50-$3162], or≥€2800 [$3163] per month), financial difficulties (yes vs no), alcohol abuse (Alcohol Use Disorders Identification Test score), number of cigarettes smoked per day at the time of inclusion,37 number of pack-years of smoking (lifetime tobacco exposure; a pack-year is defined as 20 cigarettes smoked every day for 1 year), depressive symptoms measured by the Center for Epidemiologic Studies–Depression scale, lifetime history of depression (yes vs no), respiratory problems in the preceding 12 months (yes vs no), lifetime history of cardiovascular disease (yes vs no), and lifetime history of cancer (yes vs no). In addition, we controlled for participants’ year of inclusion in the CONSTANCES cohort, the duration of follow-up, and prior lifetime episodes of smoking cessation37 (none, <1 year, or ≥1 year).

    Statistical Analysis

    To identify covariates associated with both the study exposure and the study outcomes, we conducted univariate logistic and linear regression analyses. All P values were from 2-sided tests and results were deemed statistically significant at P < .05.

    Association of EC Use With Smoking Reduction or Quitting

    Among daily smokers, the association of EC use with the number of cigarettes smoked per day with the difference in the number of cigarettes smoked per day between baseline and follow-up was estimated using mixed linear models adjusted for sociodemographic characteristics such as sex, age, marital status, educational level, and income; substance use, including alcohol abuse; number of cigarettes smoked per day; number of pack-years of smoking; and health characteristics, such as depressive symptoms and respiratory problems. The variables included in the final model were selected using the least absolute shrinkage and selection operator method.38

    To determine the likelihood of smoking cessation being associated with EC use, we used Poisson regression models with robust sandwich variance estimators, adjusted for sociodemographic characteristics, duration of follow-up, and previous smoking cessation attempts. This method was preferred to logistic regression, for which the adjusted odds ratios would have overstated the participants’ relative risk39 of quitting smoking (28% of smokers reported quitting in any year of follow-up). Because the associations between EC use and cigarette smoking can vary with individuals’ sex, age, duration of previous smoking cessation attempts, and educational level, we additionally performed analyses stratified on these characteristics.

    Association of EC Use With Smoking Relapse in Former Smokers

    To test whether EC use is associated with later smoking relapse, we focused on former smokers who quit tobacco in or after 2010, and we used Cox proportional hazards regression models adjusted for sociodemographic characteristics, including sex, age, marital status, educational level, and income; alcohol use; cigarette use; and health conditions, such as depressive symptoms and respiratory problems. To estimate the time to event (relapse or regular smoking), we calculated the number of months between the inclusion in the CONSTANCES cohort and the follow-up questionnaire in which the participant reported regular smoking. Among former smokers who did not relapse, data were censored at the last follow-up questionnaire available. We verified the proportional hazards assumption both graphically and statistically. Because the level of EC use increased and because the devices used evolved over time, we performed supplementary analyses, stratifying our sample on the year of smoking cessation.

    Missing Data and Multiple Imputations

    Overall, less than 2% of data were missing, except for data on number of pack-years of smoking, which were unavailable for 718 of 7425 participants (9.7%). Missing data on all covariates were imputed using multiple imputations (10 imputations per missing value) with fully conditional specification.40 All data analyses were conducted using SAS, version 9.4 (SAS Institute Inc).

    Results
    Study Population Characteristics

    In our study, smokers (n = 5400) were followed up for a mean (SD) period of 23.4 (9.3) months, during which 822 (15.2%) reported regular (daily) use of an EC. As shown in Table 1, univariate analyses show that, compared with the 4578 nonusers, EC users were more likely to be male (423 [51.5%] vs 2071 [45.2%]), older (mean [SD] age, 45.9 [11.6] vs 44.7 [12.5] years), and in a civil partnership or married (403 [49.0%] vs 2142 [46.8%]) and were followed up for a longer period (mean [SD], 26.2 [9.5] vs 22.9 [9.1] months). Electronic cigarette users were heavier smokers (mean [SD], 12.9 [6.8] vs 10.0 [6.6] cigarettes per day; 17.5 [14.1] vs 12.6 [12.1] pack-years of smoking) and were more likely to have previously made an attempt to quit smoking (594 [72.3%] vs 3147 [68.7%]). Electronic cigarette users were also more likely to have depressive symptoms (mean [SD] Center for Epidemiologic Studies–Depression scale score, 14.1 [10.3] vs 12.2 [9.5]), a history of depression (199 [24.2%] vs 911 [19.9%]), or respiratory problems (646 [78.6%] vs 3116 [68.1%]).

    Former smokers (n = 2025) were followed up for a mean (SD) period of 22.1 (8.6) months, during which 176 (8.7%) reported regular EC use (Table 1). Electronic cigarette users were more likely than the 1849 non-users to be male (111 [63.1%] vs 910 [49.2%]), have higher levels of tobacco smoking (mean [SD], 16.9 [12.6] vs 12.9 [13.7] pack-years) and lower levels of alcohol-related problems (mean [SD] Alcohol Use Disorders Identification Test score, 16.9 [12.6] vs 12.9 [13.7]), as well as higher levels of depressive symptoms (mean [SD] Center for Epidemiologic Studies–Depression scale score, 12.6 [9.8] vs 10.9 [8.6]).

    EC Use and Longitudinal Changes in Cigarette Smoking

    In a univariate mixed linear model (Table 2), EC users smoked significantly more cigarettes per day than nonusers (11.2 [95% CI, 10.8-11.7] vs 9.8 [95% CI, 9.6-10.0]). However, after controlling for demographic, socioeconomic, substance use–related characteristics, and health characteristics, we found that the estimated number of cigarettes smoked per day was significantly lower among EC users than among nonusers (11.2 [95% CI, 10.5-11.8] vs 12.2 [95% CI, 11.6-12.8]). After adjustment for all covariates, EC users decreased the number of cigarettes smoked significantly more during the course of follow-up than did nonusers (–4.4 [95% CI, –4.8 to –3.9] vs –2.7 [95% CI, –3.1 to –2.4] cigarettes per day).

    EC Use and Cigarette Smoking Cessation

    In both univariate and multivariate models, EC users were more likely to quit smoking during follow-up compared with nonusers (univariate relative risk, 1.59 [95% CI, 1.45-1.76]; multivariate relative risk, 1.67 [95% CI, 1.51-1.84]) (Table 2). In additional analyses, this association was stronger among participants who used ECs for more than 1 year (adjusted relative risk, 2.03 [95% CI, 1.82-2.27]) than among those who used ECs for less than 1 year (adjusted relative risk, 1.33 [95% CI, 1.15-1.54]) (eTable 1 in the Supplement). We found no statistical interaction between EC use and sex, age group, duration of prior smoking cessation, or educational level (eTable 2 in the Supplement).

    Smoking Relapse in Former Smokers

    Overall, compared with former smokers who did not use ECs, those who did were more likely to relapse to smoking (adjusted hazard ratio, 1.70 [95% CI, 1.25-2.30]) (Figure). This hazard ratio decreased with time from 1.70 (95% CI, 1.25-2.30) among persons who quit as of 2010 (n = 2025) to 0.94 (95% CI, 0.57-1.52) among persons who quit as of 2013 (n = 601) (Table 3).

    Discussion
    Main Findings

    Studying longitudinal associations between EC use and tobacco smoking patterns in a large population-based cohort study, we found that EC use was associated with a reduction in smoking level as well as an increased probability of smoking cessation. However, we also observed that, over time, EC users who quit tobacco tended to relapse to smoking more frequently than did nonusers. Thus, while EC use can help persons reduce their smoking levels in the short term, there is no evidence that it is an efficacious smoking cessation aid in the long term.

    Limitations and Strengths

    Our investigation has weaknesses that need to be acknowledged. First, our study was not designed to test whether ECs are efficacious with regard to tobacco smoking reduction. We had no information on the motives underlying EC use nor the extent to which participants intended to quit smoking. Previous studies have shown that the main reason for EC use among adults is the intention to reduce or quit smoking30 and that ECs are the most used aid for smoking cessation in France (no aid, 52%; ECs, 27%; NRT, 18%).12 Moreover, we controlled for previous smoking cessation attempts, and our results are consistent with those of other researchers who suggest that EC use is associated with an increase in the reduction of tobacco consumption over time.32 Therefore, it is likely that, among regular smokers, ECs primarily serve to help decrease tobacco use levels.

    Second, participants’ nicotine dependence was not measured, but our analyses controlled for the number of cigarettes smoked per day and the number of pack-years of smoking, which can be considered as valid proxies.41 Similarly, smoking was self-reported, which could induce bias, but such measures are generally considered valid.42 Results of the Fagerström test for nicotine dependence were also not available. Third, the mean duration of follow-up was 23 months, which is longer than in most previous studies, but it could be argued that it should be even longer because smokers often need several quit attempts before achieving successful long-term smoking cessation.43

    Fourth, participants reported current EC use and the date of initiation, from which we derived the duration of EC use. However, the daily frequency of EC use (eg, number of puffs) was not documented. Previous studies have shown that smoking cessation is primarily associated with extensive EC use.20,24 Similarly, we were not able to evaluate EC users’ nicotine intake or examine whether it is associated with smoking behavior. Most participants reported using ECs with nicotine, but the information regarding the nicotine dosage of the e-liquid was often missing. In future studies, it will be important to assess the frequency of EC use and associated nicotine levels via questionnaires or other direct means of data collection.

    Despite these limitations, our study has important strengths. We assessed the association between EC use and smoking among smokers and former smokers prospectively in a large population sample, for approximately 2 years of follow-up on average. We were able to take into consideration the duration of EC use, which seems to play a role in smoking cessation. However, our main contribution to the existing literature is the finding of an elevated rate of smoking relapse among former smokers who use ECs.

    Our results are in line with those of other studies showing that EC use can help reduce tobacco smoking32,44,45 and encourage smoking cessation.23,25 The decrease in tobacco consumption among smokers irrespective of EC use observed in national surveys17 suggests that recent policies, such as the ban on smoking in public places, the reimbursement for NRT, and the increase in the price of tobacco products, have been successful. We found that smokers who used ECs decreased their smoking significantly more than nonusers and that they had a significantly higher probability of quitting smoking during follow-up. A recent randomized clinical trial showed that, among smokers trying to quit smoking, EC use was associated with a higher level of 1-year abstinence compared with NRT (relative risk, 1.83 [95% CI, 1.30-2.58]; P < .001).25 Unfortunately, we had no information on the reasons for EC use, but previous studies indicate that, in France, 82% of smokers and 89% of former smokers who use ECs consider them an aid to quit smoking or prevent a relapse.46 It would be interesting to further explore whether this smoking reduction or cessation is observed mainly among smokers who use ECs as a cessation tool or is observed also among those who use ECs for other reasons. In additional analyses, we found that smoking cessation was associated with duration of EC use, which is consistent with findings from previous studies.35

    Although the EC users in our study were more likely to be male, there were no sex differences in the association between EC use and smoking cessation. Previous research showed no sex differences47 or higher levels of smoking cessation among men,48 but these studies were conducted prior to the introduction of ECs. In particular, women are more likely than men to quit smoking before the age of 50 years, while the opposite is true after 50 years.47 Because men and women have different patterns of use and expectancies regarding ECs,49 future research should focus on possible sex differences with regard to long-term patterns of smoking cessation.

    Although EC use among smokers is associated with an increased probability of attempts to quit smoking, its use by former smokers, on the other hand, is linked to a higher likelihood of smoking relapse. This finding may be due to higher nicotine dependency among EC users or the fact that EC use may contribute to maintaining individuals’ levels of nicotine addiction over time. In particular, in the case of technical problems with an EC (eg, low battery or lack of e-liquid) or if an EC does not give the same pleasure as conventional cigarettes,50-52 individuals may revert to smoking cigarettes.

    However, levels of smoking relapse were not increased among former smokers who quit in recent years. Measures of plasma nicotine levels have showed that, compared with older models of ECs, the new generation delivers higher levels of nicotine to the bloodstream.53,54 This finding may be an explanation as to why smokers who recently quit smoking and switched to ECs are less likely to relapse than those who quit earlier. Although we found a higher probability of relapse among former smokers who used ECs than among nonusers, the question of whether this difference could be associated with a shorter period of follow-up, technical improvements in ECs over time, or a change in the profile of EC users will need to be evaluated in future studies.

    Conclusions

    Among current smokers, EC use is associated with a decrease in the number of cigarettes smoked and with an increase in cessation attempts, especially if EC use lasts more than 1 year. However, among former smokers, EC use is associated with a higher likelihood of relapse to smoking. Although EC use may help individuals decrease smoking levels and initiate smoking cessation, it is not clear whether it leads to complete long-term cessation.

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    Article Information

    Accepted for Publication: March 29, 2019.

    Corresponding Author: Ramchandar Gomajee, MSc, Inserm Unité Mixte de Recherche en Santé 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, 27 rue Chaligny, 75012 Paris, France (ramchandar.gomajee@inserm.fr).

    Published Online: July 15, 2019. doi:10.1001/jamainternmed.2019.1483

    Author Contributions: Dr Melchior had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: El-Khoury, Goldberg, Zins, Lemogne, Kousignian, Melchior.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Gomajee, Kousignian, Melchior.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Gomajee, El-Khoury, Goldberg, Kousignian.

    Obtained funding: Zins, Lemogne, Kousignian, Melchior.

    Supervision: Kousignian, Melchior.

    Conflict of Interest Disclosures: Dr Lemogne reported receiving personal fees from Janssen-Cilag, personal fees and nonfinancial support from Lundbeck, and nonfinancial support from Otsuka Pharmaceutical outside the submitted work. Drs Lemogne, Wiernik, Lequy, and Romanello reported receiving grants from INCA during the conduct of the study. No other disclosures were reported.

    Funding/Support: The CONSTANCES (Consultants des Centres d’Examens de Santé) Cohort Study was supported and funded by the Caisse nationale d’assurance maladie des travailleurs salariés. The CONSTANCES Cohort Study is an “Infrastructure nationale en Biologie et Santé” is funded by grant ANR-11-INBS-0002 from Agence Nationale de la Recherche. CONSTANCES is also partly funded by MSD, AstraZeneca, and Lundbeck. The present analyses were supported by grant 2016-082 from Institut National du Cancer.

    Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank the “Caisse nationale d’assurance maladie des travailleurs salaries” and the “Centres d’examens de santé” of the French Social Security which are collecting a large part of the data, as well as the “Caisse nationale d’assurance vieillesse,” ClinSearch, Asqualab, and Eurocell, in charge of the data quality control.

    References
    1.
    Doll  R, Hill  AB.  Smoking and carcinoma of the lung; preliminary report.  BMJ. 1950;2(4682):739-748. doi:10.1136/bmj.2.4682.739PubMedGoogle ScholarCrossref
    2.
    Schiller  WJ. Ashes to ashes: America’s hundred-year cigarette war, the public health, and the unabashed triumph of Philip Morris. Political Science Quarterly. http://link.galegroup.com/apps/doc/A19791857/AONE?sid=googlescholar. Published June 22, 1997. Accessed December 27, 2018.
    3.
    Douglas  CE, Henson  R, Drope  J, Wender  RC.  The American Cancer Society public health statement on eliminating combustible tobacco use in the United States.  CA Cancer J Clin. 2018;68(4):240-245. doi:10.3322/caac.21455PubMedGoogle ScholarCrossref
    4.
    Elders  MJ, Perry  CL, Eriksen  MP, Giovino  GA.  The report of the Surgeon General: preventing tobacco use among young people.  Am J Public Health. 1994;84(4):543-547. doi:10.2105/AJPH.84.4.543PubMedGoogle ScholarCrossref
    5.
    Fidler  J, Ferguson  SG, Brown  J, Stapleton  J, West  R.  How does rate of smoking cessation vary by age, gender and social grade? findings from a population survey in England.  Addiction. 2013;108(9):1680-1685. doi:10.1111/add.12241PubMedGoogle ScholarCrossref
    6.
    Hartmann-Boyce  J, Chepkin  SC, Ye  W, Bullen  C, Lancaster  T.  Nicotine replacement therapy versus control for smoking cessation.  Cochrane Database Syst Rev. 2018;5:CD000146. doi:10.1002/14651858.CD000146.pub5PubMedGoogle Scholar
    7.
    Cahill  K, Stevens  S, Perera  R, Lancaster  T.  Pharmacological interventions for smoking cessation: an overview and network meta-analysis.  Cochrane Database Syst Rev. 2013;(5):CD009329. doi:10.1002/14651858.CD009329.pub2PubMedGoogle Scholar
    8.
    Stead  LF, Koilpillai  P, Fanshawe  TR, Lancaster  T.  Combined pharmacotherapy and behavioural interventions for smoking cessation.  Cochrane Database Syst Rev. 2016;3:CD008286. doi:10.1002/14651858.CD008286.pub3PubMedGoogle Scholar
    9.
    Rahman  MA, Hann  N, Wilson  A, Mnatzaganian  G, Worrall-Carter  L.  E-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis.  PLoS One. 2015;10(3):e0122544. doi:10.1371/journal.pone.0122544PubMedGoogle ScholarCrossref
    10.
    Smith  AL, Carter  SM, Chapman  S, Dunlop  SM, Freeman  B.  Why do smokers try to quit without medication or counselling? a qualitative study with ex-smokers.  BMJ Open. 2015;5(4):e007301. doi:10.1136/bmjopen-2014-007301PubMedGoogle ScholarCrossref
    11.
    Babb  S, Malarcher  A, Schauer  G, Asman  K, Jamal  A.  Quitting smoking among adults—United States, 2000-2015.  MMWR Morb Mortal Wkly Rep. 2017;65(52):1457-1464. doi:10.15585/mmwr.mm6552a1PubMedGoogle ScholarCrossref
    12.
    Guignard  R, Richard  J-B, Pasquereau  A,  et al. Quit attempts in the last quarter of 2016 and relation with Mois sans tabac: first results from the 2017 Health Barometer [in French]. Bulletin épidémiologique hebdomadaire. http://invs.santepubliquefrance.fr/beh/2018/14-15/2018_14-15_6.html. Accessed March 8, 2019.
    13.
    Hung  WT, Dunlop  SM, Perez  D, Cotter  T.  Use and perceived helpfulness of smoking cessation methods: results from a population survey of recent quitters.  BMC Public Health. 2011;11:592. doi:10.1186/1471-2458-11-592PubMedGoogle ScholarCrossref
    14.
    Kotz  D, Brown  J, West  R.  ‘Real-world’ effectiveness of smoking cessation treatments: a population study.  Addiction. 2014;109(3):491-499. doi:10.1111/add.12429PubMedGoogle ScholarCrossref
    15.
    Bao  W, Xu  G, Lu  J, Snetselaar  LG, Wallace  RB.  Changes in electronic cigarette use among adults in the United States, 2014-2016.  JAMA. 2018;319(19):2039-2041. doi:10.1001/jama.2018.4658PubMedGoogle ScholarCrossref
    16.
    Laverty  AA, Filippidis  FT, Vardavas  CI.  Patterns, trends and determinants of e-cigarette use in 28 European Union member states 2014-2017.  Prev Med. 2018;116:13-18. doi:10.1016/j.ypmed.2018.08.028PubMedGoogle ScholarCrossref
    17.
    Pasquereau  A, Andler  R, Guignard  R, Richard  J-B, Arwidson  P, Nguyen-Thanh  V. Tobacco consumption in France: preliminary results from the 2017 Health Barometer [in French]. http://invs.santepubliquefrance.fr/beh/2018/14-15/2018_14-15_1.html. Accessed June 7, 2019.
    18.
    McNeill  A, Brose  LS, Calder  R, Bauld  L, Robson  D. Evidence review of e-cigarettes and heated tobacco products 2018: a report commissioned by Public Health England. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf. Published February 2018. Accessed June 7, 2019.
    19.
    Etter  J-F, Bullen  C.  Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy.  Addiction. 2011;106(11):2017-2028. doi:10.1111/j.1360-0443.2011.03505.xPubMedGoogle ScholarCrossref
    20.
    Kalkhoran  S, Glantz  SA.  E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis.  Lancet Respir Med. 2016;4(2):116-128. doi:10.1016/S2213-2600(15)00521-4PubMedGoogle ScholarCrossref
    21.
    Bullen  C, Howe  C, Laugesen  M,  et al.  Electronic cigarettes for smoking cessation: a randomised controlled trial.  Lancet. 2013;382(9905):1629-1637. doi:10.1016/S0140-6736(13)61842-5PubMedGoogle ScholarCrossref
    22.
    Pasquereau  A, Guignard  R, Andler  R, Nguyen-Thanh  V.  Electronic cigarettes, quit attempts and smoking cessation: a 6-month follow-up.  Addiction. 2017;112(9):1620-1628. doi:10.1111/add.13869PubMedGoogle ScholarCrossref
    23.
    Brown  J, Beard  E, Kotz  D, Michie  S, West  R.  Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study.  Addiction. 2014;109(9):1531-1540. doi:10.1111/add.12623PubMedGoogle ScholarCrossref
    24.
    Brose  LS, Hitchman  SC, Brown  J, West  R, McNeill  A.  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.  Addiction. 2015;110(7):1160-1168. doi:10.1111/add.12917PubMedGoogle ScholarCrossref
    25.
    Hajek  P, Phillips-Waller  A, Przulj  D,  et al.  A randomized trial of e-cigarettes versus nicotine-replacement therapy.  N Engl J Med. 2019;380(7):629-637. doi:10.1056/NEJMoa1808779PubMedGoogle ScholarCrossref
    26.
    Zawertailo  L, Pavlov  D, Ivanova  A, Ng  G, Baliunas  D, Selby  P.  Concurrent e-cigarette use during tobacco dependence treatment in primary care settings: association with smoking cessation at three and six months.  Nicotine Tob Res. 2017;19(2):183-189. doi:10.1093/ntr/ntw218PubMedGoogle ScholarCrossref
    27.
    Biener  L, Hargraves  JL.  A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit.  Nicotine Tob Res. 2015;17(2):127-133. doi:10.1093/ntr/ntu200PubMedGoogle ScholarCrossref
    28.
    Maloney  EK, Cappella  JN.  Does vaping in e-cigarette advertisements affect tobacco smoking urge, intentions, and perceptions in daily, intermittent, and former smokers?  Health Commun. 2016;31(1):129-138. doi:10.1080/10410236.2014.993496PubMedGoogle ScholarCrossref
    29.
    Yong  H-H, Borland  R, Cummings  KM, Partos  T.  Do predictors of smoking relapse change as a function of duration of abstinence? findings from the United States, Canada, United Kingdom and Australia.  Addiction. 2018;113(7):1295-1304. doi:10.1111/add.14182PubMedGoogle ScholarCrossref
    30.
    Rutten  LJF, Blake  KD, Agunwamba  AA,  et al.  Use of e-cigarettes among current smokers: associations among reasons for use, quit intentions, and current tobacco use.  Nicotine Tob Res. 2015;17(10):1228-1234. doi:10.1093/ntr/ntv003PubMedGoogle ScholarCrossref
    31.
    Kong  G, Morean  ME, Cavallo  DA, Camenga  DR, Krishnan-Sarin  S.  Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults.  Nicotine Tob Res. 2015;17(7):847-854. doi:10.1093/ntr/ntu257PubMedGoogle ScholarCrossref
    32.
    Berry  KM, Reynolds  LM, Collins  JM,  et al.  E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of Tobacco and Health Study, 2013-2015.  Tob Control. 2019;28(1):42-49. doi:10.1136/tobaccocontrol-2017-054108PubMedGoogle Scholar
    33.
    Zins  M, Goldberg  M; CONSTANCES team.  The French CONSTANCES population-based cohort: design, inclusion and follow-up.  Eur J Epidemiol. 2015;30(12):1317-1328. doi:10.1007/s10654-015-0096-4PubMedGoogle ScholarCrossref
    34.
    Goldberg  M, Carton  M, Descatha  A,  et al; CONSTANCES team.  CONSTANCES: a general prospective population-based cohort for occupational and environmental epidemiology: cohort profile.  Occup Environ Med. 2017;74(1):66-71. doi:10.1136/oemed-2016-103678PubMedGoogle ScholarCrossref
    35.
    Zhuang  Y-L, Cummins  SE, Sun  JY, Zhu  S-H.  Long-term e-cigarette use and smoking cessation: a longitudinal study with US population.  Tob Control. 2016;25(suppl 1):i90-i95. doi:10.1136/tobaccocontrol-2016-053096PubMedGoogle ScholarCrossref
    36.
    Marti  J.  Successful smoking cessation and duration of abstinence—an analysis of socioeconomic determinants.  Int J Environ Res Public Health. 2010;7(7):2789-2799. doi:10.3390/ijerph7072789PubMedGoogle ScholarCrossref
    37.
    Farsalinos  KE, Poulas  K, Voudris  V, Le Houezec  J.  Electronic cigarette use in the European Union: analysis of a representative sample of 27 460 Europeans from 28 countries.  Addiction. 2016;111(11):2032-2040. doi:10.1111/add.13506PubMedGoogle ScholarCrossref
    38.
    Tibshirani  R.  Regression Shrinkage and Selection via the Lasso.  J R Stat Soc Series B Stat Methodol. 1996;58(1):267-288.Google Scholar
    39.
    McNutt  L-A, Wu  C, Xue  X, Hafner  JP.  Estimating the relative risk in cohort studies and clinical trials of common outcomes.  Am J Epidemiol. 2003;157(10):940-943. doi:10.1093/aje/kwg074PubMedGoogle ScholarCrossref
    40.
    Bartlett  JW, Seaman  SR, White  IR, Carpenter  JR; Alzheimer’s Disease Neuroimaging Initiative.  Multiple imputation of covariates by fully conditional specification: Accommodating the substantive model.  Stat Methods Med Res. 2015;24(4):462-487. doi:10.1177/0962280214521348PubMedGoogle ScholarCrossref
    41.
    de Leon  J, Diaz  FJ, Becoña  E, Gurpegui  M, Jurado  D, Gonzalez-Pinto  A.  Exploring brief measures of nicotine dependence for epidemiological surveys.  Addict Behav. 2003;28(8):1481-1486. doi:10.1016/S0306-4603(02)00264-2PubMedGoogle ScholarCrossref
    42.
    Wong  SL, Shields  M, Leatherdale  S, Malaison  E, Hammond  D.  Assessment of validity of self-reported smoking status.  Health Rep. 2012;23(1):47-53.PubMedGoogle Scholar
    43.
    Chaiton  M, Diemert  L, Cohen  JE,  et al.  Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers.  BMJ Open. 2016;6(6):e011045. doi:10.1136/bmjopen-2016-011045PubMedGoogle ScholarCrossref
    44.
    Andler  R, Guignard  R, Wilquin  J-L, Beck  F, Richard  J-B, Nguyen-Thanh  V.  Electronic cigarette use in France in 2014.  Int J Public Health. 2016;61(2):159-165. doi:10.1007/s00038-015-0773-9PubMedGoogle ScholarCrossref
    45.
    Zhu  S-H, Zhuang  Y-L, Wong  S, Cummins  SE, Tedeschi  GJ.  E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys.  BMJ. 2017;358:j3262. doi:10.1136/bmj.j3262PubMedGoogle ScholarCrossref
    46.
    Andler  R, Guignard  R, Wilquin  J-L, Beck  F, Nguyen-Thanh  V. L’usage de la cigarette électronique en France en 2014. http://inpes.santepubliquefrance.fr/CFESBases/catalogue/pdf/1689.pdf. Accessed June 7, 2019.
    47.
    Jarvis  MJ, Cohen  JE, Delnevo  CD, Giovino  GA.  Dispelling myths about gender differences in smoking cessation: population data from the USA, Canada and Britain.  Tob Control. 2013;22(5):356-360. doi:10.1136/tobaccocontrol-2011-050279PubMedGoogle ScholarCrossref
    48.
    Piper  ME, Cook  JW, Schlam  TR,  et al.  Gender, race, and education differences in abstinence rates among participants in two randomized smoking cessation trials.  Nicotine Tob Res. 2010;12(6):647-657. doi:10.1093/ntr/ntq067PubMedGoogle ScholarCrossref
    49.
    Piñeiro  B, Correa  JB, Simmons  VN,  et al.  Gender differences in use and expectancies of e-cigarettes: online survey results.  Addict Behav. 2016;52:91-97. doi:10.1016/j.addbeh.2015.09.006PubMedGoogle ScholarCrossref
    50.
    Simonavicius  E, McNeill  A, Arnott  D, Brose  LS.  What factors are associated with current smokers using or stopping e-cigarette use?  Drug Alcohol Depend. 2017;173:139-143. doi:10.1016/j.drugalcdep.2017.01.002PubMedGoogle ScholarCrossref
    51.
    Dawkins  L, Corcoran  O.  Acute electronic cigarette use: nicotine delivery and subjective effects in regular users.  Psychopharmacology (Berl). 2014;231(2):401-407. doi:10.1007/s00213-013-3249-8PubMedGoogle ScholarCrossref
    52.
    Hiler  M, Breland  A, Spindle  T,  et al.  Electronic cigarette user plasma nicotine concentration, puff topography, heart rate, and subjective effects: influence of liquid nicotine concentration and user experience.  Exp Clin Psychopharmacol. 2017;25(5):380-392. doi:10.1037/pha0000140PubMedGoogle ScholarCrossref
    53.
    Farsalinos  KE, Spyrou  A, Tsimopoulou  K, Stefopoulos  C, Romagna  G, Voudris  V.  Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices.  Sci Rep. 2014;4:4133. doi:10.1038/srep04133PubMedGoogle ScholarCrossref
    54.
    Yan  XS, D’Ruiz  C.  Effects of using electronic cigarettes on nicotine delivery and cardiovascular function in comparison with regular cigarettes.  Regul Toxicol Pharmacol. 2015;71(1):24-34. doi:10.1016/j.yrtph.2014.11.004PubMedGoogle ScholarCrossref
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