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    3 Comments for this article
    Level of evidence
    Aki Nilanga Bandara, BSc | University of British Columbia
    The authors’ statement that randomized clinical trials show that e-cigarettes can aid in adult smoking cessation. The authors cite RCTs plus other studies with non-RCT methodology to support their statements. Reference 7, 9 of the study are cross-sectional survey based studies;  reference 10 is a prospective 6-month pilot study (1, 2, 3). Therefore, while some statements are supported by only 2 RCTs (4, 5), the rest of the studies are cross sectional and prone to high risk bias. Authors also cited the 2019 RCT, and it is well known that the findings of this RCT confirmed that after one year 80% of the e-cigarette group were still using e-cigarettes compared to just 9% of the NRT group who were continuing to use NRT (5). Allocation of treatment in the e-cigarette group was, moreover, unrealistic: they were couriered to participants, while subjects in the NRT group had to take a voucher to a chemist to obtain treatment (5). In addition, it is not clear why authors have used NRT over varenicline (5). Varenicline is clinically proven to be outperforms NRT. 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 (6). It is also not clear why authors did not cite a more recent RCT by Halpern et al (2018), which did not find electronic cigarettes significantly better than financial incentives and pharmacological therapies (7).

    (1). Berg CJ, Barr DB, Stratton E, Escoffery C, Kegler M. Attitudes toward e-cigarettes, reasons for initiating e-cigarette use, and changes in smoking behavior after initiation: a pilot longitudinal study of regular cigarette smokers. Open J Prev Med. 2014;4(10):789-800. doi:10.4236/ojpm.2014.410089PubMedGoogle ScholarCrossref
    (2). 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
    (3). Etter JF, 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
    (4). Polosa R, Caponnetto P, Morjaria JB, Papale G, Campagna D, Russo C. Effect of an electronic nicotine delivery device (e-cigarette) on smoking reduction and cessation: a prospective 6-month pilot study. BMC Public Health. 2011;11(1):786. doi:10.1186/1471-2458-11-786PubMedGoogle ScholarCrossref
    (5).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
    (6). 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
    (7). 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.
    Response to Mr. Bandara's Comment
    Abigail Friedman, PhD | Yale School of Public Health
    Dear Mr. Bandara,

    Thank you for your interest in our article. First, we should note that you are correct regarding the RCT citations. In an earlier draft, that sentence described both associational and randomized evidence. The in-text citations were not updated when we revised that sentence to discuss RCTs alone. It was an oversight, and not intentional.

    With respect to the Halpern et al. (2018) paper: that trial’s “free cessation aid” group offered free e-cigarettes to those who had tried to quit with standard therapies and not succeeded. Consequently, comparing the “free cessation aid” and “free e-cigarettes”
    groups is not a strict test of whether e-cigarettes are more or less effective than standard therapies, and thus was not cited in our article. Specifically, the inclusion of e-cigarettes in both groups would bias a comparison of subsequent smoking cessation rates towards not finding a difference. Despite this, point estimates from that study indicate sustained smoking abstinence after 6 months in 1.0% of the free e-cigarettes group and 0.5% of the free cessation aid group. Thus, as that analysis cannot reject the null hypothesis of no difference in smoking cessation between these two groups, its estimates are consistent with e-cigarettes being at least as effective for smoking cessation as approved cessation aids.

    Your remaining points seem to take issue with Hajek et al. (2019), but do not counter our use of that article as support for the statement that “e-cigarettes can aid in adult smoking cessation.”

    Dr. Friedman
    Flavor e-cigarette use still an urgent concern
    Alison Cuccia, MSPH | Truth Initiative Schroeder Institute
    According to recent data, 96% of new e-cigarette users used a flavored product the first time they tried e-cigarettes, and about 70% of youth report current use of e-cigarette “because they come in flavors I like.”(1) The vast majority of youth use flavored e-cigarettes (PATH and NYTS).(1,2) Similarly, this data indicates that only 8.5% (n=164) of youth who began vaping at wave 2 used unflavored e-cigarettes, and only 7.8% (n=102) of “emerging adults” who began vaping at wave 2 used unflavored e-cigarettes. Thus, it is not surprising that there no significant differences in progression between those using flavors and unflavored products, and these small sample sizes lead to large confidence intervals when estimating the role of flavors in cigarette initiation (AOR for youth, 0.66; 95%CI, 0.16-2.76; P = .56; AOR for emerging adults, 3.15; 95%CI, 0.14-71.78; P = .46). Therefore, we urge caution when interpreting these findings, and emphasize the stronger empirical evidence that flavors are a significant factor in e-cigarette use by appealing to youth and novice tobacco users.

    In addition, the authors found that youth who use e-cigarettes were 6.75 time more likely to use cigarettes in the future. This is a concerning trend, as previous data from PATH suggests that youth aged 12-15 are 4 times as likely to use cigarettes. This estimate is similar to findings from a metanalysis of youth and young adult transitions from e-cigarette to cigarettes.(3) While the confidence interval of this odds ratio falls within the range of previous estimates (95% CI 3.93-11.57), this may point to an increasing trend. It will be important to continue to study this type of data to understand transitions from high nicotine e-cigarettes to combustible product use among youth.

    Truth Initiative

    1. U.S. Food and Drug Administration. Modifications to Compliance Policy for Certain Deemed Products: Guidance for Industry, Draft Guidance. In. https://www.fda.gov/media/121384/download2019.
    2. Cullen KA, Gentzke AS, Sawdey MD, et al. e-Cigarette Use Among Youth in the United States, 2019. Jama. 2019.
    3. Soneji S, Barrington-Trimis JL, Wills TA, et al. Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis. JAMA Pediatr. 2017;171(8):788-797.
    Original Investigation
    Substance Use and Addiction
    June 5, 2020

    Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation

    Author Affiliations
    • 1Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
    JAMA Netw Open. 2020;3(6):e203826. doi:10.1001/jamanetworkopen.2020.3826
    Key Points español 中文 (chinese)

    Question  Does the association between vaping uptake and subsequent smoking differ between individuals favoring tobacco- vs nontobacco-flavored e-cigarettes?

    Findings  In this cohort study with 17 929 participants, multivariable analyses of nationally representative, longitudinal survey data evaluated differences in smoking initiation and cessation subsequent to vaping uptake among those who used flavored vs unflavored e-cigarettes, separately by age group. Relative to vaping tobacco flavors, vaping nontobacco-flavored e-cigarettes was not associated with increased youth smoking initiation but was associated with an increase in the odds of adult smoking cessation.

    Meaning  In this study, adults who vaped flavored e-cigarettes were more likely to subsequently quit smoking than those who used unflavored e-cigarettes.


    Importance  Several states have banned sales of flavored e-cigarettes, but evidence on the association between vaping flavors and subsequent smoking initiation and cessation is limited.

    Objective  To evaluate whether new uptake of flavored e-cigarettes is more strongly associated with subsequent smoking initiation and cessation than uptake of unflavored e-cigarettes, separately for youths (12-17 years), emerging adults (18-24 years), and prime-age adults (25-54 years).

    Design, Setting, and Participants  This cohort study conducted secondary data analyses of longitudinal survey data from waves 1 to 4 of the Population Assessment of Tobacco and Health Study (collected from 2013 to 2018). The analytic sample was limited to 17 929 respondents aged 12 to 54 years at wave 1 who completed at least 3 consecutive waves of the survey and did not use e-cigarettes at baseline. Data were collected from 2013 to 2018 and analyzed in February 2020.

    Exposures  Flavored vs unflavored e-cigarette use reported in wave 2 of the Population Assessment of Tobacco and Health Study.

    Main Outcomes and Measures  Binary indicators captured wave 3 smoking among 7311 youths and 4634 emerging adults who did not smoke at baseline (ie, initiation) and not smoking at wave 3 among 1503 emerging adults and 4481 prime-age adults who smoked at baseline (ie, cessation). Smoking status was based on having smoked in the past 30 days for youths and established smoking (ie, current smoking among those who smoked at least 100 cigarettes in their lifetime) for emerging and prime-age adults.

    Results  The youths who did not smoke at baseline, emerging adults who smoked at baseline, and prime-age adults who smoked at baseline consisted of 51.4% to 58.0% male participants and 66.9% to 77.0% white individuals. Vaping uptake was positively associated with smoking initiation in youth (adjusted odds ratio [AOR], 6.75; 95% CI, 3.93-11.57; P < .001) and in emerging adults (AOR, 3.20; 95% CI, 1.70-6.02; P < .001). Vaping uptake was associated with cessation in adults (AOR, 1.34; 95% CI, 1.02-1.75; P = .03). Vaping nontobacco flavors was no more associated with youth smoking initiation than vaping tobacco-flavors (AOR in youth, 0.66; 95% CI, 0.16-2.76; P = .56) but was associated with increased adult smoking cessation (AOR in adults, 2.28; 95% CI, 1.04-5.01; P = .04).

    Conclusions and Relevance  In this study, adults who began vaping nontobacco-flavored e-cigarettes were more likely to quit smoking than those who vaped tobacco flavors. More research is needed to establish the relationship between e-cigarette flavors and smoking and to guide related policy.