Smoke free, but dependent on nicotine.

An important population based study of almost 19,000 people attempting to stop smoking was recently published in Addiction [1]. Despite the wide availability and free access to smoking cessation aids, only (16%) were smoke free at the one year follow-up. The biggest limitation to the study that was not addressed by the authors concerns the lack of distinction between total abstinence from smoking and nicotine use vs. abstinence from smoking but continued use of nicotine, in particular via e-cigs. I hope the authors do have this data and would analyze and submit the results for publication. This crucial issue comes to mind in light of Hajek’s study (NEJM, 2019) [2] comparing NRTs and e-cigs (2nd generation-tank refillable type). In that study, the abstinence rate for e-cigs at one year was double (18%) compared with Rx-NRTs (9%); however, 80% of those who had quit smoking using e-cigs were still using them at one year compared with 9% of those who quit using NRTs - a 10 fold difference that one cannot ignore. While we know that nothing can be worse than smoking, the controversial issue is whether we consider those who are still using e-cigs to be “abstinent” or instead, “smoke free, but dependent on nicotine”. This is not a minor question and neither is it a simple academic debate when we still do not know the long-term effects of continuous e-cigarette use, especially given the wide variety of types and their contents.