Elsevier

Drug and Alcohol Dependence

Volume 170, 1 January 2017, Pages 93-101
Drug and Alcohol Dependence

Full length article
Nicotine levels, withdrawal symptoms, and smoking reduction success in real world use: A comparison of cigarette smokers and dual users of both cigarettes and E-cigarettes

https://doi.org/10.1016/j.drugalcdep.2016.10.041Get rights and content

Highlights

  • Real world dual users were better able to maintain abstinence from cigarettes.

  • Women dual users had higher nicotine levels/reduced craving during smoking reduction.

  • Dual users were less motivated to quit smoking in the coming year than smokers.

  • Dual users did not have lower levels of carbon monoxide during ad lib use.

Abstract

Introduction

To evaluate how experienced dual users used cigarettes and e-cigarettes in real-world use and under different levels of cigarette availability.

Methods

Dual users (cigarettes + e-cigarettes; n = 74) and a smoke-only group (just cigarettes; n = 74) engaged in a 26-day study with two ad lib use intervals, a week of 75% cigarette reduction and three days of 100% cigarette reduction. After a week of ad lib use of products, all participants were asked to reduce smoking by 75% (dual users were free to use their e-cigarettes as they wished), followed by another week of ad lib use. All participants were then asked to reduce smoking by 100% (cessation) for three days. Primary outcomes were biological samples (carbon monoxide, urinary nicotine and cotinine). Participants also provided real-time reports of product use, craving, and withdrawal symptoms using a smartphone app.

Results

Dual users did not smoke fewer cigarettes than smoke-only participants during ad lib periods, but quadrupled their use of e-cigarettes during smoking reduction periods. Dual users were significantly more likely to maintain 100% reduction (97.1% vs. 81.2%). Amongst women, dual use was associated with higher nicotine levels and withdrawal suppression.

Discussion

Among a group of experienced dual users, e-cigarettes helped maintain smoking reduction and reduced some withdrawal symptoms, although both withdrawal symptoms and nicotine levels varied as a function of gender.

Introduction

Ever-use of electronic cigarettes (e-cigarettes) in a US probability sample increased from 1.8% in 2010 to 13% in 2013, while current-use (use on some days or every day) climbed from 0.3% to 6.8% over the same time period (McMillen et al., 2015). Current e-cigarette use is highest amongst daily cigarette smokers − one-third reporting use in 2014 (McMillen et al., 2015, Brown et al., 2014, Centers for Disease Control and Prevention, 2013, Dockrell et al., 2013, King et al., 2015).

Tobacco use is a causal factor in about 6 million deaths annually worldwide (World Health Organization, 2011), with the majority attributable to smoking (Prabhat, 2012). E-cigarettes likely have less severe direct health effects than do combustible cigarettes (Farsalinos and Polosa, 2014, Hecht et al., 2015, Polosa, 2015). If e-cigarettes can substitute for cigarettes, they can potentially produce public health benefit.

Whether e-cigarettes will substitute for cigarettes depends, in part, on if they yield effects approximating the cigarette effects thought to cause dependent cigarette use (reduce tobacco withdrawal symptoms, deliver meaningful levels of nicotine; Institute of Medicine, 2012). This study examines whether e-cigarettes appear to produce effects similar to cigarettes (as noted above), and whether e-cigarette use was associated with reduced cigarette use.

This study comprised both “dual users” (DUs: users of both e-cigarettes and cigarettes) and those who smoke only (SOs). This permitted analysis of the extent to which conjoint e-cigarette use was associated with different patterns of cigarette use and other related outcomes. We were interested in whether DUs 1) smoke fewer cigarettes and have lower carbon monoxide (CO) levels than SOs; 2) show elevated levels of nicotine relative to SOs, especially during periods of smoking reduction when they could use e-cigarettes ad libitum; 3) report lower levels of withdrawal symptoms during periods of smoking reduction; and 4) are more able than SOs to reduce and/or stop their cigarette use. We sought to determine whether any observed differences between DUs and SOs were related to gender and nicotine dependence, factors implicated in smoking motivation and cessation success (Perkins et al., 1999, Piper et al., 2008a, Piper et al., 2008b, Wray et al., 2015).

Survey and laboratory research has addressed the effects of e-cigarettes on the outcomes listed above. Survey research (Etter and Bullen, 2011) shows most e-cigarette users report that e-cigarettes are helpful for reducing withdrawal symptoms, craving, and smoking heaviness. Obviously, survey studies provide neither real-time data associated with e-cigarette use, nor data arising from experimental manipulations such as smoking deprivation.

Laboratory research has yielded data on the potential of e-cigarettes to displace or substitute for cigarette use (Bullen et al., 2010, Dawkins and Corcoran, 2014, Dawkins et al., 2012, Nides et al., 2014, Vansickel et al., 2010, Vansickel and Eissenberg, 2013). Such studies suggest that e-cigarettes, especially when used by experienced users, can reduce tobacco withdrawal symptoms, exert appetitive effects, and reduce urges to smoke cigarettes (Farsalinos et al., 2014). Some studies (Bullen et al., 2010, Vansickel et al., 2010) did not use experienced e-cigarette users using their own e-cigarette brands. Evidence shows that experienced users obtain stronger effects from e-cigarettes than do inexperienced users (Farsalinos et al., 2014, Nides et al., 2014, Vansickel and Eissenberg, 2013). Most studies involved only acute use of e-cigarettes and did not observe their effects over extended periods of time in real-world use (Bullen et al., 2010, Dawkins and Corcoran, 2014, Farsalinos et al., 2014, Nides et al., 2014, Vansickel et al., 2010, Vansickel and Eissenberg, 2013).

Section snippets

Study sample and data collection

This was a 26-day study, conducted March 2013 to May 2014, in the Madison and Milwaukee, WI, metropolitan areas. All participants provided written informed consent and the study received approval from the University of Wisconsin Health Sciences Institutional Review Board.

Eligibility for study participation included: minimum 18 years old; able to read and write English; smoking at least five cigarettes per day for the past six months; not currently using any smoking cessation medication;

Sample characteristics

A total of 148 participants enrolled in the study, divided evenly between the SO and DU groups (Table 1). Compared to the DU group, the typical SO participant was more likely to be female, a member of a minority group, older, to have smoked longer, to have made fewer quit attempts, and to have higher levels of Primary and Secondary dependence as assessed by the WISDM (Piper et al., 2008a, Piper et al., 2008b). Table 2 characterizes the e-cigarettes used by participants in the DU group by Device

Discussion

This research explored the extent to which e-cigarettes have the potential to substitute for cigarettes during periods of ab libitum smoking and smoking reduction. Neither self-report nor CO data showed reliable differences in cigarette consumption between the groups across any of the experimental periods. One study noted such reduction (McRobbie et al., 2015), but did not study long-term DUs; this study was conducted using participants quitting smoking. The DUs used e-cigarettes at a fairly

Role of funding source

This research was sponsored by grant 3P50CA143188-15S1 from the National Cancer Institute and the Food and Drug Administration and 1P01CA180945 from the National Cancer Institute to the University of Wisconsin Center for Tobacco Research and Intervention. Additional support was received from the Wisconsin Partnership Program. The sponsors had no role in study design; collection, analysis, and interpretation of the data; in the writing of the report; nor the decision to submit the article.

Contributors

All authors contributed to conceptualizing and designing the study. Michael C. Fiore and Timothy B. Baker obtained the funding for this research. Stevens S. Smith conducted the analyses. Douglas E. Jorenby and Timothy B. Baker led the manuscript writing; Stevens S. Smith and Michael C. Fiore provided substantial edits to the manuscript. All authors reviewed and approved the final manuscript.

Conflict of interest

No conflict declared

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