A science publisher’s own publicity for a research article on e-cigarettes and cancer has been criticised for suggesting conclusions unjustified by the data.
For a recent paper in the John Wiley & Sons journal Cancer, entitled “Electronic cigarette use among patients with cancer”, researchers investigated people enrolled in a tobacco treatment programme at a major American cancer centre to find out if e-cigarettes were linked to smoking cessation.
The press release on the study is headlined “E-cigarettes unhelpful in smoking cessation among cancer patients”, but the study authors are more cautious and conclude: “The current longitudinal findings raise doubts concerning the usefulness of e-cigarettes for facilitating smoking cessation among patients with cancer.” (Our emphasis.)
Depending on the way the data was analysed, e-cigarette users among the cancer patients were either twice as likely, or only as likely, as non-vapers to be smoking at the time of a follow-up survey.
Tobacco research experts have also found an apparently glaring problem with the study itself: it recruited smokers of tobacco, whether they were recent users of e-cigarettes or not, and did not include those who actually had stopped smoking after trying e-cigarettes.
Peter Hajek, director of the Tobacco Dependence Research Unit at Barts in London, made that observation, and also noted that the study displays “uncertainty as to whether these smokers tried e-cigarettes only once or used them for a few days or weeks and for what purpose, and present[ed] smokers who used e-cigarettes, possibly only once 13 months ago, as if they were using them throughout the year”.
Robert West, director of tobacco studies at University College London, also noted the problem with ruling out successful quitters, although he did add that the study is well-designed and describes what happens to smokers who also use e-cigarettes and who have a strong incentive to stop smoking.
Within these limitations – and others pointed out by the authors themselves – there is a good deal of value to the research, however: not least as it is said to be the first such study on cancer patients, and was conducted in one of the world’s top cancer centres, Memorial Sloan Kettering in New York.
More than 1000 participants in its tobacco cessation programme were recruited, and during the study period (January 2012 to December 2013) the numbers reporting e-cigarette use rose significantly, reaching a peak of 57% in the second quarter of 2013. About 92% of those who had used e-cigarettes were dual users with combustible tobacco, so it does seem that at least some – the remaining 8% – may have quit smoking altogether.
The focus on current smokers was driven by the fact that, as the authors note, about two thirds of adult cancer survivors who are smoking at the time of their diagnosis continue to smoke. This is an important target population for health professionals as well as a good testing ground for e-cigarettes’ efficacy in cessation.
Advice on advice
One of the aims of the study is to help guide oncologists when they have smoking cessation conversations with patients, many of whom will have lung, head or neck cancers associated with smoking and be highly nicotine-dependent.
Indeed, the authors found a significantly higher percentage of e-cigarette users had thoracic or head and neck cancers compared with non-users of e-cigarettes, and they also smoked more cigarettes; but people with these cancers are highly motivated to quit smoking, which may account for the high representation of e-cig users in that group.
In their discussion, the study authors say that in addition to e-cigarettes not being associated with smoking cessation, there was no evidence they helped cut smoking rates. They say it is plausible that many people may be using e-cigarettes “to manage nicotine withdrawal symptoms and the challenge of smoke-free environments”.
Indeed, the dynamics of dual use of e-cigarettes and combustible tobacco is a key issue raised by the study, and by other researchers. As University College London’s West commented: “A theory is beginning to emerge that perhaps e-cigarettes can be in some cases good at substituting for cigarettes and promoting complete abstinence by virtue of their superficial similarity to cigarettes, but if abstinence is not achieved (or sought) they might undermine quitting for precisely the same reason – their similarity to cigarettes inhibits deconditioning of the stimuli associated with smoking and the nicotine reward.”
The Sloan Kettering researchers say their findings “should not be interpreted to indicate that e-cigarettes will never help patients quit smoking” but that there just isn’t good evidence either way, and until more is known, “oncologists are likely to struggle with [the] complexities and have more questions than answers regarding e-cigarette use”.
They have produced an FAQ for oncologists, advising the use of approved cessation medications, referral of patients to cessation counselling, and education on e-cig risks and benefits.
If the hypothesis mentioned by West is correct, he believes that the best advice to smokers might be to consider e-cigarettes as a complete substitute for tobacco cigarettes – but if that does not work, to then use a patch or other nicotine product for partial substitution instead. These, when used for smoking reduction, have shown a clear association with quitting.
What This Means: With the number of research papers on e-cigarettes growing rapidly and with the strong media interest in them, it is inevitable that there is a lot of exaggeration and misreporting about the findings, all too common in science journalism. But the publicity for papers is often also to blame, with headlines in press releases written to attract attention rather than for accuracy.
This can be a pity, as the research can be interesting without the hyped findings – just as in this case. The Sloan Kettering researchers may not have produced the last word on e-cigarettes and smoking cessation (and nobody should expect them to), but they have added insight into a complicated and important area.
– Marc Beishon ECigIntelligence health correspondent
Photo: Luigi Rosa
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