Nicotine e-cigarettes for smoking cessation following discharge from smoke-free inpatient alcohol and other drug withdrawal services: a pragmatic two-arm, single-blinded, parallel-group, randomised controlled trial

Abstract

Background

Nicotine-containing electronic cigarettes (e-cigarettes) have been shown to be effective for smoking cessation among general populations, but there is little evidence in people with substance use disorders (SUDs). We aimed to assess the effectiveness of e-cigarettes for smoking abstinence in people with SUD following discharge from smoke-free inpatient withdrawal services.

Methods

We conducted a pragmatic, two-arm, single-blinded, parallel-group randomised controlled trial. The majority of this study took place in the community after the participants were discharged from inpatient stay. Adults who were tobacco smokers (motivated to quit; not using e-cigarettes) from five smoke-free inpatient withdrawal services in Australia were recruited and randomly assigned by computer using stratified block (1:1) to receive a 12-week supply of either e-cigarettes or combination nicotine replacement therapy (cNRT) with Quitline behavioural counselling on discharge. Participants were advised to use e-cigarettes as much or as often as necessary or desired and cNRT according to instructions. Researchers collecting outcome data were masked to treatment group. The primary outcome was 7 months continuous tobacco smoking abstinence as measured at 9 months after randomisation. The primary analysis was performed using an intention-to-treat approach, with sensitivity analyses following per-protocol, treatment adherence, and complete case analysis approaches. Serious adverse events were classified by a physician as non-serious or serious and causality assessed. We analysed serious adverse events by treatment group and calculated an incident rate ratio for each comparison. This trial is completed and is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12619001787178).

Findings

Between Sept 29, 2020, and June 3, 2022, 363 participants were enrolled. Of 363 participants, 207 (57%) were men and 151 (42%) were women; 179 (49%) were randomly assigned to e-cigarettes and 184 (51%) to cNRT. At follow-up, 19 (11%) of 179 participants in the e-cigarette group reported 7 months’ continuous abstinence, compared with 18 (10%) of 184 participants in the cNRT group, with no significant differences between groups (risk ratio 1·09; 95% credible interval [CrI] 0·52–1·89). The probability of a positive risk difference was 60% and Bayes factor was 0·04, indicating little evidence of a treatment effect. 15 serious adverse events occurred in the e-cigarette group and 13 occurred in the cNRT group (incident rate ratio 1·18; 95% CrI 0·56–2·54, p=0·65). None were treatment-related.

Interpretation

There was no evidence of a difference in cessation rates or adverse effects after 9 months of follow-up between participants given e-cigarettes or cNRT following discharge from inpatient SUD withdrawal services. Both treatments had approximately 10% smoking continuous abstinence rates among a population that is hard to treat and who have disproportionate tobacco-related morbidity and mortality.

Funding

National Health and Medical Research Council of Australia.