It has taken us a long time to realize how the tobacco industry is creating a lot of public health concerns, from increasing the risk of lung cancer and the prevalence of COPD, to recognizing it as a risk factor in cardiovascular diseases.  But while we now recognize  vehemently the harm of smoking, do we realize, understand or appreciate all the benefits and harms of available smoking cessation products? Do we?

I am not saying the conventional nicotine replacement therapy products are not helpful. THEY ARE but they come with safety concerns that we seem to embrace easily – they are not recommended during pregnancy and excessive nicotine consumption may lead to adverse effects such as nausea, headache, palpitation, high blood pressure and seizure.  They are also so damn expensive and isn’t always a reasonable option for the vulnerable patients who struggle to make ends meet. As for other options such as varenicline (Champix) and bupropion (Zyban), there are potential safety concerns (e.g. neuropsychiatric side effects – behavioural changes, depression & suicidal ideation) that should not be ignored.  The manufacturers of varenicline and bupropion have invested in a lot of money to conduct the latest EAGLE trial so that FDA finally removed the Black Box Warnings of their products last year. While objectively, one cannot deny the results of this study, there are also limitations that restrict the application of the results to all population such as those with substance use disorder (see my post if interested).  But if the makers of e-cigarettes or other products such as cytisine have the same financial resources, would they be able to produce clinical evidence with the same rigor?

The short answer is of course, we don’t know yet because there is the infamous argument of “the lack of evidence”.

But from what I can hear from patients as well as some recent reviews, e-cigarette may be very effective as a smoking cessation product. In the UK, e-cigarette is endorsed as a potential smoking cessation strategy. Of course, there are concerns with fire hazards, safety concerns of inhaling liquids that have not gone through rigorous quality control, as well as the lack of long term safety data with using such device or therapy.   But isn’t the harm from long term tobacco smoking much greater than any harm from the temporary use of e-cigarettes?  Why are we so scared even to discuss its potential benefits in smoking cessation?

Another product is cytisine.  You may not find it even listed as an option for smoking cessation in Canada. But similar to varenicline, it is a partial agonist of nicotinic receptor. However, cytisine is extracted from a natural source, rather than synthetically made. It has been studied both in terms of its efficacy as compared to placebo as well as nicotine replacement therapy. In both studies, cytisine was shown to be more effective. Recently, there was a systematic review and economic evaluation conducted in the UK comparing cytisine to varenicline. One of the authors’ conclusion is that, cytisine is estimated to be both more clinically effective and cost-effective than varenicline.  Our own CADTH has also completed a rapid response review on cytisine. Here’s a link to their report.

It seems that we are slow and conservative to embrace these potential smoking cessation products while allowing big giant pharmaceutical companies to continue to benefit from the market for smoking cessation.  While the verdict is still out, these options may be more accessible and affordable to many smokers with lower socio-economic status. Is it ethical to continue to deny their potential benefits?

Thank you for reading my post.

Note that I have no financial ties to any organizations or maker of e-cigarettes or cytisine.  

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