• May 23, 2024

Real-World Quitting

 Real-World Quitting
Photo: Pressmaster

What we know, and don’t, about how people stop smoking

By Cheryl K. Olson

Skip Murray was a failure at quitting. After trying countless times over the years to stop smoking, she was through. When she chose to try e-cigarettes, she says, “I had no intention of making a quit attempt. The purpose of my vape was to use it only when I could not smoke, as a temporary substitute.” Four months later, Murray realized that she could not remember the last time she’d lit up. She had accidentally quit smoking.

Randomized controlled trials are the widely acknowledged gold standard in research. They are great for establishing whether a particular approach can create a meaningful effect. Thus, trials of smoking cessation methods typically recruit people who intend to quit, and assign them to use specific products in particular ways. The downside? This approach fails to capture the messy quitting experiences of millions. This includes Murray, a Minnesota-based tobacco harm reduction advocate and writer.

Reviews by the Cochrane Collaboration that incorporate randomized trials and other planned intervention studies assure us that e-cigarettes have the potential to help people quit smoking. The Centers for Disease Control and Prevention’s National Health Interview Survey says 7.5 million adult Americans stopped smoking completely from 2020 to 2022. But how did they do it? Are people in the real world using reduced-harm alternatives to kick the habit?

Raymond Niaura, professor of epidemiology at the New York University School of Global Public Health, has been looking into this. “Over the years, there have periodically been reports that have come out talking about methods people use to quit smoking or try to quit,” he says. “But most information is out of date.”

For example, the 2014–2016 National Health Interview Survey (NHIS) listed 10 possible quit methods. The two most popular were giving up cigarettes all at once (a.k.a., “cold turkey”) and gradually cutting back. Although those unaided methods are popular, they aren’t considered to be evidence-based and often result in relapse down the line. E-cigarettes were a distant third in popularity but ahead of nicotine patches or gum. Most people indicated trying multiple quit methods.

How We Quit Now

Niaura and statistician Floe Foxon were already doing some analyses of NHIS data. They decided to detour and look at the latest publicly accessible figures on quitting methods, from 2022. Study participants who had stopped smoking completely in the previous two years were asked whether they had used any of a list of methods. They were also asked whether they had tried “to quit by switching to electronic or e-cigarettes.”

“We found that use of e-cigarettes was pretty high. In fact, it was the No. 1 method used to quit smoking,” says Niaura. “That caught me a little by surprise.” These results hint at a quiet revolution. E-cigarettes may be playing a larger role than popularly assumed, in both attempted and successful quitting.

Niaura and Foxon presented a poster of their findings at the March 2024 annual meeting of the Society for Research on Nicotine and Tobacco. Updated and expanded results will be published shortly. (Foxon consults for Juul through Pinney Associates. The poster and paper received no funding.)

Survey Letdowns

The NHIS is unusual in that it directly asks people how they stopped smoking. Most studies simply don’t ask. Nationally representative data on this question is surprisingly scarce. The alphabet soup of U.S. government studies such as NHANES, BRFSS and NSDUH inquire only about whether someone smokes now or used to smoke.

Even the NHIS doesn’t ask annually about quitting. Because the survey covers a massive range of health issues, questions are often dropped or altered. The 2024 version asks whether in the past 12 months “a doctor, dentist or other health professional advised you about ways to stop smoking or prescribed medication to help you quit.” This is a worthy variation, but the approach thwarts year-to-year comparisons of change.

Researchers are left to puzzle over what little information they can get. For example, the U.S. Food and Drug Administration’s Population Assessment of Tobacco and Health (PATH) survey asks about past-30-day use of cigarettes and electronic nicotine-delivery systems (ENDS). Because participants complete a series of PATH surveys over time, we can see that the link between quitting smoking and using ENDS has gotten stronger over time.

Another problem with surveys? Varying or missing options for answers. In the 2022 NHIS, says Niaura, “We don’t know how many people quit cold turkey with no assistance. They didn’t ask that.” Instead, the response options included a variety of nicotine-containing medications and several behavioral help options, such as telephone quit lines and counseling. NHIS asked about ENDS but didn’t inquire about quitting smoking via other nonmedicinal reduced-risk products, such as pouches, snus or heated tobacco.

Shifting response options do give glimpses into how assumptions change over time. “Back in the 1950s and 1960s, people were interested in things like, did you switch to a pipe or cigar to help you quit smoking,” notes Niaura. Oddly, the 2014–2016 NHIS questionnaire included the discredited cessation option of “switched to ‘mild’ cigarettes.”

A third problem with nationally representative surveys is that they can’t tell us how people go about quitting. “We don’t really understand the whole process,” says Niaura. “The high numbers in the [NHIS] survey mean this is a frequent occurrence, that smokers are using e-cigarettes and quitting. How come there’s not a ton of research being conducted on those kinds of questions?

Harking back to Murray’s experience, Niaura notes that many smokers “didn’t set a quit date, make a plan and go out and buy some e-cigarettes. And it still worked.”

“So, what’s happening there?” he wonders. “What’s their experience along the way? What difficulties do they run into? Where are they getting advice?”

Finally, Niaura ponders how e-cigarettes might be made even more effective, perhaps with some form of counseling and support, such as vape shops have provided to customers. With vape shops closing due to regulatory restrictions, this question deserves urgent attention.

Regardless of what the government says or doesn’t say, in many ways, we are in a golden era of quit methods.

Raymond Niaura, professor of epidemiology, New York University School of Global Public Health

Success Factors

A few studies have looked at factors linked to successful quitting with e-cigarettes. In a 2021 online survey, vaping more often throughout the day was linked to good outcomes. So was an abrupt switch from smoking to vaping rather than a gradual one. Using a newer device type (e.g., rechargeable pods) rather than older cig-a-like products also helped. Researchers also noted that “most people reported trying more than one e-cigarette flavor and more than one device type when trying to quit smoking.”

A qualitative study used online individual interviews with people who had quit smoking with e-cigarettes, looking for factors that separated long-term success from short-term attempts. Those who gave up had trouble finding a vape they could stick with that met their needs and prevented cravings.

I asked Murray for a reality check. To her, it makes sense that newer vaping devices could more effectively help people quit smoking. “I tried a cig-a-like. I didn’t like anything about it—how it felt, what the hit was like or how it tasted,” she says. “It was more satisfying to smoke!”

She noted that, as with all new technologies, vaping devices have improved along the way. “There were issues with earlier products that leaked or weren’t reliable.”

Based on her experience as a former vape shop owner, Murray found that for people who smoked heavily, the newer pod systems that use nicotine salts can be a game changer. “Those products provide enough nicotine to replace what they got from combustible tobacco,” she states.

“A Golden Era”

Niaura finds it frustrating that the FDA does not do more to promote the visibility of studies like these, including ones that use the FDA’s own PATH survey data. “Regardless of what the government says or doesn’t say, in many ways, we are in a golden era of quit methods,” he points out. “The good news is there are more ways to stop smoking than ever before: e-cigarettes and other reduced-risk products as well as tried-and-true conventional methods.”

“Go and try something,” he urges. “And if it doesn’t work, try something else.”

“The one valuable lesson that society should have learned is that there is no one-size-fits-all solution to the smoking epidemic. So no one product is perfect for all consumers,” concludes Murray.

“Someone who smoked six cigarettes a day for a couple of years has drastically different needs than someone who has smoked two packs a day for 30 years,” she adds. “What part of smoking was most important to them, why they smoked and when or where they smoked are all parts of the equation when it comes to finding what will work best to help them stop.”