Flavored e-cigarettes cut smoking rates and toxic exposure in high-risk groups

Flavored e-cigarettes prove more effective than low-nicotine cigarettes alone, offering new hope for those struggling with addiction in high-risk communities.

Study: Reduced Nicotine Cigarettes and E-Cigarettes in High-Risk Populations. Image Credit: Master_foto / Shutterstock

A study published in JAMA Network Open reveals that access to electronic cigarettes (e-cigarettes) with commonly preferred flavors can significantly reduce the frequency of tobacco smoking in adults with psychiatric disorders, opioid use disorder (OUD), and lower educational levels.  

Background

Cigarette smoking is disproportionately prevalent among adults with psychiatric conditions, substance use disorders, and those with lower educational levels. In an effort to reduce the prevalence of smoking, the US Food and Drug Administration (FDA) has developed a national policy to reduce nicotine content in cigarettes to minimally addictive levels.

Randomized controlled trials conducted in the general population, as well as among at-risk populations, have demonstrated that smoking cigarettes with very low nicotine content can reduce smoking frequency, exposure to toxic materials, and addiction risk.

Experts have suggested that increased availability and accessibility of e-cigarettes with commonly preferred flavors can improve the success rate of the FDA’s nicotine-reduction policy.

However, the FDA has currently allowed the use of only nicotine and methanol-flavored e-cigarettes in the US, owing to the concern that e-cigarettes with fruity or sweet flavors may increase e-cigarette use among youths. Such limitations have the potential to weaken the impact of nicotine-reduction policy in the general and at-risk populations.

In this study, scientists explored the impact of different types of cigarettes and e-cigarettes on smoking reduction among adults with psychiatric conditions, OUD, and lower educational levels.

Study design

The scientists conducted three parallel 16-week randomized controlled trials at three selected universities, including the University of Vermont, Brown University, and Johns Hopkins University. Each trial was conducted at two out of three locations between October 2020 and November 2023.

A total of 326 adults who were current smokers with no plan of quitting in the next 30 days were enrolled for the trials. This study population included participants with affective disorders (psychiatric conditions), OUD, and females of reproductive age with lower educational levels.

The participants were randomly assigned to four experimental conditions: normal nicotine content (NNC) cigarettes only, cigarettes with very low nicotine content only, cigarettes with very low nicotine content together with tobacco-flavored e-cigarettes, and cigarettes with very low nicotine content plus e-cigarettes with three participant-preferred flavors chosen from eight different options. Among these flavors, participants were allowed to choose three preferred flavors, which could include fruity, sweet, or menthol options.   

The primary outcome of the trials was the mean number of cigarettes smoked per day during the 16-week study period. Various tobacco-related biomarkers, including breath carbon monoxide, urine tobacco-specific carcinogens, and urine anatabine, were also analyzed.

Important observations

The trial findings indicated that all four experimental conditions impacted the total number of cigarettes smoked daily during the 16 weeks. This impact was consistent across study participants.

A significant reduction in tobacco smoking rate per day was observed among participants who received cigarettes with very low nicotine content plus e-cigarettes with their participant-preferred flavors, with the greatest reductions noted in this group compared to others. The most commonly preferred e-cigarette flavors were mango, fruit medley, and classic menthol.

A significant reduction in smoking rate per day was observed among participants who received cigarettes with very low nicotine content compared to those who received cigarettes with typical nicotine content. The difference in smoking reduction between the experimental conditions increased significantly over the 16 weeks.

Regarding tobacco-related biomarkers, significantly lower levels of breath carbon monoxide, urine tobacco-specific carcinogen, and urine anatabine were observed in participants who received cigarettes with very low nicotine content plus e-cigarettes with their preferred flavors.

A significantly higher number of days without smoking, lower addiction level, and lower craving level were noted in participants who received cigarettes with very low nicotine content plus e-cigarettes with their preferred flavors.

Significance

The findings of these three randomized controlled trials indicate that access to e-cigarettes with participant-preferred flavors can help achieve a higher reduction in daily smoking frequency than that could be achieved by using cigarettes with very low nicotine content alone. These findings are applicable to people with psychiatric disorders, opioid use disorder, or lower educational levels, who are at higher risk for smoking, addiction, and smoking-related adverse health outcomes.

The trials also found that access to flavored e-cigarettes not only reduced daily smoking rates but also led to lower exposure levels to tobacco-specific carcinogens among these high-risk populations. Moreover, flavored e-cigarettes have also been found to reduce dependency and cravings in these smokers.

These observations indicate that access to flavored e-cigarettes could be effective in quitting smoking as well as preventing smoking relapse.

A well-regulated marketplace with a strong focus on nicotine exposure regulation should allow adult access to e-cigarettes while preventing youth access to the same. This would be the ideal situation to control nicotine exposure as well as its harmful health effects in the general and at-risk populations.

The current trial findings support this notion and provide a reason to continue exploring whether such balance can be achieved in the US marketplace. However, it is important to note that the current study population, focused on at-risk groups, does not represent the US general population, which might restrict the generalizability of the findings.