Nicotine Patches and Gums Vs. Electronic Cigarettes
For many smokers hoping to kick their tobacco habit, quitting smoking means using an over-the-counter nicotine replacement product or making the switch to e-cigs, but it’s not immediately clear which is the best option. Nicotine gums and patches offer the nicotine you crave in a non-smoky form, and initially may appear safer than e-cigarettes for several reasons.
Secondly, the tirade of criticism that they (and many others) are tossing at e-cigs might make you think that there is some risk to using them, or that they can’t help people quit. Gums and patches are pushed by huge, “reliable” organizations, whereas e-cig manufacturers are usually much smaller start-up operations, again, creating a sense that nicotine replacement therapy (NRT) products like gums are just plain better than e-cigs. However, the truth of the matter is quite different.
The gums and patches offered by companies like Nicorette and NicoDerm essentially work in the same way as electronic cigarettes. Both use pharmaceutical-grade nicotine extracted from a tobacco plant in order to reduce the cravings and withdrawal effects associated with stopping smoking. The reason for this is simple, since smokers are really addicted to the nicotine but are harmed by the other chemicals in tobacco smoke, providing the nicotine without the co-existing risks would reduce the damage people addicted to the substance are doing to their bodies. This is the core of harm reduction, and it is at the heart of both approved NRT products and e-cigarettes.
Smokers can opt to quit by using either approved NRT or e-cigs in the same way, by reducing the amount of nicotine they consume gradually. Plus, even if smokers can’t reduce their nicotine consumption this way, it’s better to be chewing nicotine-containing gum, slapping patches on your arm or “vaping” (using e-cigarettes) than smoking cigarettes.
The only real difference is that electronic cigarettes use a delivery method which is considerably more like actually smoking. In fact, that’s undoubtedly why they've gained so much interest despite the almost stubborn resistance to change coming from organizations such as the FDA. Although the active compound is the same – nicotine – the technologies are treated in a hugely different fashion.
As you might expect, given the common drug used by patches, gums and electronic cigarettes, there isn't really much of a difference in side effects either. Generally speaking, mild discomfort at the site of the patch or jaw pain from chewing gum are common in the approved NRT products, whereas mouth and throat irritation are the most common side-effects from e-cigs. In fact, the most notable unique side effects come from gums and patches. The excessive chewing of nicotine gums can be associated with gum disease and hair loss and patches can cause unusually vivid dreams. The down-sides of chewing nicotine gum seem more extreme, but they ordinarily occur when the gum is used for a long time or against the recommendations on the product itself.
Overall, there is no real difference in side effects between the approaches, with all of them being broadly well-tolerated in studies. Unlike Chantix, which can have extremely severe side effects, e-cigarettes, gums and patches are much more likely to result in a significant decrease in the side effects of smoking, such as a reduction in coughing.
It’s worth mentioning the fact that e-cigs have been found to contain tobacco-specific nitrosamines, which are sensationally described as carcinogens by regulators and the media. However, it isn't so often explained that many other products contain these same carcinogens. They are found in nicotine patches and gums in similar quantities (as well as other nitrosamines which are found in cosmetics, baby bottles and even drinking water at similar levels as in e-cig cartridges). In fact, the reason nicotine patches and gums aren't banned for containing these carcinogens is that the amount of them found isn't considered dangerous – it’s well within safe levels. So there is a small risk for e-cigs, gums and patches here, but nothing to be worried about. In comparison, cigarettes have up to 1,400 times the quantities of nitrosamines.
For a smoker consuming around one and a half packs of cigarettes per day, six weeks of treatment with nicotine patches costs between $80 and $163, and with gum it can be anything from $92 to $197. This can be averaged to about $120 for patches and $145 for gums, but this figure will probably increase, since the medicines are usually used for much longer (up to 20 weeks). This means that for the cheaper treatment – patches – you’ll spend around $360.
As a comparison, e-cig starter kits cost about $60 (but can be much cheaper) and you can get 36 ml of e-liquid for around $15, meaning that for the average cost of six weeks’ use of patches you could buy a starter kit and 144 ml of e-liquid (good for 72 days – over 10 weeks – of 2 ml per day vaping). If you use the more accurate, 18 week figure for the cost of patches and gums, you could even afford a high-end e-cig, a tank and a huge supply of e-liquid. E-cigs are cheaper than patches and gums, but the choice between the two becomes even simpler when you consider the effectiveness of the different approaches.
There was what could be referred to as a “honeymoon period” with NRT treatments. Initially, results appeared positive, with early research showing that anything from 31 to 44 percent of smokers were able to quit using gums. However, there are many issues with these initial pieces of research (shown by the fact that unusually large numbers of the placebo-receiving patients were also able to remain abstinent for a year), which took a while to be revealed.
When the gums and patches were available over-the-counter, more accurate studies were able to be completed. A piece of research published in 2003 revealed that only 7 percent of those using over-the-counter gums and patches were able to remain abstinent from cigarettes for over six months. A British Medical Journal article reviewed several clinical trials of nicotine replacement therapies, and found a similar rate of 6.75 percent of those using NRT being able to remain abstinent from cigarettes for six months. Many explanations of the differences between the initial studies and the later ones have been suggested, generally including selective recruitment of participants and the provision of unrealistic levels of additional support. In other words, the highly-positive results don’t reflect the real world; they just reflect an interest in selling NRT products.
If you think these reflect the very worst results of studies into the effectiveness of NRT, you’re wrong. One piece of research conducted throughout the 90s in California indicated that whilst over 50 percent more smokers used NRT products between 1992 and 1999, the long-term quit rates actually didn't increase. Although it helped with short-term quitting attempts, the users of pharmaceutical stop-smoking aids didn't increase the likelihood of abstinence in the long-term. This is probably because, unlike in the early, industry-funded trials, only 20 percent of those in the study received counseling, and since they didn’t get the medicine for free, most didn't use it for the recommended amount of time.
If you doubt the criticisms of industry-funded trials, independent research has shown that they are much more likely to produce positive results than non-industry trials. In fact, the researchers found that 51 percent of the studies funded by the industry produced a significant result, in comparison to only 22 percent of non-industry funded trials. Clearly, something about who conducted the trials is having a notable impact on the results of the studies, or in other words, the industry-funded trials don’t appear to be as trustworthy.
In truth, the rates of success with NRT appear to be around 7 percent. The problem with disseminating research from several sources is that there are many potential ways in which the results can be distorted. Relying on press reporting means that you’ll only hear about the “extreme,” news-worthy results and trusting every result means that you’ll weigh a poorly-conducted study as holding similar importance to a well-conducted one. These issues are addressed with systematic reviews from organizations like the Cochrane Collaboration, who weigh all of the evidence accurately, according to how reliable the studies are, the number of participants and the recorded outcomes. Looking at a complete pool of well-conducted studies and therefore encompassing data from a huge number of participants, the results it obtains are extremely reliable.
When NRT was reviewed by the Cochrane group, the overall finding was that they increase the likelihood of quitting smoking by around 60 percent in comparison to an inactive placebo medicine (in other words, no treatment). This definitely means that they are effective, but the results clearly show that they aren't particularly effective.
In fact, whilst the researchers point out that the “absolute” quitting rates can vary according to the trial, the wide range of research considered shows that 3 to 5 percent of people can remain abstinent from smoking for between six months and a year if they try to quit on their own. They estimate that 2-3 percent can be added to the rates with the use of NRT, creating a 5 to 8 percent success rate overall. The effectiveness of medicines can be expressed as a “number needed to treat,” which means the number of treatments that would need to be issued for one to be effective. The best result is 1, because then everybody treated would achieve the desired outcome. The estimate for NRT is between 33 and 50.
Sadly, the Cochrane review for e-cigarettes isn't yet available, but there have been studies conducted into the effectiveness of e-cigarettes for smoking cessation. These have generally produced pretty positive effects. One study found that 11 percent of smokers given an e-cigarette were able to stop smoking for an entire year, with the majority of those no longer using an e-cig at the end of the study period, and an additional 23 percent reduced their cigarette consumption by 50 percent or more. The Italian smokers used for this study had no intention of quitting, indicating that e-cigarettes are more effective for smokers who don’t even want to quit than existing NRT products are for those who are actively trying to quit.
Other studies, such as one from Michael Siegel have found that as many as 31 percent of electronic cigarette using participants were abstinent at six months. The study also showed that the participants who used the e-cig more than 20 times per day had a smoking abstinence rate of 70 percent. Another study on smokers who didn't want to quit found that 22.5 percent of those who used an e-cigarette were abstinent after six months, with the figure rising to 55 percent if people who reduced their cigarette consumption by over 50 percent were included.
Overall, it seems that e-cigarettes are more effective in smokers who don’t even want to quit that patches and gums are in those who do. Of course, more research is needed into the effects of e-cigarettes, but as things stand now there is still ample evidence to suggest that e-cigarettes are much better for smoking cessation than existing interventions. Perhaps the upcoming Cochrane review will challenge the statistics, but things still look good for e-cigs.
Conclusion – Nicotine Patches and Gums, or E-Cigs?
Unfortunately for GlaxoSmithKline and the other organizations profiting from peddling NRT gums and patches, they don’t really work very effectively. Yes, they perform better than no treatment at all, but anything with a success rate of under 10 percent should be seriously reconsidered as an approach to treatment.
E-cigarettes, although they’re held back by the fact there hasn't been enough time for long-term studies to surface, initially appear to be much more effective. The fact that studies show smokers who don’t even want to stop are more likely to succeed using e-cigs than people who actively try using gums and patches should make your mind up, before you even consider the cost of treatment and how enjoyable the products are to use.
You can slap an ineffective patch on your arm and chain-chew gum, or you can enjoy a safer smoking-like experience using a product that has true potential for harm reduction.