CADTH Health Technology Review
Pharmacological Interventions for Vaping Cessation
Rapid Review
Authors: Sara D. Khangura, Sarah C. McGill
Key Messages
The use of electronic nicotine delivery systems and other vaping products is on the rise, and the health effects from these products remain uncertain.
No evidence-based guidelines regarding the use of pharmacological vaping cessation interventions were identified.
Some guidelines suggest that it may be reasonable to apply smoking cessation interventions and/or protocols for vaping cessation, but no guidance specific to the use of pharmacotherapy was identified.
Context and Policy Issues
Vaping is the use of an electronic device that heats a liquid substance which produces aerosol vapour and is then inhaled and exhaled by the user.1 Often (but not always) the liquid and its aerosol vapour contain nictorine2,3; in these cases, the devices are termed electronic nicotine delivery systems (ENDS).4-6 The use of vaping devices is generally described as a smoking cessation aid for use in the short term only4,5,7-13; that is, ENDS and other vaping products are neither recommended for people who do not smoke nor for long-term use in people who smoke and are trying to quit.11,14
Nonetheless, the use of ENDS is increasing rapidly across the world,10,15 particularly among adolescents and younger adults.9,11,14,16-20 Whereas the use of ENDS products in adults generally follows their use of combustible tobacco products (i.e., often used as a cessation aid), use of ENDS products in children, youth, and younger adults often begins before the use of combustible tobacco products, causing concern that ENDS and other vaping products may serve as a “gateway” to the use of combustible tobacco products — especially in younger populations.10,11,16,21
There is currently limited evidence describing the health effects of ENDS and other vaping products — particularly given the wide variety of available ENDS products — including a lack of data describing associated morbidity and mortality.14 However, a growing body of literature describes the risk of e-cigarette or vaping-associated lung injury that can be caused by ENDS devices.14,22-24 In addition, there is the risk of toxicity and/or adverse reactions that can be caused by the aerosol vapour,4 particularly in children and youth.11,24 Concerns have also been raised about the insufficiency of current regulatory limitations in place in Canada that govern the distribution, marketing, and use of ENDS.24
Given the rising use of ENDS and other vaping products, as well as the uncertainty concerning their health effects, there is a need for evidence-based guidance to support vaping cessation. The purpose of this report is to identify and describe evidence-based guidelines to inform the use of pharmacological interventions to support vaping cessation.
Research Question
What are the evidence-based guidelines regarding the use of pharmacological vaping cessation interventions in people of any age who use vaping products?
Methods
Literature Search Methods
A limited literature search was conducted by an information specialist on key resources including MEDLINE, the Cochrane Database of Systematic Reviews, the international HTA database, the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search strategy comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. The main search concepts were vaping, or electronic nicotine delivery systems, and pharmacological interventions. Search filters were applied to limit retrieval to health technology assessments and guidelines. The search was limited to English language documents published between January 1, 2016, and March 12, 2021.
Selection Criteria and Methods
One reviewer screened citations for eligible sources. In the first level of screening, titles and abstracts were reviewed and potentially relevant sources were retrieved and assessed for eligibility. The final selection of full-text sources was based on the inclusion criteria presented in Table 1.
Criteria | Description |
Population | People of any age (i.e., youth or adult populations) who use vaping products |
Intervention | Pharmacological vaping cessation interventions (e.g., nicotine replacement therapy, cytisine, varenicline) |
Comparator | Not applicable |
Outcomes | Recommendations regarding best practices (e.g., appropriate patient populations or clinical settings, recommended treatment strategies, dosing algorithms) |
Study designs | Evidence-based guidelines |
Exclusion Criteria
Sources were excluded if they did not meet the selection criteria outlined in Table 1, were duplicate publications, or were published before 2016. Guidelines with unclear methodology were excluded.
Critical Appraisal of Individual Studies
Critical appraisal was not undertaken as no eligible guidelines were identified.
Summary of Evidence
Quantity of Research Available
A total of 41 citations were identified in the electronic literature search. Following screening of titles and abstracts, 16 citations were excluded and 25 potentially relevant sources from the electronic search were retrieved for full-text review. Eighteen potentially relevant sources were retrieved from the grey literature search for full-text review. Of these potentially relevant articles, 43 publications were excluded for various reasons, with no publications meeting the inclusion criteria for this report. Appendix 1 presents the PRISMA25 flow chart of the study selection. Additional references of potential interest are provided in Appendix 2.
Summary of Findings
No evidence-based guidelines informing the use of pharmacological vaping cessation interventions were identified; therefore, no summary can be provided.
Limitations
No relevant evidence-based guidelines describing pharmacotherapy for vaping cessation were identified.
Conclusions and Implications for Decision- or Policy-Making
No evidence-based guidelines regarding the use of pharmacological vaping cessation interventions in people of any age who use vaping products were identified.
Pharmacological support for smoking cessation has been demonstrated to be effective,26 and there are multiple evidence-based recommendations and guidelines informing the use of pharmacotherapy for this purpose8,27-29; however, no guidance specific to the use of pharmacotherapy to support vaping cessation was identified. Some guidance and recommendations that were developed to support smoking cessation state generally that recommendations are inclusive of ENDS and other vaping products28-30 and/or that, despite a current lack of evidence, it may be reasonable to manage vaping cessation in a way similar to smoking cessation. However, these sources do not make explicit, evidence-based recommendations to inform vaping cessation, and do not provide guidance specific to the use of pharmacotherapy.3,28-32 Other recommendations that focused on the regulation, prevention, and management of ENDS and other vaping products, but did not provide recommendations regarding vaping cessation, were also identified.4,33,34 Sources of guidance bearing some relevance to this report are listed in Appendix 2.
The current lack of available evidence describing the use of pharmacotherapy and other interventions to support vaping cessation has been identified as a knowledge gap in the literature.35 Similarly, while previous CADTH reports have sought evidence describing interventions to support smoking cessation36-40 — including 1 describing the use of ENDS products to support smoking cessation41 — only 1 recent CADTH report sought evidence describing the clinical effectiveness of nicotine replacement therapy for vaping cessation in adults, but no relevant studies were identified.42 This lack of clinical evidence is consistent with the findings of the current report, which has identified a lack of available guidelines informing the use of any pharmacological interventions to support vaping cessation.
There is some early evidence suggesting that pharmacotherapy may benefit vaping cessation efforts.18 One case study reported the success of nicotine replacement therapy for vaping cessation in a single user of ENDS, and highlighted the need for treatment protocols and guidelines to advance best practice and outcomes for ENDS users who want to quit.15 Notably, 1 published protocol was identified describing initiation of a randomized controlled trial to evaluate the efficacy of a combined behavioural and pharmacological intervention using varenicline and counselling to support vaping cessation.35 Continued research in this area will provide evidence to inform recommendations regarding vaping cessation.
Given the rapid rise in the use of ENDS and other vaping products alongside the uncertainty around their health effects, there is a need for evidence-based guidance regarding vaping cessation interventions.
References
1.Vaping in Canada: what we know. Ottawa: Health Canada, Government of Canada; 2021: https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping/canada.html. Accessed 2021 Mar 24.
2.Statistics Canada. Canadian tobacco and nicotine survey, 2019. The Daily – Statistics Canada’s official release bulletin. 2020. https://www150.statcan.gc.ca/n1/daily-quotidien/200305/dq200305a-eng.htm. Accessed 2021 Mar 25.
3.Rigotti NA. Vaping and e-cigarettes. In: Aronson MD, Hatipoglu U, eds. UpToDate. Waltham (MA): UpToDate; 2021: http://www.uptodate.com. Accessed 2021 Mar 19.
4.Brady BR, De La Rosa JS, Nair US, Leischow SJ. Electronic cigarette policy recommendations: a scoping review. Am J Health Behav. 2019;43(1):88-104. PubMed
5.Kamat AD, Van Dyke AL. Use of electronic nicotine delivery systems among adolescents: status of the evidence and public health recommendations. Pediatr Ann. 2017;46(2):e69-e77. PubMed
6.Sahr M, Kelsh S, Blower N, Sohn M. Pilot study of electronic nicotine delivery systems (ENDS) cessation methods. Pharmacy (Basel). 2021;9(1):21. PubMed
7.Dautzenberg B, Adler M, Garelik D, et al. Practical guidelines on e-cigarettes for practitioners and others health professionals. A French 2016 expert's statement. Rev Mal Respir. 2017;34(2):155-164. PubMed
8.Leone FT, Zhang Y, Evers-Casey S, et al. Initiating pharmacologic treatment in tobacco-dependent adults. An official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020;202(2):e5-e31. PubMed
9.Ferkol TW, Farber HJ, La Grutta S, et al. Electronic cigarette use in youths: a position statement of the Forum of International Respiratory Societies. Eur Respir J. 2018;51(5):05.
10.Bals R, Boyd J, Esposito S, et al. Electronic cigarettes: a task force report from the European Respiratory Society. Eur Respir J. 2019;53(2):1801151. PubMed
11.Patnode CD, Henderson JT, Melnikow J, Coppola EL, Durbin S, Thomas R. Interventions for tobacco cessation in adults, including pregnant women: an evidence update for the U.S. Preventive Services Task Force. (Evidence Synthesis, No. 196.). Rockville (MD): Agency for Healthcare Research and Quality (US); 2021: https://www.ncbi.nlm.nih.gov/books/NBK567066/. Accessed 2021 Apr 12.
12.Pierre S, Rivera C, Le Maitre B, et al. Guidelines on smoking management during the perioperative period. Anaesth Crit Care Pain Med. 2017;36(3):195-200. PubMed
13.U.S. Preventive Services Task Force, Krist AH, Davidson KW, et al. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force Recommendation Statement. Jama. 2021;325(3):265-279. PubMed
14.McDonald CF, Jones S, Beckert L, et al. Electronic cigarettes: a position statement from the Thoracic Society of Australia and New Zealand. Respirology. 2020;25(10):1082-1089. PubMed
15.Silver B, Ripley-Moffitt C, Greyber J, Goldstein AO. Successful use of nicotine replacement therapy to quit e-cigarettes: lack of treatment protocol highlights need for guidelines. Clin Case Rep. 2016;4(4):409-411. PubMed
16.Stanwick R. Position statement: E-cigarettes – Are we renormalizing public smoking? Reversing five decades of tobacco control and revitalizing nicotine dependency in children and youth in Canada. Reaffirmed 2018. Paediatr Child Health 2015;20(2):101-105. Ottawa: Canadian Paediatric Society; 2015: https://www.cps.ca/en/documents/position/e-cigarettes. Accessed 2021 Mar 20.
17.Singh S, Windle SB, Filion KB, et al. E-cigarettes and youth: Patterns of use, potential harms, and recommendations. Prev Med. 2020;133:106009. PubMed
18.Harrison S. So you want to quit vaping? No one actually knows how. Wired. 2019 Oct 4. https://www.wired.com/story/so-you-want-to-quit-vaping-no-one-actually-knows-how/. Accessed 2021 Mar 19.
19.Adams ZW, Kwon E, Aalsma MC, Zapolski TCB, Dir A, Hulvershorn LA. Treatment of adolescent e-cigarette use: limitations of existing nicotine use disorder treatment and future directions for e-cigarette use cessation. J Am Acad Child Adolesc Psychiatry. 2021;60(1):14-16. PubMed
20.Graham AL, Jacobs MA, Amato MS. Engagement and 3-month outcomes from a digital e-cigarette cessation program in a cohort of 27 000 teens and young adults. Nicotine Tob Res. 2020;22(5):859-860. PubMed
21.Singh B, Hrywna M, Wackowski OA, Delnevo CD, Jane Lewis M, Steinberg MB. “Knowledge, recommendation, and beliefs of e-cigarettes among physicians involved in tobacco cessation: A qualitative study”. Prev Med Rep. 2017;8:25-29. PubMed
22.Evans ME, Twentyman E, Click ES, et al. Update: Interim guidance for health care professionals evaluating and caring for patients with suspected e-cigarette, or vaping, product use-associated lung injury and for reducing the risk for rehospitalization and death following hospital discharge - United States, December 2019. MMWR Morb Mortal Wkly Rep. 2020;68(5152):1189-1194. PubMed
23.Singh A, Tan Q, Saccone NM, Lindner DH. A case of vaping TCH oil leading to vaping associated pulmonary injury: our approach to its diagnosis, management, and recommendations. Case Rep Pulmonol. 2020;2020:6138083. PubMed
24.Stanbrook MB. Vaping-associated lung illnesses highlight risks to all users of electronic cigarettes. CMAJ. 2019;191(48):E1319-E1320. PubMed
25.Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34. PubMed
26.Mills EJ, Wu P, Lockhart I, Thorlund K, Puhan M, Ebbert JO. Comparisons of high-dose and combination nicotine replacement therapy, varenicline, and bupropion for smoking cessation: a systematic review and multiple treatment meta-analysis. Ann Med. 2012;44(6):588-597. PubMed
27.Harvey J, Chadi N, Canadian Paediatric Society AHC. Preventing smoking in children and adolescents: recommendations for practice and policy. Paediatr child health. 2016;21(4):209-221. PubMed
28.Integrating tobacco interventions into daily practice. (Clinical best practice guidelines). 3rd ed. Toronto: Registered Nurses' Association of Ontario (RNAO); 2017: https://rnao.ca/sites/rnao-ca/files/bpg/RNAO_Integrating_Tobacco_Interventions_into_Daily_Practice_2017_Third_Edition_Best_Practice_Guideline_0.pdf. Accessed 2021 Mar 26.
29.U.S. Preventive Services Task Force, Owens DK, Davidson KW, et al. Primary care interventions for prevention and cessation of tobacco use in children and adolescents: US Preventive Services Task Force Recommendation Statement. Jama. 2020;323(16):1590-1598. PubMed
30.Ordean A, Wong S, Graves L. No. 349-Substance use in pregnancy. J Obstet Gynaecol Can. 2017;39(10):922-937.e922. PubMed
31.Rigotti NA. Pharmacotherapy for smoking cessation in adults. In: Aronson MD, Kathuria H, eds. UpToDate. Waltham (MA): UpToDate; 2021: http://www.uptodate.com. Accessed 2021 Mar 19.
32.Rosen JB, Sockrider M. Management of smoking and vaping cessation in adolescents. In: Mallory GB, Blake D, eds. UpToDate. Waltham (MD): UpToDate; 2021: http://www.uptodate.com. Accessed 2021 Mar 26.
33.Mamudu HM, Sanborn T, Dobbs PD. Electronic nicotine delivery systems: Recommendations to regulate their use. Am J Public Health. 2019;109(11):1531-1532. PubMed
34.Ribisl KM, Seidenberg AB, Orlan EN. Recommendations for U.S. public policies regulating electronic cigarettes. J Policy Anal Manage. 2016;35(2):479-489. PubMed
35.Caponnetto P, Maglia M, Polosa R. Efficacy of smoking cessation with varenicline plus counselling for e-cigarettes users (VAREVAPE): a protocol for a randomized controlled trial. Contemp Clin Trials Commun. 2019;15:100412. PubMed
36.Non-pharmacological and pharmacological intervention for smoking cessation programs in youth: a review of clinical effectiveness and guidelines. (CADTH rapid response: summary with critical appraisal). Ottawa: CADTH; 2020 Feb: https://www.cadth.ca/sites/default/files/pdf/htis/2020/RC1235%20Smoking%20Cessation%20Youth%20Final.pdf. Accessed 2021 Mar 15.
37.Pharmacist-led interventions for tobacco smoking cessation: a review of clinical effectiveness and cost-effectiveness. (CADTH rapid response: summary with critical appraisal). Ottawa: CADTH; 2019 Sep: https://www.cadth.ca/sites/default/files/pdf/htis/2019/RC1174%20Pharm-led%20smoking%20Cessation%20Final.pdf. Accessed 2021 Apr 12.
38.Pharmacological agents for smoking cessation: clinical effectiveness and cost-effectiveness. (CADTH rapid response report: reference list). Ottawa: CADTH; 2017 Nov: https://www.cadth.ca/sites/default/files/pdf/htis/2017/RA0939%20Pharmacological%20smoking%20cessation%20Final.pdf. Accessed 2021 Apr 12.
39.Cytisine for smoking cessation: clinical effectiveness and cost-effectiveness. (CADTH rapid response: summary of abstracts). Ottawa: CADTH; 2017 Sep: https://www.cadth.ca/sites/default/files/pdf/htis/2017/RB1136%20Cytisine%20for%20Smoking%20Cessation%20Final.pdf. Accessed 2021 Apr 12.
40.Nicotine replacement therapy, bupropion and varenicline for tobacco cessation: a review of clinical effectiveness. (CADTH rapid response report: summary with critical appraisal). Ottawa: CADTH; 2016 Mar: https://www.cadth.ca/sites/default/files/pdf/htis/mar-2016/RC0747%20Pharmacologic%20Smoking%20Cessation%20Therapy%20Final.pdf. Accessed 2021 Apr 12.
41.Electronic cigarettes for the reduction or cessation of smoking: clinical utility, safety, and guidelines. (CADTH rapid Response: summary of abstracts). Ottawa: CADTH; 2017 Sep: https://www.cadth.ca/sites/default/files/pdf/htis/2017/RB1130%20E-Cigarettes%20Final.pdf. Accessed 2021 Apr 12.
42.Nicotine replacement therapy for vaping cessation in adults: clinical effectiveness. (CADTH rapid response report: reference list). Ottawa: CADTH; 2020: https://cadth.ca/sites/default/files/pdf/htis/2020/RA1091%20NRT%20Vaping%20Final.pdf. Accessed 2021 Apr 12.
Appendix 1: Selection of Included Studies
Appendix 2: References of Potential Interest
Additional References
Guidance Specific to Vaping/Vaping Products (but No Recommendation Specific to Pharmacotherapy as a Cessation Aid)
1.Rigotti NA. Vaping and e-cigarettes. In: Aronson MD, Hatipoglu U, eds. UpToDate. Waltham (MA): UpToDate; 2021: http://www.uptodate.com. Accessed 2021 Mar 19.
2.Rosen JB, Sockrider M. Management of smoking and vaping cessation in adolescents. In: Mallory GB, Blake D, eds. UpToDate. Waltham (MD): UpToDate; 2021: http://www.uptodate.com. Accessed 2021 Mar 26.
Guidance for Tobacco/Smoking That Mentions Vaping/Vaping Products (but No Recommendation Specific to Pharmacotherapy as a Cessation Aid for Vaping/Vaping Products)
3.Rigotti NA. Pharmacotherapy for smoking cessation in adults. In: Aronson MD, Kathuria H, eds. UpToDate. Waltham (MA): UpToDate; 2021: http://www.uptodate.com. Accessed 2021 Mar 19.
4.U.S. Preventive Services Task Force, Owens DK, Davidson KW, et al. Primary care interventions for prevention and cessation of tobacco use in children and adolescents: US Preventive Services Task Force Recommendation Statement. Jama. 2020;323(16):1590-1598. PubMed
5.Integrating tobacco interventions into daily practice. (Clinical best practice guidelines). 3rd ed. Toronto: Registered Nurses' Association of Ontario (RNAO); 2017: https://rnao.ca/sites/rnao-ca/files/bpg/RNAO_Integrating_Tobacco_Interventions_into_Daily_Practice_2017_Third_Edition_Best_Practice_Guideline_0.pdf. Accessed 2021 Mar 26.
6.Ordean A, Wong S, Graves L. No. 349-Substance use in pregnancy. J Obstet Gynaecol Can. 2017;39(10):922-937.e922. SOGC Clinical Practice Guideline. Previous CADTH Reports PubMed
Reports Describing Evidence Addressing Vaping/Vaping Products
7.Electronic cigarettes for the reduction or cessation of smoking: clinical utility, safety, and guidelines. (CADTH rapid Response: summary of abstracts). Ottawa: CADTH; 2017 Sep: https://www.cadth.ca/sites/default/files/pdf/htis/2017/RB1130%20E-Cigarettes%20Final.pdf. Accessed 2021 Apr 12.
Reports Describing Evidence Addressing Tobacco/Smoking
8.Nicotine replacement therapy, bupropion and varenicline for tobacco cessation: a review of clinical effectiveness. (CADTH rapid response report: summary with critical appraisal). Ottawa: CADTH; 2016 Mar: https://www.cadth.ca/sites/default/files/pdf/htis/mar-2016/RC0747%20Pharmacologic%20Smoking%20Cessation%20Therapy%20Final.pdf. Accessed 2021 Apr 12.
9.Non-pharmacological and pharmacological intervention for smoking cessation programs in youth: a review of clinical effectiveness and guidelines. (CADTH rapid response: summary with critical appraisal). Ottawa: CADTH; 2020 Feb: https://www.cadth.ca/sites/default/files/pdf/htis/2020/RC1235%20Smoking%20Cessation%20Youth%20Final.pdf. Accessed 2021 Mar 15.
10.Pharmacist-led interventions for tobacco smoking cessation: a review of clinical effectiveness and cost-effectiveness. (CADTH rapid response: summary with critical appraisal). Ottawa: CADTH; 2019 Sep: https://www.cadth.ca/sites/default/files/pdf/htis/2019/RC1174%20Pharm-led%20smoking%20Cessation%20Final.pdf. Accessed 2021 Apr 12.
11.Nicotine replacement product use in children: safety. (CADTH rapid response: reference list). Ottawa: CADTH; 2018 Oct: https://www.cadth.ca/sites/default/files/pdf/htis/2018/RA0980%20Final.pdf Accessed 2021 Apr 12.
12.Pharmacological agents for smoking cessation: clinical effectiveness and cost-effectiveness. (CADTH rapid response report: reference list). Ottawa: CADTH; 2017 Nov: https://www.cadth.ca/sites/default/files/pdf/htis/2017/RA0939%20Pharmacological%20smoking%20cessation%20Final.pdf. Accessed 2021 Apr 12.
13.Cytisine for smoking cessation: clinical effectiveness and cost-effectiveness. (CADTH rapid response: summary of abstracts). Ottawa: CADTH; 2017 Sep: https://www.cadth.ca/sites/default/files/pdf/htis/2017/RB1136%20Cytisine%20for%20Smoking%20Cessation%20Final.pdf. Accessed 2021 Apr 12.
14.Smoking reduction and cessation interventions for pregnant women and mothers of infants: a review of the clinical effectiveness. (CADTH rapid response report: summary with critical appraisal). Ottawa: CADTH; 2017 Jul. https://www.cadth.ca/sites/default/files/pdf/htis/2017/RC0900_Smoking%20reduction%20and%20cessation%20interventions%20for%20pregnant%20women%20and%20mothers%20of%20infants%20Final.pdf Accessed 2021 Apr 12.
15.Nicotine replacement therapy, bupropion and varenicline for tobacco cessation: a review of clinical effectiveness. (CADTH rapid response report: summary with critical appraisal). Ottawa: CADTH; 2016 Mar: https://www.cadth.ca/sites/default/files/pdf/htis/mar-2016/RC0747%20Pharmacologic%20Smoking%20Cessation%20Therapy%20Final.pdf. Accessed 2021 Apr 12.
ISSN: 2563-6596
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