Jeffrey A. Singer

Finnish researchers published the results of a randomized controlled trial in today’s JAMA Internal Medicine, comparing varenicline (Chantix) to nicotine e‑cigarettes in helping tobacco smokers quit smoking. The researchers concluded, “This randomized clinical trial found that varenicline and nicotine‐​containing ECs were both effective in helping individuals in quitting smoking conventional cigarettes for up to 6 months.”

Varenicline works on receptor sites in the brain to reduce the craving for and satisfaction with nicotine. The Food and Drug Administration denies tobacco smokers wishing to quit access to varenicline unless they get a permission slip (prescription) from a government‐​approved gatekeeper (usually a physician, nurse practitioner, or physician assistant). However, as of 2022, eight states allow pharmacists to prescribe varenicline, sparing smokers the expense in time and money of a visit to the doctor’s office to get a prescription.

This is a significant study because most studies compare varenicline to placebo or e‑cigarettes to placebo. However, this was a high‐​quality comparative effectiveness study. The study was randomized and placebo‐​based, and the participants, study nurses, and researchers were all masked as to group assignment. One group received nicotine e‑cigarettes plus placebo tablets; another group received varenicline and an e‑cigarette that did not contain nicotine; the third group received a nicotine‐​free e‑cigarette and a placebo tablet.

The group of 458 adults (age range 25–75) were given these treatments, along with tobacco cessation counseling, for twelve weeks. After twenty‐​six weeks, the researchers assessed the participants’ quit rates. They found no statistically significant difference between the quit rates of those on varenicline alone vs those on nicotine e‑cigarettes alone (43.8 percent and 40.4 percent, respectively).

In the UK, the National Health Service considers nicotine relatively harmless, considers nicotine e‑cigarettes to be an effective tobacco cessation strategy, and encourages primary care practitioners to suggest it to their patients who smoke. Australia, on the other hand, highly regulates nicotine e‑cigarettes, tightly restricts their supply, and requires people to get a doctor’s prescription for them. Unfortunately, very few Australian doctors will prescribe it, and even if adults who want to quit are fortunate enough to get a doctor’s permission slip, most pharmacies don’t stock them. Australia now has a black market and the associated violent crime one would expect to see with such prohibition.

This study vindicates the NHS’s position regarding e‑cigarettes.

Meanwhile, as the FDA continues its painfully slow process of deciding which e‑cigarettes American adults will be free to buy, and as some politicians wage war on nicotine products, a black market in illicit e‑cigarettes grows.