Effect of an electronic nicotine delivery system with 0, 8, or 36 mg/mL liquid nicotine versus a cigarette substitute on tobacco-related toxicant exposure: a four-arm, parallel-group, randomised, controlled trial

Background: Electronic nicotine delivery systems (ENDSs) are used by some smokers to reduce cigarette consumption, but their effectiveness is uncertain. We aimed to examine the extent to which ENDSs or a non-nicotine cigarette substitute influence tobacco-related toxicant exposure and cigarette consumption in smokers interested in smoking reduction. Methods: We did a four-arm, parallel-group, randomised controlled trial at two sites in the USA (Penn State University, Hershey, PA, and Virginia Commonwealth University, Richmond, VA). We enrolled adults aged 21–65 years who smoked more than nine cigarettes per day (for at least the past year), with exhaled CO of more than 9 parts per million at screening, who were not currently using an ENDS, and who were interested in reducing smoking but not quitting. Participants were randomised (site-specific with allocation concealment; 1:1:1:1) to receive either a cartomiser-based, pen-style ENDS (eGo-style) paired with 0, 8, or 36 mg/mL liquid nicotine (participants and researchers masked to concentration) or a non-ENDS cigarette-shaped plastic tube that delivered no nicotine or aerosol (cigarette substitute; unmasked) for 24 weeks. Conditions were chosen to reflect a range of nicotine delivery including none (cigarette substitute and 0 mg/mL ENDS), low (8 mg/mL), and cigarette-like (36 mg/mL), and all conditions were paired with smoking reduction instructions. The primary outcome was concentration of the tobacco-specific carcinogen metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL; urinary total) collected at randomisation and at 4, 12, and 24 weeks. Multiple imputation with and without covariate adjustment was used in addition to sensitivity analyses. This trial is registered with ClinicalTrials.gov, NCT02342795. Findings: Between July 22, 2015, and Nov 16, 2017, 684 individuals were screened and 520 (76%) were enrolled and randomised. 188 (36%) of 520 participants were lost to follow-up by week 24; attrition did not differ by study group (39 [30%] of 130 in the cigarette substitute group, 56 [43%] of 130 in the ENDS with 0 mg/mL nicotine group, 49 [38%] of 130 in the ENDS 8 mg/mL group, and 44 [34%] of 130 in the ENDS 36 mg/mL group). Urinary total NNAL at 24 weeks in the ENDS with 36 mg/mL nicotine group was 210·80 pg/mg creatinine (95% CI 163·03–274·42) compared with 346·09 pg/mg creatinine (265·00–455·32) in the cigarette substitute group (p=0·0061). No other significant differences between groups were observed for any time point for urinary total NNAL. Serious adverse event frequency was similar across groups (12 events in 12 participants [9%] in the ENDS with 36 mg/mL nicotine group, seven events in six participants [5%] in the 8 mg/mL group, 11 events in ten participants [8%] in the 0 mg/mL group, and 13 events in 13 participants [10%] in the cigarette substitute group), and all of these were deemed unrelated or unlikely to be related to study product use. There was one death between randomisation and 24 weeks (suicide; in the ENDS with 0 mg/mL nicotine group). Interpretation: Use of an ENDS with cigarette-like nicotine delivery can reduce exposure to a major pulmonary carcinogen, NNAL, even with concurrent smoking. Future ENDS trials should involve products with well characterised nicotine delivery, including those with nicotine delivery approaching that of a cigarette. Funding: National Institutes of Health, US Food and Drug Administration.

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Work Title Effect of an electronic nicotine delivery system with 0, 8, or 36 mg/mL liquid nicotine versus a cigarette substitute on tobacco-related toxicant exposure: a four-arm, parallel-group, randomised, controlled trial
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Open Access
Creators
  1. Caroline O. Cobb
  2. Jonathan Foulds
  3. Miao Shan Yen
  4. Susan Veldheer
  5. Alexa A. Lopez
  6. Jessica M. Yingst
  7. Christopher Bullen
  8. Le Kang
  9. Thomas Eissenberg
  10. Sophia I. Allen
  11. Phoebe Brosnan
  12. Nadia Chowdhury
  13. Caroline O. Cobb
  14. Jacob T. Graham
  15. Erin Hammett
  16. Sharilee Hrabovsky
  17. Breianna L. Hummer
  18. Courtney Lester
  19. Alexa A. Lopez
  20. John P. Richie
  21. Christopher Sciamanna
  22. Shumei Sun
  23. Thokozeni Lipato
  24. Jessica M. Yingst
License CC BY 4.0 (Attribution)
Work Type Article
Publisher
  1. The Lancet Respiratory Medicine
Publication Date August 1, 2021
Publisher Identifier (DOI)
  1. https://doi.org/10.1016/S2213-2600(21)00022-9
Deposited November 16, 2021

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  • Created
  • Added CobbFouldsLancetonline20TLRM2357.pdf
  • Added Creator Caroline O. Cobb
  • Added Creator Jonathan Foulds
  • Added Creator Miao Shan Yen
  • Added Creator Susan Veldheer
  • Added Creator Alexa A. Lopez
  • Added Creator Jessica M. Yingst
  • Added Creator Christopher Bullen
  • Added Creator Le Kang
  • Added Creator Thomas Eissenberg
  • Added Creator Sophia I. Allen
  • Added Creator Phoebe Brosnan
  • Added Creator Nadia Chowdhury
  • Added Creator Caroline O. Cobb
  • Added Creator Jacob T. Graham
  • Added Creator Erin Hammett
  • Added Creator Sharilee Hrabovsky
  • Added Creator Breianna L. Hummer
  • Added Creator Courtney Lester
  • Added Creator Alexa A. Lopez
  • Added Creator John P. Richie
  • Added Creator Christopher Sciamanna
  • Added Creator Shumei Sun
  • Added Creator Thokozeni Lipato
  • Added Creator Jessica M. Yingst
  • Published
  • Updated
  • Updated
  • Updated