Finding ‘what works’ to help more people quit tobacco

10-chrisChris Bullen
The University of Auckland
10-flag New Zealand
08 Nov 2014


You are the author of the only randomized trial comparing e-cigarettes to nicotine replacement therapy. Please tell us about this trial and the findings:

We took an interest in e-cigarettes/ENDS when they first emerged on the scene in New Zealand in 2007, because users were reporting they helped them to quit smoking when other stop-smoking medications had failed. So we did a small cross-over trial that we published in Tobacco Control in 2010 showing they were about as good at reducing withdrawal symptoms as nicotine inhalers, and as good as delivering nicotine, but the delivery of nicotine in both devices was nowhere near as fast or in as high doses as smoking tobacco. People liked them a lot more than the inhaler.

We then scaled up and undertook a pragmatic randomised controlled trial with 657 participants to test the comparative quitting effectiveness of a popular brand of a ‘cigalike’ e-cigarette versus nicotine patches, and with a placebo e-cigarette. This study was designed to reflect as much as possible “real world” conditions that most users find themselves in, with minimal behavioral support and basic instructions.

The main outcomes paper was published in The Lancet in September 2014 and has attracted a lot of interest. We found the e-cigarettes — both placebo and nicotine — were only modestly effective at helping smokers quit, about the same as patches when users are not provided with behavioural support. We also found no significant differences in side effects between the e-cig and patches groups.

But the product we used was at times unreliable and didn’t deliver nicotine that well. It is now obsolete.  This reflects the rapid pace of evolution of these products. We hypothesise that newer models of e-cigarettes, that are more reliable and efficient at delivering nicotine, when used with behavioural support in some way (text, online, telephone, face to face, etc.) may well lead to improved cessation results.

A key point for research in this area of novel products is that people don’t use them in the same way as a pharmaceutical cessation medication: they may use e-cigarettes and smoke tobacco at times in the course of the same day, and may do so for many months. More research is needed to understand whether this ultimately leads to quitting or just long-term “dual use”.

What is the main focus of your work now?

My group is interested in finding our “what works” to help more people quit smoking: it could be novel medications or novel ways of using them, SMS messaging,health systems changes, or ways of scaling up the reach of interventions, such as via social media. Whatever may be worth investigating, we are interested. But since the publication of our paper in 2013 I’ve almost exclusively focused on doing what I can to build the scientific knowledge base on e-cigarettes — they are under-researched, with many fundamental questions for smokers, healthcare workers, the tobacco control community and regulators that need answers.

What do you hope to accomplish with your work?

I’m fortunate to be working in New Zealand, a small country where successive governments have had a commitment to tobacco control. Our current government has agreed to drive smoking rates down to 5% or less by 2025. I’m hoping we can make a small contribution to achieving that goal. I’m very keen to see our decision-makers formulate policy, regulations and guidelines based on the best available scientific evidence, not merely on “expert” opinion or ideology.

I’m also committed to ensuring minority populations and other marginalized population groups  — groups typically with high smoking prevalence and health burden — have a voice, and are not overlooked by researchers and decision makers.

What are some of the challenges you have faced in your work?

One of the greatest challenges in research is obtaining funding to support the work you want to do. We spend many hours writing grant applications!

What are some success stories as a result of your work?

It is very rewarding to know that our research can help make a difference. In 2007 our group lead the writing of national smoking cessation guidelines, that included the “ABC” approach — Ask, give Brief advice, provide Cessation support — that has become the basis for the New Zealand health sectors’ approach to massively increasing support for smokers to quit. Now almost 95% of hospital patients in the country are asked if they smoke, given brief advice and provided with evidence-based support before they leave hospital. A rapid increase in “ABC” delivery has been happening in primary care as well.

Our group also undertook the world’s first trial of SMS messaging for cessation and found it was an effective intervention. Our national telephone quitline then adopted the model we developed into its services.

Please add anything we have not asked about but you believe is important for the audience to know about:

At the core I’m interested in innovation — new ideas and methods — hopefully some of them might help more people decide not to start smoking or more smokers to quit. I would welcome conversations with anyone who shares this interest.