Electronic cigarettes for smoking cessation: An overview of systematic reviews and evidence and gap map

Electronic cigarettes (EC) are considered a smoking cessation tool in some countries, such as the United Kingdom, but uncertainty remains internationally over whether their benefits outweigh potential harms when used for this purpose. This overview (1) synthesised existing evidence from systematic reviews (SR) on the effectiveness and safety of ECs to explore and address these uncertainties and disagreements and (2) mapped primary intervention studies to identify priorities for further research.

Overview of SRs published from 1 January 2015 and meeting the inclusion criteria of the Cochrane review of EC for smoking cessation. We searched seven databases to April 2024. We followed Cochrane screening and data extraction methods. We adapted Campbell Collaboration and 3ie methods for the Evidence and Gap Map (EGM). We assessed review quality using AMSTAR-2.

We included 14 reviews of intervention studies (7 high quality; 7 low quality), with search dates from 2014 to 2023, in adult populations including the general population, people at risk of lung cancer, with comorbid health conditions and pregnant people. Eighteen studies were included across multiple reviews, some of which included multiple meta-analyses. Across 21 meta-analytic comparisons of nicotine EC versus other interventions, all reported point estimates favouring nicotine EC for smoking cessation, with relative risks/odds ratios typically in the range 1.17-1.67 versus nicotine replacement therapy and 1.46-2.09 versus non-nicotine EC, with higher-quality reviews giving more consistent estimates. Of 13 reviews that meta-analysed serious adverse events (SAEs), two reported point estimates suggesting increased SAEs with nicotine EC; other estimates included the possibility of no difference. For adverse events, pooled estimates generally indicated little or no difference between groups. Our EGM mapped 90 primary, complete studies and identified absolute gaps in evidence comparing the effects of nicotine EC to cytisine, bupropion and nicotine pouches. Most studies used collected data from high-income countries.

Meta-analyses of electronic cigarettes (EC) for smoking cessation report point estimates favouring higher ≥6-month smoking cessation rates with nicotine EC compared with nicotine replacement therapy, non-nicotine EC/placebo, behavioural or no support and mixed support. Evidence on serious adverse events (SAEs) remains inconclusive. Evidence gaps were identified in SAE data and in studies from low- and middle-income countries.