Critical Appraisal of Evidence on Real-World Effectiveness of E-cigarettes for Smoking Cessation

This report critically appraises a cross-sectional study on the real-world effectiveness of e-cigarettes for smoking cessation. The study's authorship, research questions, design, methods, and results are analyzed. The study is found to be the best evidence for practice, suggesting that e-cigarettes are more effective than NRT products for smoking cessation.

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Critical Appraisal of Evidence
Student Name:
HLSC122 Semester 2, 2018
Assessment 3: Critical appraisal of evidence
Word count:

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Critical Appraisal of Evidence
Brown, J., Beard, E., Kotz, D., Michie, S., & West, R. (2014). Real-world
effectiveness of e-cigarettes when used to aid smoking cessation: A cross-sectional
population study. Addiction, 109(9), 1531- 1540. doi:10.1111/add.12623
Introduction:
Critical-appraisal involves a systematic way of determining the strengths and
weaknesses of the methods employed in the study (Boswell, n. d., p.412). This report
carefully scrutinizes the cross-sectional study on ‘the real-world effectiveness of e-
cigarettes that aids in smoking cessation’. Brown (2014, p.1531) has given a clear title
with an focused-abstract condensing the main points of the study. They stated an
understandable purpose that is appropriate to health-practice. It answers their study-
questions with a detailed description about scope and limitations. It gives the rationale
and potential importance in conducting the study with a clear background to this study,
PART-A
Authorship:
Authorship includes the person who has conducted the study, their job-titles, and
qualifications with designations (Boswell, n. d, p.414). The study-authors Brown, Beard,
Kotz & West are expertise in the cancer-research and health-behavior research field
while Brown and Michie are from the Clinical, educational with health-psychology
department whereas Kotz is from the Family-Medicine and Public-health & Primary-
Care department whereas Michie & West is from the Nation’s Centre for smoking-
cessation & training. This indicates that the study-authors’ qualifications and affiliations

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are related to their topic written. They have avoided all the possible biases in
measurement, sampling, response and publication aspects.
They acknowledged Jarvis, Shahab & Raupach for issuing valuable comments in
their draft. No conflicts of interest were noted. The study’s funding sources include UK-
Society’ fellowship for the Addiction-study, Cancer-Research centre UK; Pfizer (includes
Pfizer investigator-initiated award) and GlaxoSmithKline & Johnson-and-Johnson.
Research questions
Brown (2014, p.1532) has stated an achievable research-question as ‘How
electronic-cigarettes are more effective as compared to NRT (nicotine-replacement
therapy) bought over-the-counter as well as un-aided smoke-quitting among the general
smoking-population, those who aim to quit’, as suggested by Grove (2015, p.150-151).
According to Greenhalgh (2017), justifications has to be given for selecting particular
research-question, which is evidenced here by mentioning that though smokers are
licensed to use NRT to quit-smoking, the effectiveness of e-cigarettes should be
evaluated to rule-out the most effective quitting method. Moreover, the increased
popularity of e-cigarettes, presence of evidence in 2-RCTs suggesting effect of
electronic-cigarettes in smoking-cessation but with several factors affecting real-world
effectiveness and use of NRT without professional-support with lack of greater-success
in it (Kotz, 2014, p.491–9) has motivated them to propose this study.
Research design
According to Liamputtong (2016), research-design is defined as the overall-plan
that addresses the study’s question. They have selected cross-sectional house-hold

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survey-design under non-experimental type to gather data from representative-samples
of smoking-population (sample-surveys) to evaluate the e-cigarette’s real-world
effectiveness by comparing the abstinence rates (self-reported) of smokers between the
e-cigarettes users (without behavior-supports and/or pharmacological cessation) and
NRT users to achieve their research-question.
Research-methods
Research-methods are the specialized techniques utilized to structure a
research-study and to gather and analyze information in a systematic-manner (Polit,
2017, p.764-766). They recruited 5863 adult-smokers (within past 12 months), who has
tried to quit at-least once in their study-period either in case of e-cigarette (n=464; 219
females), NRT-purchased OTC (n=1922; 982 females) or without aid in their last
cessation attempt (n=3477; 1699 females).
They recruited 1800 new-participants aged ≥16years each month through
random-location sampling (different-locations) and computer-aided face-to-face survey
with the help of trained interviewer. They used larger representative samples of the
adult-English population by giving equal chance to the entire population to get recruited
to avoid sampling bias (Polit, 2017, p.337-340). They obtained informed consent from
all the participating samples for anonymized data sharing. They got ethical-clearance
from the University-College’s ethics-committee, London. They haven’t mentioned about
the protection of study-samples but their text suggests that they haven’t imposed any
harm on them. It is noted that they have randomized the study-location and has
surveyed newer samples every month to avoid bias, which is highly-acceptable.

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Surveys usually get information from samples through self-reporting method in
which the subjects respond to a set of questions that are posed by interviewers
(Gerrish, 2015, p.255). They used computerized face-to-face interviews to gather self-
reported abstinence data which will not be subjected to any biases as noted in clinical-
trials (Wong, 2012, p.47–53). They have measured the confounders of varied quitting-
methods that could affect the outcome adequately.
Results
In quantitative-analysis, the numerical data is manipulated to evaluate the
magnitude and reliability of the relationships between them. They performed point-
estimation (confidence-interval) to draw inferences (Newcombe, 2012, p.26) and Bi-
variate analysis to analyze usage of varied quitting-methods and confounding-variables;
through χ2-tests for categorical and ANOVA for continuous-variables. ANCOVA is used
to evaluate the difference between the smokers and non-smokers in-regard to the
strength of smoking-urge, based on varied quitting-method and omnibus findings were
examined by post-hoc (Sidak-adjusted) χ2 & t-tests, which will aid to achieve their
research-question.
They have well-presented their data in tables about associations between
sample characteristics and varied quitting-techniques, difference between smoking and
non-smoking people in strength of smoking-urges by quitting-method and associations
between quitting-techniques and abstinence. The results suggest that use of e-
cigarettes is highly effective than NRT-products. The limitations that include increased
reliance upon recalling data-questions and absence of biochemical verification for
abstinence, questions the reliability of the study. But, use of bi-variate analysis and

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measures to control possible confounders confirms that the study-finding can be best
used in practice.
PART-B
At the end of detailed appraisal, this research-study is found to meet all the PICO
elements that are provided in the scenario’s clinical question. P (Population)- Adult
English population, I (Intervention)- Using electronic-cigarettes, C (Comparator)- NRT
purchased by OTC or without professional-support for smoke-cessation and O
(outcome)- Real-world effect in smoke-quitting (Hoffmann, 2017, p.22-23).
The author’s recommendations include: 1). Use of electronic-cigarettes are found
to aid in long-lasting smoke cessation than that of NRT products obtained by over-the-
counter or without professional guidance. 2). It is the first research-study to identify the
benefits of using electronic-cigarettes in smoke quitting, especially in its emerging
period. 3). Further studies should be conducted in a broader area of smoke-dependency
measures along with evaluation of smoke-dependence before quitting attempt to draw
high-quality inferences.
The study-findings yields a stronger-evidence based measure to be practiced in
the healthcare settings. It is definitely best evidence that is obtained by controlling
several confounders to avoid biased outcome. It enable clinical expertise in the health-
professionals with appropriate evidence to motivate Joanne to use electronic-cigarettes
to aid in continued smoking-cessation than that of NRT-products that are bought Over-
the-counter and/or un-aided without professional-support (Brown, 2014, pp.1538). This
quality-evidence will enable patient values within their preferences by easing their

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smoke-quitting in a shorter duration with lesser complications but with continued
cessation than NRT-products as given by Melnyk (2014, p.5). This quality-evidence can
help Jonnane to quit smoking by e-cigarettes rather than ineffective NRT-products and
enhance her values. No organization barriers but the individual barriers such as
acceptance and reliability in using e-cigarettes can prevent these recommendations
from being adopted.
Conclusion
The critical-appraisal suggests that this study has a clear background, focused-
objective, testable research-questions, elaborate literature-review, appropriate design,
large sample-size, control of confounders, random-location sampling and personal
survey with detailed statistical-methods and relevant findings indicating that the study
forms the best-evidence for practice. In-spite of certain drawbacks, this study forms
best-evidence suggesting the real-world effectiveness of using electronic-cigarettes to
quit smoking as compared with NRT-products got OTC and un-aided support.

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Reference
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of e-cigarettes when used to aid smoking cessation: A cross-sectional population
study. Addiction, 109(9), 1531- 1540. doi:10.1111/add.12623
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