Despite what you might have heard about smoking making a comeback, so far the numbers suggest that fewer people are lighting up than in the past: About 11.6 percent of people in the United States smoked in 2022, down from 22.5 percent in 2002. Still, smoking remains a leading cause of preventable death worldwide, and it is notoriously one of the most difficult habits to break. A group of international experts recently argued that electronic cigarettes, or vapes, may be an underused tool for quitting conventional tobacco cigarettes.
In a special communication published in JAMA in July, a committee of researchers and clinicians from the United States, Britain and Australia wrote that doctors should mention e-cigarettes as an option when talking to patients who want to quit smoking.
Although e-cigarettes were launched about 20 years ago, supposedly in part to help people quit smoking, the data has been scarce as to whether they’re effective — or even safe. “E-cigarettes are one of the most controversial topics in medicine and public health,” said Nancy Rigotti, a professor of medicine at Harvard Medical School and Massachusetts General Hospital and co-author of the article.
It hasn’t helped that a potentially life-threatening condition linked to vapes surfaced in 2019. Called EVALI (which stands for e-cigarette or vaping product use-associated lung injury), more than 2,800 people developed the condition and more than 60 died in the outbreak, which was linked to black-market vaping products that contained vitamin E acetate, an additive used as a thickener in illicit THC vapes. Vaping can also increase the risk of lung infection, pneumonia and bronchitis, according to the American Lung Association.
Yet recent evidence finds that vaping may be just as or more effective than traditional therapies to quit smoking, such as nicotine patches and gum, Rigotti and her colleagues from the Treatment Research Network of the International Society for Research on Nicotine and Tobacco work group wrote.
The authors also say that e-cigarettes may be a less harmful alternative to cigarettes — while acknowledging that vaping still carries risks worth considering.
Why e-cigarettes might help people quit smoking
Getting people off tobacco cigarettes is a major public health priority, “but quitting smoking is really, really hard,” said Tracy Smith, a professor in the Addiction Sciences Division of the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina and one of the JAMA article’s co-authors.
Nicotine is the reason so many people struggle to quit. The highly addictive chemical compound is in all tobacco products, including conventional tobacco cigarettes, chewing tobacco and e-cigarettes.
Nicotine isn’t harmless — there are concerns about its effects on the brain development of young people, for example, and its effects on the heart (including increasing heart rate and blood pressure) may be risky for people with cardiovascular disease. But when it comes to smoking-related deaths, “nicotine itself doesn’t kill,” Rigotti said. “It’s the burning of tobacco in cigarettes that creates the carcinogens and other chemicals that are the primary killers.”
E-cigarettes still contain nicotine, so they are no less addictive. But because nothing is burned, “they’re substantially less harmful than smoking,” said Jamie Hartmann-Boyce, an associate professor of health policy and management at the University of Massachusetts Amherst and author of an accompanying editorial to the recent JAMA article.
A systematic review published in August found with high certainty that nicotine e-cigarettes result in better smoking quit rates than nicotine replacement therapy, like nicotine gum. Another recent overview of systematic reviews observed that e-cigarettes had higher smoking cessation rates than other interventions after six months.
E-cigarettes may have an edge over nicotine replacement therapy for a few reasons. “When you smoke a cigarette, nicotine is delivered very rapidly to the brain,” Smith explained. Nicotine intake from e-cigarettes is similarly rapid, while gum, patches or lozenges take longer, Rigotti said.
Behavioral cues and routine also reinforce addiction. “For a lot of people, nicotine e-cigarettes are better able to mimic those [cues] than, for example, wearing a patch,” said Hartmann-Boyce.
The health concerns about using e-cigarettes to quit smoking
More studies on vaping are needed, experts said. “Right now we don’t have a lot of data on long-term effects of e-cigarettes,” said Noreen T. Nazir, a cardiologist and chair of the American College of Cardiology Smoking Cessation and Prevention Work Group who is unaffiliated with the JAMA study. Because of this, Nazir said it’s likely these JAMA recommendations will not be widely accepted into clinical practice yet.
E-cigarette aerosol generally contains fewer harmful chemicals than cigarette smoke, but it’s not risk-free. The vapor may contain potentially dangerous chemicals, heavy metals and volatile organic compounds. Devices that haven’t gone through the FDA’s tobacco product review process are especially concerning.
“The downside is the U.S. product is so uncontrolled,” Benowitz said. “We have a bunch of products that have not been safely regulated.”
For people who do make the switch to e-cigarettes, experts stress the importance of using one of the vaping devices the FDA has authorized for sale in the U.S., which ensures it has gone through the agency’s review process. Choosing one of these devices is “hugely important in terms of the safety profile,” Hartmann-Boyce said.
A particular concern is the popularity of e-cigarettes among children, teens and young adults, said Benjamin Toll, a professor of public health sciences and psychiatry and director of the Tobacco Treatment Program at Medical University of South Carolina. Toll was not involved in the JAMA article.
These recommendations don’t suggest e-cigarettes are healthy and “are really strictly for adult cigarette smokers,” Toll said. “They are not for kids, and they are not for non-smokers.” While he said he is supportive of vaping to help adults quit smoking, he noted that there also needs to be a focus on ensuring that children and teens don’t use these products.
What the committee is recommending
Clinicians often feel conflicted when patients ask about vapes, studies reveal. Most are likely to only recommend people try e-cigarettes (if ever) after smoking cessation medications or therapies cleared by the Food and Drug Administration haven’t been successful, but it might be worth offering e-cigarettes along with these interventions as an initial approach, Rigotti said. “We discussed it a lot, and we ended up saying that people shouldn’t have to fail other treatments to use e-cigarettes.”
Given the high public health burden and known deadly risks of smoking, “what we’re saying here is that we need to add e-cigarettes to this discussion that they already have with their patients” about quitting, Rigotti said.
The work group writes that clinicians should advise patients to fully substitute e-cigarettes for combustible cigarettes rather than using both. “You have to completely switch to truly cut down on your exposure to known carcinogens and toxicants,” Toll said.
The FDA hasn’t approved e-cigarettes as a smoking cessation product, and most large professional organizations haven’t weighed in on their use for this purpose. “There’s still a lot of controversy around the world about the role of e-cigarettes, and I think that’s unfortunate,” said Neal Benowitz, a professor of medicine emeritus at the University of California San Francisco who was not part of the JAMA study.
“The bottom line is that smoking is so much worse than any other form of nicotine, and whatever we can do to get people off cigarettes will really benefit their health,” Benowitz said.
While switching to e-cigarettes might be a helpful first step, the long-term goal should be to stop nicotine use entirely. “At the start, it’s absolutely appropriate to make e-cigarettes a part of the stop-smoking journey,” Toll said, “but it’s not the end of that journey, in my opinion.”
As Hartmann-Boyce writes in her editorial: “E-cigarettes are not a magic bullet for smoking cessation, but unfortunately no such thing exists.”
The challenge is that quitting vaping can be just as hard as quitting smoking. Research on this “is still very much in its early days,” Smith said, but many of the same tools approved for conventional smokers may also help people stop vaping, such as a combination of medication and counseling. Recent studies have shown promise on this front, Hartmann-Boyce said, such as a text message support program and the oral medication varenicline combined with behavioral counseling.
“I think a lot of people who smoke are worried about swapping one addiction for another,” Hartmann-Boyce said, “and that is a completely legitimate concern.”
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