Smoking e-cigarettes a possible strategy in quitting tobacco cigarettes, study suggests

A new study suggests that, for smokers who want to quit, e-cigarettes used in combination with smoking-cessation counseling may be more helpful than counseling alone.

Most smokers say they want to quit, but fewer than one in 10 succeed in quitting each year, according to the U.S. Centers for Disease Control and Prevention. The odds improve with conventional smoking-cessation therapy, which may include cognitive behavioral therapy, motivational interviewing and shared decision-making with a health care professional about smoking cessation drugs or nicotine-replacement therapies, experts say. 

Even then, at the end of the six-month study, only 38.5% of participants in a control group who used only those combined strategies were abstaining from tobacco cigarettes, said Dr. Reto Auer, lead author of the study, which was published Wednesday in the New England Journal of Medicine. For an intervention group that used the combined strategies along with an electronic nicotine-delivery system — commonly known as a vape or e-cigarette — the percentage of abstainers jumped to 59.6.

“This is wonderful news for smokers,” said Auer, a primary care physician and clinical researcher who teaches at the Institute of Primary Health Care at the University of Bern, Switzerland. “We found a significant increase in the proportion of people who quit smoking.”

That news comes with a big caveat, though. Former smokers “might not die” from that habit anymore, Auer said, but they may “continue to be in addictive behavior” if they replace tobacco cigarettes with e-cigarettes. The CDC says that e-cigarettes are safer than cigarettes, but not necessarily safe. The aerosol they use includes not just nicotine but heavy metals like lead, volatile organic compounds and cancer-causing agents.

The study was the largest yet comparing the effectiveness of e-cigarettes used in combination with smoking-cessation therapy with smoking-cessation therapy alone, Auer said.

It included 1,246 adult participants who were smoking at least five cigarettes a day but wanted to set a quit date. At regular intervals over six months, the control group got standard-of-care smoking-cessation counseling. The intervention group got the counseling plus two “e-cigarette starter kits” with a choice of free e-liquid flavors and nicotine concentrations. They were allowed to use the devices at will and replenish them.

While the difference between the number of control and intervention participants who quit smoking was significant, so was the difference in the number of those participants who were using e-cigarettes at the six-month mark.

Nearly half of the participants in the intervention group were using e-cigarettes exclusively, versus just 3% of those in the control group. There was also a stark difference among those who abstained from both tobacco and e-cigarettes. Just 11.2% of those in the intervention group achieved that feat, versus 35.5 % of those in the control group.

In New York, where a 2021 state Department of Health survey found that more than a fifth of high school students reported using e-cigarettes during the past month, experts reacted cautiously.

“You could argue that switching from cigarettes to vapes is good, because that’s harm reduction, but then you could make the argument that vaping in general is harmful,” said Northwell Health’s Dr. Richard Stumacher, associate chief medical officer for Northern Westchester Hospital and former head of pulmonary critical care there. “Lungs were designed to inhale only one thing, and that’s air. They’re designed to tolerate insults like smoke or other chemicals for a short period of time, not on an ongoing basis.”

Stumacher said e-cigarettes could be a tool for quitting. The rapid onset of nicotine they deliver mimics the experience of smoking more closely than most other nicotine replacement therapies now in use, making the devices potentially useful but carrying addictive risk.

As a tool, it needs to be used “with guidance, with someone who knows what they’re doing, with a product that’s vetted,” with an aim of reducing nicotine intake, he said. But the vaping industry is largely unregulated, and scientists need more time — “something on the order of 20-plus years” — to fully understand the potential damage that e-cigarette use may cause to the human body, Stumacher said.

Dr. Rachel Boykan, a pediatrician and professor of clinical pediatrics at the Renaissance School of Medicine at Stony Brook University, called the study results “promising” but said there were “inherent concerns with using these very high nicotine content devices to stop tobacco smoking.”

Long-term data already in the scientific literature suggest that “people don’t quit nicotine using these products,” she said. And, for young people, their use should be out of the question, she said. “We know nicotine interferes with brain function. It impacts cognitive development at a crucial time, it contributes to anxiety, depression, ADHD,” she said.

Tony Abboud, executive director of Vapor Technology Association, an industry group, said in a statement that the study joined a “growing body of research that proves how helpful and successful e-cigarettes can be to adults who would like to quit smoking.”

Some earlier research supports a measured approach, though. A 2021 American Journal of Public Health meta-analysis of 64 scientific papers about the association between e-cigarette use and smoking cessation concluded that the devices should not be approved as consumer products but might “warrant consideration as a prescription therapy.”