To Beat Cigarette Addiction, Experts Embrace Vapes

Clinicians can now recommend vapes, along with nicotine patches and gums, to their adult patients who want to quit smoking traditional cigarettes.The guidance, from a leading international group of tobacco researchers, represents a sharp pivot from an earlier stance that evolved as evidence mounted that vaping may be more effective in helping people quit cigarettes than traditional nicotine replacement therapies like varenicline or bupropion.The recommendations, published on July 30 in JAMA, mark one of the strongest endorsements to date from international experts for incorporating e-cigarettes into routine smoking cessation counseling.“The evidence base supporting the effectiveness of e-cigarettes to help smokers quit has continued to accumulate and now matured to the point where it should be discussed with adult smokers who are seen in clinical practice,” said Nancy Rigotti, MD, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital in Boston, an author of the recommendations.Developed by researchers from the Society for Research on Nicotine & Tobacco’s Treatment Research Network, an international professional organization focused on nicotine and tobacco science, the guidance advises clinicians to discuss e-cigarettes as one evidence-based treatment option alongside nicotine replacement therapy during shared decision-making conversations with patients who smoke.In 2021, the US Preventive Services Task Force concluded that evidence was insufficient to recommend e-cigarettes for smoking cessation. According to Rigotti, those recommendations predated much of the evidence now available.Clinicians are seeking practical guidance on how to discuss the controversial topic with patients, which prompted experts within the Society for Research on Nicotine & Tobacco to develop consensus recommendations, Rigotti said.“This is a very encouraging step to help reduce combustible cigarette smoking among those individuals who are still smoking,” said Robin J. Mermelstein, PhD, director of the Institute for Health Research and Policy at the University of Illinois Chicago, who was not involved in developing the recommendations.Following the EvidenceThe guidance relies heavily on recent evidence, including a systematic review showing up to roughly 7% more smokers achieved total cessation using nicotine e-cigarettes after 6 months than those who used other methods such as patches.The guidance also reflects evidence that smokers who switch completely to nicotine e-cigarettes may substantially reduce their exposure to many of the toxic chemicals produced by combustible tobacco.Previous studies have found exposure to tobacco-specific nitrosamines, volatile organic compounds, and carbon monoxide-related toxicants may be up to 90% lower among people who completely switch to vapes.However, no long-term studies beyond 2 years have definitively established the health effects of prolonged e-cigarette use, Rigotti cautioned.The recommendations are intended for one group only: adults who currently smoke cigarettes, not youth, Rigotti said.Some experts in tobacco control question whether promoting e-cigarettes as a harm-reduction tool for adults could undermine efforts to discourage nicotine use among adolescents, potentially sending mixed messages after years of public health campaigns warning about youth vaping and nicotine addiction.But discussing e-cigarettes with adult smokers “does not mean that a clinician is not also concerned about youth vaping,” Rigotti said.Mermelstein said youth vaping has been driven by marketing by industry.“Counseling patients, in the framework of shared decision-making, is likely to have no real effects on increasing youth use of e-cigarettes,” she said.Counseling PatientsThe guidance also advises clinicians to address widespread misconceptions that vaping is as harmful as or more dangerous than smoking.“Clinicians should be very clear about one important point: e-cigarettes are nowhere near as harmful as combustible cigarettes,” Mermelstein said. “The harms of combustible cigarettes are tremendous.” She said many misconceptions stem from a misconception that nicotine is associated with the development of cancer, not just the addictive part of a cigarette.“Clinicians need to be confident in telling patients that nicotine does not cause cancer and does not cause lung disease,” she said.Rigotti and colleagues advise clinicians to steer patients toward products that have received marketing authorization from the FDA’s Center for Tobacco Products rather than products sold without the agency’s review.“Authorization means that the FDA has judged that the benefit of the e-cigarette product is greater than its risk, at a population level,” she said.More than 40 nicotine e-cigarette products — including tobacco-flavored products sold under the Vuse Solo, NJOY Ace, and Logic brands — have received FDA marketing authorization, allowing them to be legally sold in the US.However, no vaping products have been approved by the FDA as a smoking cessation treatment, a separate regulatory pathway that requires manufacturers to demonstrate the product’s safety and effectiveness as a therapy for quitting smoking.“Until there is an FDA-approved e-cigarette for smoking cessation, use of FDA-authorized e-cigarettes allows as much confidence in product safety and effectiveness as the consumer tobacco regulatory structure allows,” said Elly L. Leavens, PhD, assistant professor in the Department of Population Health at the University of Kansas Medical Center in Kansas City, who led the new recommendations.While the goal for patients should be for patients to stop all use of combustible tobacco products, Mermelstein said some patients may choose to use e-cigarettes long term as a lower-risk alternative to smoking without any intention to quit completely. In that case, she compared vaping with other harm-reduction strategies such as wearing a seat belt, applying sunscreen, or choosing low-fat foods to reduce cardiovascular risk.“We all engage in many daily activities that have ‘risk’ or that may be ‘addictive,’” she said.In an editorial accompanying the guidance, Jamie Hartmann-Boyce, DPhil, assistant professor of health policy and management at the University of Massachusetts Amherst, wrote that although evidence supporting e-cigarettes has strengthened, clinicians should still consider unanswered questions about their long-term health effects and the tobacco industry’s role in the e-cigarette market.Rather than viewing the issue as a choice between traditional cessation therapies and vaping, clinicians should present patients with transparent information about the evidence while acknowledging uncertainty and respecting patients’ values, Hartmann-Boyce wrote.“e-cigarettes are not a magic bullet for smoking cessation,” she wrote, “but unfortunately no such thing exists.” Various recommendation authors reported receiving consulting and reviewer fees, honorarium, and grants from Qnovia; Eli Lilly; Achieve Life Sciences; the Health Research Council of New Zealand; Health Canada; and the National Heart, Lung, and Blood Institute, among others.Lara Salahi is a health journalist based in Boston.