US doctors are being urged to discuss vapes with adult smokers who want to quit, as tobacco researchers say the evidence supporting their use has strengthened considerably in recent years.
New recommendations published in JAMA say nicotine vapes should be included in conversations about evidence-based ways to stop smoking, alongside established treatments such as nicotine patches and gum, varenicline and bupropion.
The guidance comes from researchers in the Treatment Research Network of the Society for Research on Nicotine & Tobacco, an international professional organisation focused on nicotine and tobacco science.
It marks a significant change in the US clinical debate around vaping, which has remained more cautious than in countries including the UK despite growing evidence that vapes can help smokers quit.
Nancy Rigotti, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital and an author of the recommendations, said: “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.”
Evidence has moved on since 2021
The recommendations come five years after the US Preventive Services Task Force concluded there was insufficient evidence to recommend vapes for smoking cessation.
Rigotti said that assessment came before much of the evidence now available.
Recent research includes systematic review evidence showing nicotine vapes can help more smokers achieve complete cessation than nicotine replacement therapy such as patches and gum.
The latest Cochrane review, covering 104 studies and 30,366 adults, found high-certainty evidence that nicotine vapes increase quit rates compared with nicotine replacement therapy, equivalent to around four additional people quitting for every 100.
The evidence also suggests smokers who switch completely from cigarettes to vaping can substantially reduce their exposure to many of the toxic chemicals created when tobacco burns.
Studies have reported large reductions in exposure to tobacco-specific nitrosamines, volatile organic compounds and carbon monoxide-related toxicants among people who stop smoking and switch entirely to vaping.
The researchers acknowledge that important uncertainties remain, particularly around the effects of vaping over decades. Long-term studies extending much beyond two years are still limited.
Doctors urged to correct misconceptions
The recommendations say clinicians should also tackle misconceptions about the relative harms of smoking and vaping when speaking to adult smokers.
Robin Mermelstein, director of the Institute for Health Research and Policy at the University of Illinois Chicago, who was not involved in drawing up the recommendations, said: “Clinicians should be very clear about one important point: e-cigarettes are nowhere near as harmful as combustible cigarettes.”
“The harms of combustible cigarettes are tremendous.”
She also said confusion about nicotine itself was contributing to inaccurate beliefs about vaping.
“Clinicians need to be confident in telling patients that nicotine does not cause cancer and does not cause lung disease,” she said.
The recommendations apply specifically to adults who already smoke. They are not intended to encourage vaping among young people or people who do not currently use tobacco.
Rigotti said discussing vaping with adult smokers “does not mean that a clinician is not also concerned about youth vaping”.
Mermelstein added: “Counseling patients, in the framework of shared decision-making, is likely to have no real effects on increasing youth use of e-cigarettes.”
Smokers should be given a choice
Rather than treating vaping as an option only after conventional treatments have failed, the researchers want clinicians to include it when discussing the available routes away from cigarettes.
The emphasis is on shared decision-making, allowing smokers to weigh the evidence, risks and uncertainties of different approaches.
Where someone has no preference, approved smoking cessation medicines can still be prioritised. But smokers interested in vaping should be given accurate information about it rather than automatically being steered towards another treatment. The central aim remains complete cigarette cessation.
Some smokers may continue vaping for longer if doing so helps them remain smoke-free. Ending nicotine use can be considered later, once the immediate risk of returning to cigarettes has reduced.
FDA authorisation does not mean quit-smoking approval
The recommendations do not change the regulatory status of vapes in the US.
No vape has been approved by the Food and Drug Administration as a smoking cessation medicine.
Some products have received FDA marketing authorisation through the agency’s tobacco regulation process, which allows them to be sold legally after an assessment of their impact on public health.
That is separate from approval as a medicine specifically proven to treat tobacco dependence.
The researchers advise clinicians to direct smokers towards FDA-authorised products where possible.
Lead author Elly Leavens, assistant professor at the University of Kansas Medical Center, said: “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.”
A shift towards harm reduction
The recommendations bring the US clinical debate closer to the growing evidence base around tobacco harm reduction while stopping short of presenting vaping as risk-free.
An accompanying JAMA editorial by Jamie Hartmann-Boyce, assistant professor of health policy and management at the University of Massachusetts Amherst, said doctors should give patients clear information about what is known, what remains uncertain and the available alternatives.
“e-cigarettes are not a magic bullet for smoking cessation,” she wrote, “but unfortunately no such thing exists.”
The recommendation authors reported a range of research grants, consulting work, reviewer fees and honoraria from organisations including Qnovia, Eli Lilly, Achieve Life Sciences, Health Canada and the US National Heart, Lung, and Blood Institute.