Counseling Patients About e-Cigarettes for Smoking Cessation

Although e-cigarettes are generally considered to be less harmful than combustible cigarettes, whether vaping should be explicitly incorporated into tobacco smoking cessation strategies is controversial. In 2021, the US Preventive Services Task Force (USPSTF) found insufficient evidence to determine the balance of benefits and harms of e-cigarettes for smoking cessation in adults. At that time, the USPSTF cited a lack of well-designed, randomized controlled trials (RCTs) that reported smoking abstinence and adverse events. Other concerns included potential effects of e-cigarette promotion on already high rates of e-cigarette initiation in children and adolescents.

Subsequent studies have supported the utility of e-cigarettes for smoking cessation. A Swiss RCT that compared e-cigarettes to usual care cessation strategies (counseling and medications) found that the e-cigarette group was more likely to be abstinent from tobacco at 6 months (number needed to treat [NNT] = 6-8); adverse events were similar between groups. A Cochrane review of 88 studies, including 47 RCTs, found high-certainty evidence that e-cigarettes increased smoking cessation at 6 months to 1 year compared to nicotine replacement therapy (NRT) and other smoking cessation treatments. e-Cigarettes were associated with a similar incidence of adverse events to NRT and more adverse events than counseling (number needed to harm [NNH] = 7). Serious adverse events were not increased in the e-cigarette groups. Another RCT in persons of low socioeconomic status found that vaping nicotine was more effective than NRT for achieving tobacco abstinence at 6 months (NNT = 5).

A working group of the international Society for Research on Nicotine and Tobacco recently published recommendations to US-based clinicians on integrating e-cigarettes into conversations with patients about the risks and benefits of pharmacologic treatments for smoking cessation. Notably, the group recommends that “patients should not be required to first try or fail an FDA-approved medication before using an e-cigarette for cessation because supporting cigarette cessation is the primary goal.” If a patient chooses e-cigarettes, they advise using products authorized for sale by the US Food and Drug Administration and counseling patients to completely substitute e-cigarettes for combustible cigarettes as quickly as possible.

Like combustible cigarettes, e-cigarettes appear to increase the risk of chronic respiratory conditions in adults. An FPIN Clinical Inquiry found several observational studies that associated e-cigarette use with asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlap syndrome. Nonetheless, the working group endorsed long-term e-cigarette use as a harm reduction strategy for maintaining complete abstinence from combustible cigarettes in patients who are unable to transition away from nicotine altogether.