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Am Fam Physician. 2023;107(5):online

Author disclosure: Dr. Madden serves as a paid consultant to Reynolds American on the topic of tobacco harm reduction.

To the Editor: The article by Dr. Gaddey and colleagues summarizes traditional smoking cessation strategies but misses the mark in discussing data on the benefits of electronic cigarettes (e-cigarettes) for tobacco (or smoking) harm reduction.1

The article mischaracterizes the findings of the Cochrane review on e-cigarettes for smoking cessation.2 In a recent update, the authors of the Cochrane review analyzed data from multiple studies and determined that there is high-certainty evidence that e-cigarettes containing nicotine increase quit rates compared with nicotine replacement therapy (NRT) and moderate-certainty evidence that they increase quit rates compared with e-cigarettes that do not contain nicotine.

A 2019 randomized controlled trial found that people who used e-cigarettes for smoking cessation were nearly twice as likely to have abstained from cigarettes for one year as those who used traditional NRT (18% vs. 9.9%).3 Although many of the people in the e-cigarette group who quit smoking were still vaping one year later, the evidence clearly shows that by switching from smoking to vaping, people in this group had significantly reduced risks to their health.

Since September 2021, the U.S. Food and Drug Administration (FDA) has authorized the marketing of more than 20 e-cigarette or vaping products as “appropriate for the protection of public health.” 4 The FDA's Center for Tobacco Products authorization is predicated on a review of thousands of studies and data that show these products are more likely to be helpful to adult smokers seeking to move away from smoking cigarettes than they are to attract youth and other non–tobacco users.

I encourage readers to consider tobacco harm reduction as an end for our patients who smoke and have not successfully quit with traditional cessation methods or want to continue using tobacco or nicotine products. A total of 15 former presidents of the Society for Research on Nicotine and Tobacco published a detailed review of the evidence on tobacco harm reduction.5 They are all strongly in support.

If you support harm reduction for motorcyclists (helmets) and automobile drivers (seatbelts), opioid use disorder (buprenorphine or needle exchanges), and those who engage in risky sexual practices (pre-exposure prophylaxis for HIV prevention), then you must also consider harm reduction for patients who smoke.

In Reply: I thank Dr. Madden for highlighting the ongoing discussion about e-cigarettes for tobacco cessation and their safety. In November 2022, the Cochrane review on e-cigarettes for smoking cessation was updated with the addition of 17 new studies. Primary outcomes included abstinence from smoking after six months, adverse events, and serious adverse events. Consistent with the previous review, nicotine e-cigarette use resulted in higher quit rates than NRT (relative risk = 1.63; 95% CI, 1.30 to 2.04) and an additional four successful quit attempts per 100. Nicotine e-cigarette use also increased quit rates compared with non-nicotine e-cigarette use (additional seven successful quit attempts per 100). Nicotine e-cigarettes may also be more helpful than no support or behavioral support only. The rates of adverse and serious adverse events were similar between groups.1

One study showed that 18% of e-cigarette users quit smoking compared with 9.9% of traditional NRT users. However, NRT had previously failed in 75% of the participants, potentially confounding the results.2 Additionally, quit rates with bupropion/NRT are comparable to e-cigarettes at six months (25% to 26%) and one year (20%) and to varenicline (Chantix) at 24 weeks (26%).3,4 Therefore, these medications demonstrate similar results to e-cigarettes for aiding tobacco cessation.

There is an ongoing debate about the benefits vs. harms of e-cigarette use as a tobacco harm–reducing strategy and the overall impact on public health. In 2021, the FDA authorized the marketing of e-cigarettes for “addicted adult smokers for the purpose of reduction or cessation in cigarette consumption and thus exposure to harmful chemicals.” The FDA acknowledged concern about adolescent use and cited that most adolescents use non–tobacco-flavored products and have an overall low risk of transition to combustible cigarettes.5 In 2022, 14.1% of high school students and 3.3% of middle school students reported e-cigarette use. Of those users, up to 30% of high school students and 11.7% of middle school students reported daily use.6 The long-term health consequences of e-cigarette use are unknown.

The contents of this article are solely the views of the authors and do not necessarily represent the official views of the U.S. Air Force, the U.S. military at large, the U.S. Department of Defense, or the U.S. government.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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