A new article published in JAMA finds the health risks of smoking cigarettes far outweigh the potential risks from switching to e-cigarette use.

Clinicians should include nicotine-containing e-cigarettes alongside other evidence-based options for quitting cigarette smoking in conversations with adult patients, according to a new Special Communication published today in JAMA that is co-authored by a University of Maryland School of Medicine (UMSOM) faculty member. The Society for Research on Nicotine and Tobacco (SRNT) convened the group of 24 tobacco treatment and addiction experts to review the latest literature and make recommendations directed at healthcare practitioners.

The paper concludes that the mounting scientific evidence for the effectiveness of e-cigarettes for smoking cessation warrants discussing e-cigarettes as an option alongside FDA-approved medications and nicotine replacement therapies for reducing the harms caused by smoking traditional cigarettes, which include increased risk of lung and other cancers, cardiovascular disease, stroke, and chronic obstructive pulmonary disease (COPD).

“This advice is directed at adults who are trying to quit smoking tobacco, and not at those who have never used nicotine or who are not currently using it,” said study co-author Bethea “Annie” Kleykamp, PhD, Assistant Professor of Psychiatry at UMSOM.

Although smoking rates are lower than ever for the general population, smoking prevalence remains elevated for middle-aged individuals and has increased in recent years among older populations. One in five U.S. adults currently reports using tobacco, and most adults who use tobacco products use combustible (smoked) tobacco. Smoked cigarettes remain the leading cause of preventable disease and death in the U.S., leading to more than 480,000 deaths annually, according to the Centers for Disease Control and Prevention.

“People continue to live with and die from smoking-related diseases, and many smokers, particularly older adults, have tried repeatedly to quit without success,” Dr. Kleykamp said. “This paper is not about encouraging nicotine use among people who don’t smoke. It is about ensuring that clinicians have accurate, evidence-based information to discuss all available options with adult patients who currently smoke cigarettes, which include nicotine e-cigarettes.”

Dr. Kleykamp said the workgroup was motivated in part by requests from clinicians seeking practical guidance on how to respond when patients ask about vaping as a way to quit smoking. The recommendations in the paper advise clinicians to prioritize patient goals and preferences while discussing all evidence-based cessation options, including FDA-approved medications such as varenicline, bupropion, and nicotine replacement therapies such as nicotine gums, lozenges and transdermal patches. They also recommend correcting common misconceptions about nicotine and e-cigarettes, including informing patients that the by-products of smoking tobacco — not nicotine — cause most smoking-related diseases. The recommendations also  encourage complete substitution of cigarettes with e-cigarettes rather than long-term dual use, as well as connecting patients with behavioral counseling.

The paper stresses that e-cigarettes, similar to other nicotine products, are not risk-free and are not currently approved by the U.S. Food and Drug Administration as smoking cessation medications. However, certain e-cigarette products have received FDA authorization through the agency’s Center for Tobacco Products after review of evidence indicating that they may benefit public health when compared to continued cigarette smoking. The authors do not recommend people use e-cigarette products the FDA has not authorized.

In writing the paper, the working group studied Cochrane systematic reviews of multiple randomized clinical trials for smoking cessation, while also considering evidence of the harms of combustible cigarettes and the risks of other nicotine products. One Cochrane Review of over 100 studies and 30,000 adults who smoke found that e-cigarettes were associated with a greater likelihood of quitting smoking than nicotine replacement therapy. A separate Cochrane Review found smoking cessation rates with e-cigarettes comparable to those of the medications varenicline and cytisine. In some cases, they also found that harms commonly believed to be associated with nicotine e-cigarettes were not supported by evidence. For instance, in 2019, an outbreak of pulmonary disease designated E-cigarette or Vaping-Associated Lung Injury (EVALI) was later determined to originate with illicit cannabis vaping products rather than e-cigarette products.

The recommendations in the paper may be controversial, Dr. Kleykamp acknowledged. While public health authorities and associations in some other nations, notably the UK,  have been more open to broadening the discussion around smoking cessation to include e-cigarettes, many U.S. experts have remained more skeptical. The American Heart Association and the American Lung Association recommend smokers avoid e-cigarettes and instead stick with approved medications such as varenicline or nicotine gum, citing the fact that e-cigarette vapor still contains toxic and addictive compounds.

Dr. Kleykamp emphasized that the working group approached this study from a harm reduction perspective. For  cigarette smokers who have been unable to quit through using nicotine replacement therapies or other medications, the more cigarette-like nature of e-cigarettes helps to provide the cues of smoking as well as nicotine replacement that can successfully compete with the urge to smoke combustible tobacco. Although e-cigarettes may still contain toxicants, levels are substantially lower than in combustible cigarettes.

“Any honest discussion about this topic has to start with the reality that cigarette smoking remains by far the most dangerous and lethal way people use nicotine,” Dr. Kleykamp said. “Tens of millions of U.S. adults still smoke cigarettes, and many have not been able to quit with the approved medications currently available to them. E-cigarettes are not risk-free, but for an adult who smokes, the relevant comparison is not between e-cigarette use and using nothing—it is between e-cigarette use and continuing to smoke. The goal is to help people move away from smoked tobacco as quickly and completely as possible, and evidence indicates that e-cigarettes can help some adults make that transition.”