New evidence-informed guidance on e-cigarette use for smoking cessation

Cigarette smoking—which is maintained predominantly by nicotine dependence—continues to be a leading cause of preventable death and disease worldwide. More than half of U.S. adults attempt to quit in any given year, but less than 10% are successful. Completely substituting nicotine e-cigarettes (vapes) for cigarettes is associated with marked reductions in toxicant exposure and downstream harm. To support the delivery of accurate, evidence-based information and guidance for clinicians on the use of e-cigarettes for smoking cessation, an international multidisciplinary group of experts in tobacco treatment has summarized research related to using e-cigarettes for smoking cessation and released recommendations for clinicians to help them enter into conversations with patients about e-cigarette use for smoking cessation. The document addresses several specific questions, with key points highlighted below.Can e-cigarettes facilitate smoking cessation?A Cochrane systematic (living, updated monthly) review reports high-certainty evidence that the use of nicotine e-cigarettes is associated with higher quit rates than nicotine replacement therapy (NRT; e.g., nicotine patch with or without gum, lozenge or nasal spray). Another Cochrane review found that e-cigarettes result in cessation rates comparable to those of highly effective pharmacotherapies, such as varenicline and cytisine.Are e-cigarettes less harmful than combustible cigarettes?Substantial evidence shows reduced physiologic harm with use of e-cigarettes compared to continued smoking because e-cigarettes expose users to fewer carcinogens and other toxicants generated by combustion. Although toxicants may still be present in e-cigarettes, levels are substantially lower than for cigarette smoking, up to 90% lower in some cases. Nicotine e-cigarettes do not appear to be associated with serious short-term negative health effects, but little data exists on the effects of long-term use (> 2 years).Despite robust evidence for reduced harm, many clinicians and the public mistakenly believe that e-cigarettes are as harmful as or more harmful than cigarettes.Workgroup recommendations for clinicians: how to discuss e-cigarettes as a potential cessation strategy for adults who smoke cigarettesInclude e-cigarettes on the list of options to support smoking cessation, alongside approved medications (e.g., NRT, varenicline, bupropion). Patients should not be required to first try or fail an approved medication before using e-cigarettes for cessation. Present the risks and benefits of each cessation option, including approved pharmacotherapies and e-cigarettes (topics to be covered in discussions with patients are presented in the article).Assess and correct the patient’s misperceptions regarding the harm and safety of cigarettes vs e-cigarettes. Discuss and correct existing patient knowledge of all cessation options (evidence-based pharmacotherapy and e-cigarettes).Ask patients key questions to guide the decision-making process (questions to consider are outlined in the article, for example, questions related to the patient’s goals, how the patient feels about using an alternative nicotine product to quit smoking, which part of quitting is the most challenging, availability of support from family and friends to quit smoking, what smoking cessation methods have they tried before, what are their major concerns with the options discussed or the option chosen). After a risk-benefit conversation, if the patient prefers to try an e-cigarette to quit smoking, they should be supported in doing so.Guidance for patients interested in using e-cigarettes for smoking cessationUse products that have been authorized for sale (although explain that e-cigarettes have not been approved for use as smoking cessation agents).It is unknown which device brand, flavour or nicotine dose is best and may vary with the individual; the patient may need to try a few different products to find one that is an adequate substitute. The chosen e-cigarette should deliver enough nicotine to be satisfying and reduce cravings for cigarettes. Because nicotine is often misperceived as the primary source of smoking-related harm, patients may be tempted to choose lower nicotine concentrations than needed. This reduces cessation success and may lead users to self-titrate their nicotine intake by using the e-cigarette more and inhaling more deeply at lower nicotine levels, thereby increasing exposure to non-nicotine e-cigarette constituents (e.g., propylene glycol, vegetable glycerin, flavourants and their thermal degradation products).Completely substitute e-cigarettes for combustible cigarettes. Counsel patients to fully switch as quickly as possible. Transitioning away from cigarettes as quickly as possible should be encouraged to reduce the dangers associated with continued cigarette smoking at any level.Seek support for patients through behavioural counselling, similar to what is recommended when using pharmaceutical treatment to help with quitting smoking.Arrange for follow-up visits with a clinician. Follow-up should include an assessment of smoking status, adverse effects and adherence with e-cigarette use instructions. If consistent use of e-cigarettes plus behavioural counselling does not result in a reduction in cigarette smoking, discuss possible changes to e-cigarette use, including increasing the nicotine level, frequency of use, or both.Once cigarette abstinence is achieved, if the patient is still using e-cigarettes, consider the longer-term goals regarding continued e-cigarette use vs complete nicotine abstinence. The most important goal is maintaining complete abstinence from cigarettes. If the only way for the patient to attain this goal is through long-term e-cigarette use, this decision should be supported. Literature is emerging on interventions to support e-cigarette cessation.The authors stress that the significant burden of cigarette smoking, combined with data on the efficacy of e-cigarettes for smoking cessation, clearly indicates that it is time to include e-cigarettes in patient-centred conversations regarding cigarette smoking cessation.Reference:Leavens ELS, Pebley K, Smith TT, et al; Society for Research on Nicotine and Tobacco, Treatment Research Network, Harm Reduction Workgroup. Nicotine e-cigarettes for cigarette smoking cessation. Recommendations to US-based clinicians. JAMA 2026; published online July 30, 2026. (accessed July 30, 2026).

New evidence-informed guidance on e-cigarette use for smoking cessation

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