Q&A:

3.1 Do e-cigarettes help people quit smoking?

Yes. There are now four strands of evidence that suggest e-cigarettes are effective in helping people to quit smoking:

1. Evidence from randomised controlled trials, notably, Hajek et al 2019, which showed vaping to be about twice as effective as NRT; “E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support.“
2. Observational studies (watching what happens when people use e-cigarettes) for example, Jackson et al 2019; “Use of e‐cigarettes and varenicline are associated with higher abstinence rates following a quit attempt in England.“
3. Population data (unusually rapid reductions in smoking prevalence or cigarette sales visible in market data), for example, Zhu S-H et al, 2018. “The substantial increase in e-cigarette use among US adult smokers was associated with a statistically significant increase in the smoking cessation rate at the population level. These findings need to be weighed carefully in regulatory policy making regarding e-cigarettes and in planning tobacco control interventions.“
4. The thousands of testimonials of users who have struggled to quit smoking using other methods. See, for example, CASAA (12,500 testimonials) and, before dismissing ‘anecdotes’ see Carl V Phillips on why Anecdotes ARE scientific data

None of these is decisive in its own right, but all four strands point towards e-cigarettes displacing smoking.

There are also several pathways by which vaping can displace smoking, not simply as a quit aid. The following mechanisms are possible:

1. As an aid for someone who already wants to quit smoking – a kind of souped-up NRT.
2. By encouraging people who would not otherwise try to quit to give it a try, because it continues pleasurable aspects of a habit they like. In this way, it increases the number of quit attempts.
3. It may form part of a (reluctant) response to a tobacco control measure – for example, the economic pressure created by cigarette taxation
4. It may never be a conscious effort to quit smoking, but become a change of behaviour by default.
5. It may prevent relapse to smoking among people who have already quit smoking, but miss it or are vulnerable to relapse to smoking (e.g. due to stressful life events).
6. It may displace smoking uptake in young people or be a diversion from smoking experimentation that would otherwise consolidate into a more entrenched smoking habit

We need to avoid simplistic analogies with smoking cessation treatments and see the emergence of reduced-risk products as a pervasive technology diffusion and disruption in a market dominated until now by a very dangerous product.

Further reading and viewing

• Clive Bates, Colin Mendelsohn. Do vapour products reduce or increase smoking? 19 October 2017 [link]
• Villanti AC et al. How do we determine the impact of e-cigarettes on cigarette smoking cessation or reduction? Review and recommendations for answering the research question with scientific rigor. Addiction. 2017 [link]
• Carl V Phillips, Science lesson: how vaping leads to smoking cessation, 2017  [link]
• For more on this, see Robert West’s presentation:

Should health professionals recommend smokers to switch to e-cigarettes? from Robert West on Vimeo.

3.2 Isn’t most vaping ‘dual-use’ of e-cigs and cigarettes?

Many vapers do use both e-cigarettes and cigarettes.  But this is not the bad thing that it is often made out to be. The proportion of dual users has been falling in the UK and the United States, and in the UK is now well below half.  This is probably due to several factors: many dual users are in transition from smoking to vaping over a period of months or years.  Also, as the technologies improve over time, it is likely that more of the users will find exclusive vaping a satisfactory alternative to smoking. Dual-use should be properly understood as part of a behavioural pathway that evolves over time, not something this is static and fixed. Vaping may start with no intention to quit smoking, but as the user becomes more familiar and finds the product they like they gradually make more use of the product in more situations.

We should remember that just about every attempt to quit smoking using established methods involves continuing to smoke, usually by serial quitting and relapse.  Unless cold-turkey, smoking cessation therapies or behavioural counselling are 100% and immediately effective, people who are trying to quit will continue to smoke over the course of quitting.

It’s also worth remembering the effect that anti-vaping messages have on smokers and dual-users.  If they are being told there is no benefit and that it is harmful or anti-social, why should they feel motivated to make a complete switch?  Many of the same activists who are raising dual-use as a problem (it isn’t) are also doing what they can to slow down or reverse the migration from dual-use to exclusive vaping (which is a major problem).

Further reading

• Clive Bates. Claim 10: Dual-use undermines the value of vaping, August 2019 [link] in Vaping risk compared to smoking: challenging a false and dangerous claim by Professor Stanton Glantz [link]
• Simonivicius et al. What factors are associated with current smokers using or stopping e-cigarette use? Drug and alcohol dependence, 2019 [link]
• Persoskie A et al. Perceived relative harm of using e‐cigarettes predicts future product switching among US adult cigarette and e‐cigarette dual users, Addiction, 2019 [link]

3.3 What is the difference between NRTs, smoking cessation pharmaceuticals and vape products?

From a public health perspective, we should support the use of whatever options we can to reduce smoking, which is the primary driver of disease.  The impact of any approach to quitting smoking is a product of two things – (1) how effective it is and (2) how willing people are to use it. At least in the UK and the US, e-cigs are now the most used product by smokers trying to quit smoking, more than any of the officially-approved smoking cessation medications.

The great strength of the vaping approach is that it is effective at replacing cigarettes because it replicates many aspects of smoking but without the harm (for example, nicotine effects, sensory experience, hand-to-mouth movement, and a behavioural ritual).  But it also does this in a way that appeals to smokers – it is fun and interesting and there is a sub-culture to go with it.  The secret of vaping is the combination of effectiveness and appeal.  There may be occasions when it makes sense for a vaper to use NRT – for example, while learning to vape, on long flights, perhaps even overnight.  The consumer market is developing diverse nicotine products – for example, oral nicotine pouches – which may also help.

Further reading

• Notley et al. The unique contribution of e-cigarettes for tobacco harm reduction in supporting smoking relapse prevention, 2018. [link] found that: E-cigarettes meet the needs of some ex-smokers by substituting physical, psychological, social, cultural and identity-related aspects of tobacco addiction
• Louise Ross, Pragmatism versus dogma: freeing the inner vaper in smokers – Michael Russell Oration 2020, Global Forum on Nicotine (online) [link]

Louise Ross: A new way of stopping smoking though! We had something in the palms of our hands, and I knew this was the future. The difference was so marked. It wasn’t a medication. It didn’t have a prescribing protocol. Clinicians didn’t know what to say about it. It didn’t give hiccups, gastric irritation, skin rash, nausea, crazy dreams. People liked using it. They described it as a revelation. They told their smoking friends and went full-on evangelical about it.

3.4 Should the healthcare system cover e-cigarettes as smoking cessation aids?

Generally, no. These are consumer choices and alternatives to smoking and not medications.  People who can afford to smoke can afford to vape. The healthcare system should, however, offer encouragement, advice and expertise to potential switchers and possibly partner with vape shops or chains for delivery.  One of the strengths of the ‘tobacco harm reduction’ approach is that the health gains are made on the initiative of the users and at the users’ own expense.

3.5 What about people who are disadvantaged and cannot afford to vape? Should they get support?

There may be a case for support. If people can afford to smoke, they can generally afford to vape – and the tax system should aim to keep it that way.  So healthcare providers should not be funding vaping long term. However, for the economically disadvantaged (very poor, homeless, etc) there are issues at the point of transition:

1. There are upfront costs for a device – the user may save money in the medium term, but if they don’t have the upfront cash the savings can’t be made
2. The user may worry about ending up paying for both cigarettes and vaping equipment if the latter doesn’t work for them – and this is a barrier to experimentation
3. Some sort of inducement to try might be necessary and be highly cost-effective for the provider

3.6 Should the healthcare system help vapers to go nicotine-free and quit vaping?

It might be a surprise, but I would say no. In the nicotine field, public resources should be focussed exclusively on reducing smoking.  This is because the risks of vaping are very low and therefore the benefits of quitting vaping are also very low.  So it follows that it is unlikely ever to be cost-effective to spend public resources on providing services for quitting vaping, especially if the alternative is to spend more on quitting smoking.  Also, some caution is needed: continued vaping may protect against relapse to smoking.  Many users find they enjoy vaping and that it adds to their wellbeing without a substantial increase in risk – much as many can enjoy alcohol, even though it is extremely damaging for some.  If people want to quit nicotine altogether that is fine and they should go ahead, but there is no reason for a healthcare system to cover it.  In my view, when someone has quit smoking, public health has done its job.