Experts Say Doctors Should Discuss Vaping With Smokers Who Want to Quit

A large international group of nicotine researchers says U.S. doctors should discuss e-cigarettes with adult smokers seeking help to quit, even though the products are not approved as cessation medicines.

The recommendations published July 30 in JAMA challenge the uncomfortable position many American clinicians have adopted on vaping: refusing to discuss a tool that has repeatedly outperformed nicotine replacement therapy in clinical trials.

The paper does not tell doctors to recommend vaping to every patient. It proposes including e-cigarettes in shared decision-making alongside nicotine patches, gum, varenicline, bupropion, and other evidence-based options.

Smokers would not have to fail with approved medicines first

The position paper was developed by a 24-member harm reduction workgroup within the Treatment Research Network of the Society for Research on Nicotine and Tobacco (SRNT). It was reviewed by the network’s advisory committee and the SRNT board.

The lead authors were University of Kansas School of Medicine researcher Eleanor L. S. Leavens and Medical University of South Carolina researchers Kinsey Pebley and Tracy T. Smith. Alana M. Rojewski and Adrienne L. Johnson were co-senior authors.

Their central recommendation is straightforward. Adult smokers should not be forced to try and fail with an approved medicine before discussing e-cigarettes with a clinician.

When a patient has no preference, the authors say doctors should prioritize approved cessation medicines. But a smoker who wants to try vaping should receive accurate information and practical support, rather than a lecture based on exaggerated perceptions of risk.

The paper is a “Special Communication,” not a clinical trial or an official national guideline. It summarizes existing evidence and proposes a pathway doctors can use when counseling adults who smoke.

Nicotine vapes outperform replacement therapy in Cochrane reviews

The strongest evidence supporting that pathway comes from Cochrane, an independent research network known for its systematic reviews of medical evidence.

Cochrane’s latest living review of e-cigarettes for smoking cessation includes 104 studies involving 30,366 adults. It found high-certainty evidence that nicotine vapes help more people quit for at least six months than nicotine replacement therapy (NRT), including patches and gum.

The review included nine randomized studies directly comparing nicotine vapes with NRT, involving 2,703 participants. It also found that nicotine vapes probably work better than non-nicotine vapes and may outperform behavioral support alone.

That evidence is not new, but the willingness of a major group of American researchers to translate it into practical clinical advice is significant. U.S. health authorities have spent years acknowledging that vaping may help some smokers while still steering clinicians almost exclusively toward conventional treatments.

A successful product must be capable of replacing cigarettes

The authors also address a fact frequently ignored by regulators: a product cannot help smokers switch if it fails to provide enough nicotine or satisfaction to replace smoking.

The nicotine concentration printed on a package tells only part of the story. Actual delivery depends on the device, aerosol production, formulation, and how the product is used.

A vape that delivers too little nicotine may leave withdrawal symptoms unresolved. The user may compensate by vaping more often, inhaling more deeply, or continuing to smoke.

That does not mean the highest nicotine concentration is automatically best. The authors recommend considering actual delivery, craving relief, satisfaction, emissions, and the product’s ability to replace cigarettes.

The same logic applies to flavor and product design. A product that regulators make deliberately unpleasant or ineffective may look safer on paper while being less useful to smokers attempting to escape combustion.

The researchers acknowledge major evidence gaps. Studies have not established the ideal device, flavor, brand, or nicotine dose. Long-term health data beyond about two years also remain limited.

Complete switching, not permanent dual use, is the goal

The recommendations are not an endorsement of indefinite dual use. The primary objective is complete cigarette cessation.

Reducing cigarette consumption can lower some exposures, but smoking even a few cigarettes maintains significant health risks. The authors therefore describe dual use as a transitional stage that should be kept as brief as possible.

Clinicians should combine e-cigarette use with counseling and follow-up. If a patient continues smoking at the same rate, the clinician could adjust nicotine delivery, change how the product is used, or suggest another treatment.

Longer-term vaping may be appropriate when it prevents a return to smoking. Complete nicotine abstinence can be considered later, after cigarette abstinence is secure.

The authors say switching completely reduces exposure to many toxicants created by tobacco combustion. They caution that lower exposure to individual chemicals does not translate directly into an equivalent percentage reduction in overall health risk.

FDA authorization is not approval as a cessation medicine

No e-cigarette has been approved by the Food and Drug Administration (FDA) as a smoking cessation drug or medical device.

The agency lists nicotine patches, gum, lozenges, sprays and inhalers, along with varenicline and bupropion, among its approved cessation treatments.

Some e-cigarettes have received marketing authorization through the FDA’s tobacco-product pathway. That process asks whether marketing a product is appropriate for the protection of public health. It does not establish that the product is safe, effective, or approved to treat nicotine dependence.

In May, the FDA said it had authorized 45 vaping products for legal marketing. Even those products cannot be promoted as FDA-approved smoking cessation aids.

The new paper does not change that legal distinction. It does, however, expose the widening gap between clinical evidence and the official American cessation playbook.

Doctors routinely help patients choose among treatments with different benefits, limitations, and risks. The SRNT workgroup says vaping deserves a place in that conversation; not after every other method has failed, but when an informed adult smoker believes it offers the best chance of leaving cigarettes behind.