Experts say it’s time to include nicotine e-cigarettes in smoking cessation conversations

Cigarette smoking kills nearly half a million Americans each year, yet most people who smoke are unable to quit despite multiple attempts. Helping more people to quit smoking remains one of the greatest opportunities to reduce tobacco-related disease and death.

An interdisciplinary group of tobacco treatment experts is urging clinicians to broaden the treatment options they discuss with patients who want to stop smoking cigarettes.

In new recommendations published in JAMA, the researchers outline how clinicians can incorporate nicotine e-cigarettes as part of patient-centered conversations about smoking cessation. The goal is not to encourage nicotine use but to help more people to stop smoking combustible cigarettes – the leading cause of preventable death in the U.S.

Developed by the Harm Reduction Work Group of the Society for Research on Nicotine and Tobacco’s Treatment Research Network, the recommendations provide clinicians with practical guidance for discussing smoking cessation. Rather than taking a one-size-fits-all approach, the authors encourage clinicians to present patients with a “menu of options” for quitting and work with them to weigh the risks and benefits.

The paper also includes a conversation guide that walks clinicians through key questions to consider, strategies for addressing common misconceptions and evidence-based recommendations for counseling patients who choose to use nicotine e-cigarettes.

“We’ve had clinicians asking us for years how they should talk to their patients about e-cigarettes, and we really didn’t have anywhere to point them,” said Alana Rojewski, Ph.D., associate director of the Tobacco Treatment Program at MUSC Hollings Cancer Center. “There was plenty of research literature but nothing that offered practical guidance on how to have these conversations in clinical practice.”

A patient-centered approach to quitting smoking

“The main takeaway is for clinicians to include e-cigarettes in their toolkit of smoking cessation options,” said Tracy Smith, Ph.D., an addiction scientist and co-leader of the Cancer Prevention and Control Research Program at Hollings.

The authors emphasize that the best approach to quitting smoking will vary from person to person and should be tailored to each patient’s goals, preferences and medical needs.

“There isn’t a one-size-fits-all approach to quitting,” Smith added. “Our job is to provide patients with accurate information and a menu of evidence-based options that give them the best chance of success.”

A major point of emphasis is on shared decision-making between clinicians and patients. If a patient has no preference about treatment options, smoking cessation medications already approved by the U.S. Food and Drug Administration (FDA) remain an appropriate place to start. However, if a patient prefers to try nicotine e-cigarettes, clinicians should support that decision rather than requiring them to try and fail other therapies first.

That recommendation reflects a stark reality: Continuing to smoke cigarettes carries significant health risks, and delaying treatment can have serious consequences.

“Time is of the essence when we’re trying to get people off cigarettes,” Smith said. “The priority is helping people quit combustible cigarettes as quickly and effectively as possible.”

That message is particularly important for people whose health is already affected by smoking, including cancer survivors and people living with cardiovascular disease or other chronic illnesses.

Importantly, the recommendations are intended only for adults who currently smoke cigarettes. The authors explicitly state that nicotine e-cigarettes should not be used by youth or people who have never used tobacco products.

Correcting common misconceptions

Another major goal of the paper is correcting misconceptions about nicotine e-cigarettes among both patients and providers. The researchers note that public perceptions of nicotine e-cigarettes have become increasingly negative despite growing evidence supporting their use as smoking cessation tools.

One of the most common misconceptions is that nicotine itself is responsible for smoking-related diseases, such as cancer and heart disease. In reality, most smoking-related illnesses are caused by the toxic chemicals produced when tobacco is burned, not nicotine itself.

Because e-cigarettes do not involve combustion, they expose users to substantially fewer harmful chemicals. The paper cites high-certainty evidence from Cochrane systematic reviews showing that nicotine e-cigarettes can be more effective than nicotine replacement therapies, such as patches and gum, at helping people to stop smoking. Other reviews have similarly found that their effectiveness is comparable to FDA-approved smoking cessation medications.

But that does not mean nicotine e-cigarettes are risk-free.

“The evidence for helping people quit smoking is pretty good, but they’re not a magic bullet,” Smith said. “There are lots of people who try e-cigarettes for whom they don’t work or who end up using both products for a prolonged period of time. Like every smoking cessation treatment, there are risks and benefits that patients and clinicians should discuss together.”

Researchers also acknowledge that safety data on nicotine e-cigarettes are still limited. While e-cigarettes have been available for years, scientists will need decades of additional research to understand their long-term health effects fully.

“The lack of long-term safety data is a potential risk,” Rojewski said. “But helping people transition away from combustible cigarettes is what’s most important. The sooner we can help someone quit, the better. Every conversation about smoking cessation is an opportunity to improve someone’s health and reduce their risk of developing smoking-related disease.”

Practical guidance for clinicians

Beyond recommending that clinicians discuss nicotine e-cigarettes with patients who smoke, the paper offers practical recommendations for doing so. Those recommendations encourage clinicians to:

• Discuss nicotine e-cigarettes alongside smoking cessation medications.
• Recommend FDA-authorized nicotine e-cigarette products when appropriate.
• Ask key questions to understand a patient’s goals, preferences and treatment history.
• Support patients in completely transitioning away from cigarettes as soon as possible.
• Incorporate behavioral counseling and follow-up care into treatment plans.

Behavioral counseling remains a critical component of treatment, regardless of the smoking cessation strategy. Combining counseling with medication has long been the gold standard. Through counseling, patients can identify smoking triggers, set quit goals and develop strategies for navigating everyday situations that may increase the urge to smoke.

“Smoking isn’t just nicotine dependence – it’s also a learned behavior that’s woven throughout people’s daily lives,” Rojewski explained. “People often smoke when they drink their morning coffee, drive to work or cope with stress. Quitting requires relearning those behaviors and developing new habits that support long-term success.”

Supporting patients through research and treatment

The recommendations align closely with the patient-centered approach already used by the MUSC Health Tobacco Treatment Program. The program provides evidence-based counseling and medications while tailoring treatment plans to individual patients.

The paper also highlights the collaborative tobacco research efforts at Hollings. Multiple investigators from the center’s Tobacco Research Group, including Smith; Rojewski; Mariel Bello, Ph.D.; Matthew Carpenter, Ph.D.; and Erin McClure, Ph.D., contributed their expertise in tobacco treatment, nicotine dependence, harm reduction and cancer prevention.

These new recommendations are one example of how years of tobacco research are being translated into evidence-based guidance that clinicians can use to support patients. Ultimately, the recommendations are intended to help clinicians to have more informed and nuanced conversations about smoking cessation while keeping the focus on what matters most: helping people to quit cigarettes.

“Our goal isn’t to recommend one product over another,” Rojewski said. “It’s to give clinicians the tools they need to have patient-centered conversations that get smokers closer to quitting.”