Is electronic cigarette (e-cigarette) use safer than tobacco smoking?

From the Guidelines

Vaping is not a safer alternative to smoking and should not be recommended as a first-line therapy for smoking cessation due to the lack of long-term safety data and high rates of ongoing use. According to a recent study published in the Journal of the American College of Cardiology 1, nicotine e-cigarettes may be more effective than nicotine replacement therapy (NRT) for smoking cessation, with a relative risk of 1.69 [95% CI, 1.25-2.27] and a 4% absolute increase in success rates. However, this benefit is offset by the risk of long-term dependence on e-cigarettes, with 80% of users still using the device at 1 year.

Some key points to consider when evaluating the risks and benefits of vaping versus smoking include:

• The potential for e-cigarettes to affect endothelial function, vascular stiffness, and blood pressure, although possibly less than combustible cigarettes 1
• The lack of data on the long-term risks of e-cigarettes on overall health and cardiovascular risk, despite physiologic and toxicology studies suggesting a potential increase in cardiovascular risk 1
• The substantial variability in e-cigarette additives, flavorings, and nicotine dose, which may impact cardiovascular risk 1
• The importance of policy-level interventions to reduce secondhand smoke exposure, which has similar deleterious physiologic effects as active cigarette smoking 1

In terms of smoking cessation, FDA-approved methods like nicotine replacement therapy, prescription medications, and behavioral support are proven to be more effective and safer than switching to vaping. These methods should be prioritized for patients attempting to quit smoking, rather than relying on e-cigarettes as a cessation tool. Ultimately, the safest choice is to avoid both smoking and vaping entirely, as both pose significant health risks and can lead to nicotine addiction and other harmful effects.

From the Research

Comparison of Vaping and Smoking

• Vaping is considered by some to be a safer alternative to smoking, but the evidence is not conclusive 2.
• Electronic nicotine delivery systems (ENDS), including e-cigarettes, have been shown to have varying amounts of toxicants, nicotine, and carcinogens, which can put users at risk for lung diseases and COVID-19 similar to smokers 3.
• Some studies suggest that e-cigarettes may be safer than conventional cigarettes, but harmful effects from short-term e-cigarette use have been described, and the potential long-term effects of e-cigarette consumption have been scarcely investigated 2.

Smoking Cessation Methods

• Nicotine replacement therapy (NRT) has been shown to increase smoking cessation rates by approximately 1.5- to 2-fold after 12 months, but there has been no major improvement in effectiveness for smoking cessation with the introduction of new preparations of nicotine 4.
• Varenicline, a partial agonist at nicotinic alpha4beta2 receptors, has been shown to be as least as good as and probably more effective than bupropion for smoking cessation 4, 5.
• A network meta-analysis found that varenicline monotherapy or its combination with other interventions were superior in achieving smoking cessation compared to bupropion, nicotine replacement therapy, counselling, and placebo 5.

Cardiovascular Risks

• E-cigarettes have been shown to have adverse effects on cardiovascular health, including an increased risk of cardiovascular disease, similar to traditional cigarette smoking 6.
• The cardiovascular risks associated with e-cigarette vaping are still being studied, but the current evidence suggests that e-cigarettes may not be a safe alternative to traditional cigarettes 6.