Is it okay for a healthy adult to use e-cigarettes as a tobacco cessation method?

E-Cigarettes for Tobacco Cessation in Healthy Adults

The US Preventive Services Task Force (USPSTF) has concluded there is insufficient evidence to recommend for or against e-cigarettes for smoking cessation, and clinicians should instead focus on offering proven behavioral counseling and FDA-approved pharmacotherapy (nicotine replacement therapy, bupropion, or varenicline) to help adults quit smoking. 1

Why E-Cigarettes Are Not Recommended as First-Line Cessation Tools

Insufficient Evidence for Effectiveness

• The USPSTF reviewed available randomized trials and found mixed results on whether e-cigarettes increase smoking cessation rates, with the evidence base too limited to make a definitive recommendation 1
• Few well-designed randomized trials have evaluated e-cigarettes for tobacco cessation, and those that exist show inconsistent findings 1
• Critically, continued e-cigarette use after intervention phases remained high in trials, indicating ongoing nicotine dependence rather than true cessation 1

Known and Unknown Harms

Short-term adverse effects commonly reported include:

• Coughing, nausea, throat irritation, and sleep disruption 1
• These effects are generally mild and transient 1

Serious safety concerns that remain unresolved:

• E-cigarettes contain and emit numerous potentially toxic substances beyond nicotine 1, 2, 3
• The 2019 EVALI (e-cigarette or vaping product use-associated lung injury) outbreak resulted in over 2,800 cases and 68 deaths in the US, primarily linked to THC-containing products with vitamin E acetate 1
• Long-term health effects of e-cigarette use are completely unknown, as data beyond two years of follow-up do not exist 1
• Nicotine itself has significant cardiovascular effects and may contribute to coronary artery disease, atherosclerosis, and aortic aneurysms 2, 3, 4

Emerging Evidence on Dual Use

• Toxicant levels may actually be higher in people who use both e-cigarettes and conventional cigarettes compared to cigarette-only users 1
• This is particularly concerning since many people attempting to quit with e-cigarettes end up using both products simultaneously 4

What You Should Recommend Instead

Proven First-Line Approaches

Behavioral counseling interventions have high-certainty evidence for effectiveness and should be offered to all adults who smoke 1

FDA-approved pharmacotherapy options with proven efficacy include:

• Nicotine replacement therapy (NRT) - patches, gum, lozenges, nasal spray, or inhaler 1
• Bupropion SR 1
• Varenicline 1

Combination therapy (behavioral counseling plus pharmacotherapy) has been shown to increase smoking cessation rates more than either approach alone 1

Assessment Framework

Use the 5 As approach at every clinical encounter 1:

1. Ask about tobacco use
2. Advise to quit through clear, personalized messages
3. Assess willingness to quit
4. Assist in quitting with proven interventions
5. Arrange follow-up and support

Critical Caveats and Public Health Considerations

Youth Gateway Effect

• E-cigarette use among youth has reached epidemic levels in the US 1
• There is substantial evidence that e-cigarette use in youth increases the risk of transitioning to combustible cigarette smoking 1
• The potential benefit of e-cigarettes for adult cessation (if ever proven) must be weighed against their role in driving overall tobacco use among young people 1

Regulatory Status

• E-cigarettes are not FDA-approved as smoking cessation aids, unlike standard nicotine replacement therapies 2, 3
• The Forum of International Respiratory Societies recommends that electronic nicotine delivery devices should be restricted or banned until more safety information is available 2, 3

If Patients Are Already Using E-Cigarettes

• Advise them not to use both combustible cigarettes and e-cigarettes simultaneously (dual use) 4
• Counsel them that e-cigarettes are not risk-free and the goal should be complete nicotine cessation 2
• Consider transitioning them to evidence-based cessation methods with proven long-term safety profiles 1

Bottom Line for Clinical Practice

Do not recommend e-cigarettes as a tobacco cessation tool for your patients. Instead, offer the combination of behavioral counseling and FDA-approved pharmacotherapy, which has high-certainty evidence for both effectiveness and safety 1. The unknown long-term harms, lack of regulatory approval, concerns about continued nicotine dependence, and youth gateway effects make e-cigarettes an inappropriate first-line or even second-line cessation strategy in routine clinical practice 1, 2, 3.