E-cigarettes found effective in smoking cessation.

Unpopular opinion: e-cigarettes are not the devil.

Buckle up! It’s time for some nuance.

Yes, e-cigs contain nicotine, which is an addictive substance—and one that is harmful to young people. Yes, I find people vaping in public to be irritating. And, above all, adolescents should not be vaping, nor should any kind of marketing directed at them be legal or tolerated.

Photo by Elsa Olofsson on Unsplash

But over the years, I’ve noticed that attitudes towards e-cigarettes among physicians, public health experts, science communicators, and the general public seem to be extreme. For my part, as I wrote in Slate, the 2016 Surgeon General’s warning about vaping was, on close reading, surprisingly underwhelming.

Public health experts detest e-cigarettes. Should they?

There is so much disdain for vaping, even among level-headed experts with nuanced opinions on substance use disorder treatments, that some misinformation about e-cigarettes has emerged. So let’s discuss the facts and then move on to some new research.

• Myth: e-cigarettes contain tobacco. Reality: they do not.

• Myth: e-cigarettes are just as dangerous as tradition cigarettes or chewing tobacco. Reality: e-cigarettes are actually safer because they do not contain tobacco (and therefore, the harmful chemicals produced when smoked or ingested). Which leads to…

• Myth: e-cigarettes cause cancer, just like traditional cigarettes and chewing tobacco do. Reality: Because e-cigarettes do not contain tobacco, they do not cause cancer, as traditional cigarettes do.

• Myth: all e-cigarettes cause vaping-associated lung injury. Reality: only illicit market devices containing adulterants used to make vaping marijuana possible cause vaping-associated lung injury, a rare but serious condition.

• Reality (no myth to debunk here): e-cigarettes contain nicotine. Nicotine is an addictive and harmful compound, especially to developing brains. That is why adolescents and young adults should especially refrain from using any nicotine-containing product.

There’s one more implied myth to debunk—and that is that e-cigarettes have no redeeming value. That’s just not true. If used correctly, by a specific population, they are potentially an important harm reduction tool.

Study finds e-cigarettes effective in getting heavy smokers to quit.

A new study published in JAMA Internal Medicine found that e-cigarettes were as effective as varenicline pills (pronounced “vair-IN-uh-cleen,” brand name “Chantix”) in helping heavy smokers quit over a 6 month period. Both e-cigarettes and varenicline were vastly superior to placebo. Over 40% of volunteers randomized to use e-cigarettes or varenicline had quit smoking regular cigarettes by the 6-month follow up time, compared to under 20% who were given placebos (either placebo pills or vaping devices without nicotine).

While this clinical trial was designed to asses e-cigarette and varenicline efficacy at 6 months, the researchers followed the volunteers for a year. By a year, quit rates had fallen slightly in the varenicline group (from 44% to 39%) and more in the e-cig group (from 40% to 29%). Meanwhile, the quit rate in the placebo group remained around 20%. So, while the researchers didn’t study it, it could end up that varenicline is more effective than e-cigs in the long run. That said, not every thing works well for all people. Some people may not like taking pills, or find the side effects of varenicline to be too bothersome. A disadvantage to varenicline is that people have to remember to take it. An advantage to e-cigs is that if a person feels the urge to smoke, they can simply use pull out their vaping device when needed and step outside. Indeed, some smokers might be accustomed to certain social aspects of it, so vaping does carry that “culture” forward a bit.

As an aside, I always find it interesting when a placebo treatment is effective in a study like this. The volunteers in this clinical trial were people with moderate-to-severe dependence on nicotine who really wanted to quit. Quitting smoking is not easy. So, it’s remarkable to me that 6 months later, around 20% of those in the placebo group had managed to do so. It reveals how powerful a little motivation (potentially enhanced by a good doctor-patient relationship) can be.

Relapsing is not failure.

A related question is whether these tools—whether varenicline or e-cigs—help people quit smoking permanently. The answer both matters and does not. On one hand, it would be best if these options led to permanent abstinence from tobacco-containing products. But it turns out that quitting permanently is not easy. So what if people eventually relapse, say after two years, and get in a cycle of quitting and smoking? While that’s not ideal, interventions that led to temporary smoking cessation are still effective. If someone who otherwise would have smoked traditional cigarettes daily for a decade only smokes for 33%-50% of that time due to a quit-relapse cycle, their risk of developing lung cancer would still be lower. The key is getting people to decrease their risk. A lower amount of tobacco consumption means a lower risk of cancer. So, when patients tell me they “failed” because they quit smoking but relapsed, I reframe it. I say, “No, you succeeded in reducing your risk. And you can do it again, if you are ready to try.”

More harm than good?

The question is not “Are e-cigarettes doing more harm than good?” Anyone who does not use tobacco (or other nicotine-containing products) should not start. But for people who smoke traditional cigarettes, they are a much better alternative.

That said, it remains unclear whether e-cigarettes are, on aggregate, more of an on-ramp (“gateway” drug to traditional smoking) than off-ramp (an effective way to quit smoking). That is, we don’t know whether e-cig presence on the market leads to more smoking than would have occurred without them or helps more smokers quit who couldn’t have otherwise.

But we should acknowledge the nuance around this technology. E-cigarettes and other electronic nicotine delivery devices do have potential uses in adult medicine. Just like methadone and buprenorphine are lower-risk compounds used to treat one disease (opioid use disorder), nicotine-only e-cigarettes appear to be an important option for those who want to quit traditional smoking, and avoid the dramatic cancer risks that come with it.

Questions? Comments? Please leave your thoughts in the Comment section.