E-cigarettes gain an endorsement from JAMA after outperforming nicotine patch in randomized trials
STUDY: Leavens ELS et al, JAMA 2026
FUNDING: Independent
Background
Two-thirds of adults who smoke want to quit, but fewer than 10% succeed each year. E-cigarettes heat a nicotine liquid without burning tobacco, avoiding the combustion causes most smoking-related disease. Still, they can injure the lungs, and many clinicians discourage them.
Some of those concerns were fueled by youth anti-vaping campaigns and the 2019 lung injury outbreak, which was traced to illicit THC cartridges contaminated with vitamin E acetate. JAMA added to the fears, publishing warnings about e-cigarettes in its family of journals. But for adults who already smoke, the risk:benefit ratio may be different.
The Panel
- 24 tobacco researchers and clinicians from the Society for Research on Nicotine and Tobacco reviewed the evidence and reached consensus over about a year.
- The recommendations apply to adults who already smoke. Anyone under 21 or new to nicotine should avoid all nicotine products.
The Evidence
- A Cochrane review found high-certainty evidence that nicotine e-cigarettes lead to higher quit rates than nicotine replacement therapy. About 1 in 10 users had quit smoking at 6 months.
- Quit rates are similar to varenicline (Chantix) and cytisine (an herbal version of varenicline used in Europe).
- Toxin exposure is up to 90% lower than with cigarettes. Short-term trials show no serious harms, but we lack data beyond 2 years.
- E-cigarettes deliver nicotine quickly, like a cigarette. That raises dependence risk but makes them a more satisfying substitute than the patch. However, pairing a patch with nicotine gum may work similarly.
Recommendations
- I’d recommend as-needed nicotine gum alongside varenicline, bupropion, and nicotine replacement patches. But if the patient prefers vaping, that is far safer than smoking.
- Correct misperceptions: nicotine drives addiction, while smoke causes cancer and lung disease.
- Ask about goals. Does the patient want to quit all nicotine, or just cigarettes?
For patients who choose to vape:
- Use FDA-authorized products.
- Pick a nicotine strength high enough to ease cravings. Low doses lead to deeper, more frequent puffs and more exposure to other chemicals.
- Vape whenever the urge to smoke arises, rather than continuously all day.
- Switch from cigarettes completely, and quickly. Dual use is common, but even a few cigarettes a day keep cardiovascular risk elevated.
- Follow up within a few weeks. If smoking hasn’t dropped, raise the nicotine level or frequency of use.
Practice implications
- Direct patients to the FDA’s Searchable Database to find authorized devices, refer them to 1-800-QUIT-NOW for free counseling.
- Here are behavioral tips on quitting smoking.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
