Dual use, referring to people who smoke and vape concurrently, is a phenomenon often cited by opponents of vaping to discredit its harm reduction impact. To their claim that switching is not quitting, they add that dual use simply extends people’s addiction to nicotine, doesn’t help them quit smoking, and may even be worse for health than smoking alone.
Proponents of tobacco harm reduction counter that dual use is typically a transition period to much safer products, but that even long-term dual use has its benefits.
Published research, and the way it’s interpreted, underpins these contradictory positions, which are then fought out in the media and other forums—often in response to survey findings like a recent rise in dual use in the United Kingdom.
Some research has indicated, for example, that most dual users do not go on to switch entirely—although most people seeking to quit cigarettes by any method are not initially able to do so.
“Dual use is always an improvement on exclusive smoking and often a stage in a pathway towards exclusive vaping.”
Other research has found dual users to be “at least as likely to quit as exclusive smokers” and “slightly more likely to try to quit.” And if splitting your nicotine use between cigarettes and far safer vapes means you smoke less, there’s evidence that you are already reducing your risks.
“Dual use is always an improvement on exclusive smoking and often a stage in a pathway towards exclusive vaping,” British tobacco harm reduction advocate Clive Bates, of Counterfactual Consulting, told Filter.
Bates, who has been heavily involved in the dual-use debate, recently offered a “translation” of the title of a study published in the Tobacco Control journal, “I’m both smoking and vaping,” which he found unhelpful.
Translation: “I am migrating my nicotine use towards much safer forms of nicotine product and it is highly unlikely I will be smoking in ten years. I will, therefore, avoid nearly all the serious long-term disease risks associated with prolonged smoke inhalation.” It’s a win. https://t.co/qo1l1s5b2P
— Clive Bates (@Clive_Bates) October 7, 2024
In his blog, The Counterfactual, Bates has presented evidence that dual use “is not the most common form” of vape use, and that in the United States, “just 29 percent of adult [vape] users were dual users in 2021.” He also highlighted how critics fail to recognize that some dual users, with no intention of quitting cigarettes, become “accidental quitters.”
“It was about four months later when I realized I didn’t know when was the last time I smoked.”
Skip Murray—who, like Bates, has written for Filter—was one of them. With years of quit attempts behind her, she was resigned to the idea that she would always smoke.
In 2015, she started using vapes as a way of getting nicotine in places she was unable to smoke in Minnesota, while continuing to smoke the rest of the time. But Murray soon found she was increasingly choosing to vape in situations where she had the option of smoking.
“I quickly went from two packs a day to less than one pack,” she told Filter. “It was about four months later when I realized I didn’t know when was the last time I smoked.”
Dr. Riccardo Polosa, a professor of internal medicine at the University of Catania, Italy, pointed to a steep reduction in dual use prevalence over time in the US, which he said can largely be credited to the evolution of vaping technology.
“As the satisfaction with vaping increases, more users are likely to transition completely away from tobacco smoking, and dual use will keep declining,” he told Filter.
“It was finding flavors I really enjoyed that led me to vaping more and more, and ultimately setting a quit date.”
This chimes with the experiences of Jason Hodge, who started smoking in 1997. In 2015, Hodge became a dual user after a vape shop opened near his workplace in Oklahoma. “I only vaped during working hours, and smoked at home,” he told Filter.
It wasn’t until 2022 that Hodge made the decision to completely stop smoking, having been a dual user for seven years.
“I have been successful in refraining from smoking since then,” he said, “due to the high quality of vaping devices and liquids that are now on the market, compared to choices that I had at the beginning of my vaping journey.”
Seven years is a long time, but for many people it takes time. Michael Redfearn, who lives in Delaware, was a dual user for eight months before he “finally felt confident enough to try and make a quit attempt,” he told Filter.
In his case, as for many others, vape flavors were key. “I was about 80 percent [smoking] and 20 percent vaping for a long time,” Redfearn said. “It was finding flavors I really enjoyed that led me to vaping more and more, and ultimately setting a quit date.” He now vapes exclusively.
“Long-term dual use, while not ideal, still represents harm reduction.”
For people who do experience an extended period of dual use, there’s good news.
“Long-term dual use, while not ideal, still represents harm reduction,” Dr. Polosa said.
“Even if someone continues smoking and vaping concurrently, they’re likely smoking few cigarettes per day,” he continued. “Reducing cigarette consumption from 20 to five, for example, can still lead to significant reductions in health risks. Even when complete cessation doesn’t occur, there is often a marked reduction in cigarette consumption, which brings notable health benefits.”
Research to back this up includes a study looking at large-scale US data, which noted that “Many smokers do not quit but instead reduce the number of cigarettes they smoke per day (CPD) over their lifetime.”
It concluded that “Reductions in CPD over the lifetime meaningfully decreased death risk.” In describing this pattern, the researchers found “particularly strong associations for lung cancer and respiratory disease.”
“If tobacco control activists are worried about dual use, they might want to reconsider the deceptive alarmism about vaping risks.”
Quitting cigarettes altogether is still the safest option. And Bates argues that outlandish claims in some studies of dual use, together with the wider landscape of fearmongering and misinformation against vapes, dissuade people from making faster progress in their dual-use journeys.
“If tobacco control activists are worried about dual use, they might want to reconsider the deceptive alarmism about vaping risks,” he said. In the current context, “We shouldn’t be surprised if [people] don’t migrate neatly from smoking to vaping.”
“While dual use may not seem like an immediate success from a cessation perspective, it can contribute to significant harm reduction,” Polosa emphasized. “Encouraging people to stick with vaping while gradually phasing out smoking is more effective than condemning dual use altogether. From a public health standpoint, any reduction in cigarette consumption is a win.”
Photograph by Vaping360 via Flickr/Creative Commons 2.0
Both The Influence Foundation, which operates Filter, and the Center of Excellence for the Acceleration of Harm Reduction, founded by Dr. Polosa, have received grants from Global Action to End Smoking. Filter‘s Editorial Independence Policy applies.
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