New England Journal of Medicine Backs Vapes as Harm Reduction

    Earlier in February, the New England Journal of Medicine published both a study highlighting the harm reduction efficacy of vapes and an accompanying editorial, stating that “US public health agencies and professional medical societies should reconsider their cautious positions on e-cigarettes for smoking cessation.”

    Coming from one of the world’s most prestigious peer-reviewed journals, these felt like highly significant choices. The editorial was authored by Harvard Medical School Professor Nancy Rigotti and represented her own view, though the publication made the decision to solicit it. It added that, “The evidence has brought e-cigarettes to a tipping point. The burden of tobacco-related disease is too big for potential solutions such as e-cigarettes to be ignored.”

    The new study, led by researchers at the University of Bern, Switzerland, tracked 1,246 participants who wished to stop smoking. A control group received smoking-cessation counseling and a voucher which they could put toward options including nicotine replacement therapy (NRT). An intervention group received the same counseling, plus the option of NRT (which they’d have to pay for) and free nicotine vapes.

    The participants were tracked for six months. The proportions with “validated continuous abstinence from tobacco smoking” throughout were 16.3 percent for the control group and 28.9 percent for the vapes group. Abstinence from smoking in the seven days prior to six-month followup was found to be 38.5 percent in the control group and 59.6 percent in the vapes group.

    “The addition of e-cigarettes to standard smoking-cessation counseling resulted in greater abstinence from tobacco use among smokers than smoking-cessation counseling alone,” the authors concluded.

    “The study sees a pragmatic approach in recommending vapes to smokers.”

    A spokesperson for the University of Bern told Filter that most people who smoke want to stop, but are unable to do so even with traditional cessation products: “According to the study, this is where vapes could help as part of a smoking cessation counseling.”

    “The study sees a pragmatic approach in recommending vapes to smokers instead of leaving them alone with their dependence and the health consequences of their habit,” the spokesperson continued. “By using vapes, smokers could reduce the risk of tobacco-related diseases until they later decide to stop using nicotine altogether.”

    Much past evidence has shown the positive health impacts of switching from cigarettes to vapes. But most people who do so don’t participate in any formal cessation program. Many would also object to the suggestion that quitting low-risk nicotine consumption, which can have benefits, should be everyone’s goal.

    Both the findings of the study and its platform have been welcomed by tobacco harm reduction experts.

    It “should remove any doubt among practicing physicians about recommending vapes.”

    “Critics of e-cigarettes and vapor products have complained that there is no clinical trial evidence that they help smokers quit,” despite persuasive evidence of a population-level transition, Brad Rodu, professor of medicine at the University of Louisville in Kentucky, told Filter.

    Such complaints just became that bit harder to justify. Noting the reputation of the New England Journal of Medicine, Dr. Rodu added that the publication of this research “should remove any doubt among practicing physicians about recommending [vapes]—indeed any smoke-free tobacco products—as cessation options for adult smokers.”

    Dr. Rigotti, author of the NEJM editorial, also told Filter that she was “cautiously hopeful that the journal’s reputation and its decision to publish the trial” would help dispel skepticism around vapes as harm reduction, though “much more is needed.”

    Why, then, does such skepticism persist?

    According to Rigotti, there are numerous reasons, including widespread misunderstanding of nicotine’s role in smoking-related disease and death, among both clinicians and the public. “And honestly,” she added, “there are many in health care (and even the public) who are wary of products whose sale benefits the tobacco industry, given its long history of deception about cigarettes.”

    “The evidence has reached a point where the health care community should move from ‘whether’ to ‘how and in what circumstances’ e-cigarettes can contribute.”

    In her article, Rigotti described the study as adding “valuable new data” on the question of vapes helping people quit cigarettes, and wrote that, “It is now time for the medical community to acknowledge this progress and add e-cigarettes to the smoking-cessation toolkit.”

    Asked to elaborate on her editorial’s assertion that we’ve arrived at a “tipping point,” Rigotti told Filter: “I think that the evidence about the efficacy and short-term safety of e-cigarettes for smoking cessation has reached a point where the health care community should move from ‘whether’ to ‘how and in what circumstances’ e-cigarettes can contribute to … reducing the enormous toll of tobacco-related suffering, disease and death.”

    “Any reluctance to recommend vastly safer cigarette substitutes among health professionals,” Rodu said, “must be balanced by this fact: Nearly a half-million [US] smokers die prematurely each year.”



    Photograph by Vaping360 via Flickr/Creative Commons 2.0

    Update, February 28: This article has been edited to add that Dr. Rigotti’s editorial represented her personal view, though NEJM made the decision to solicit it.

    • Kiran is a tobacco harm reduction fellow for Filter. She is a writer and journalist who has written for publications including the Guardian, the Telegraph, I Paper and the Times, among many others. Her book, I Can Hear the Cuckoo, was published by Gaia in 2023. She lives in Wales.

      Kiran’s fellowship is supported by an independently administered tobacco harm reduction scholarship from Knowledge-Action-Change—an organization that has separately provided restricted grants and donations to Filter.

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