Electronic cigarettes heat a nicotine-containing solution to create an inhalable aerosol. While e-cigarettes generate markedly lower levels of almost all toxins compared to regular cigarettes, the risks and benefits for public health have been hotly debated because of concerns about youth use and uncertainty about their utility as a smoking cessation aid.
In October 2021, the US Food and Drug Administration’s Center for Tobacco Products (CTP) authorized the marketing of three e-cigarette products through the Premarket Tobacco Product Application pathway. This pathway requires that a product be considered appropriate for the protection of public health and signaled to some that the CTP is persuaded there is a benefit to having at least having some e-cigarettes on the market.
Then on June 23, 2022, the FDA issued an order banning the sale of electronic cigarettes by the manufacturer Juul only to temporarily suspend that order on July 5, 2022, citing “scientific issues unique to the Juul application that warrant additional review.” However, in announcing the temporary suspension, the FDA’s statement went on to say, “the stay and the agency’s review does not constitute authorization to market, sell, or ship JUUL products.”
While clinical trials show evidence that using an e-cigarette can help people quit smoking, findings from real-world population studies have been mixed. Virtually all studies investigating whether e-cigarettes can help people to quit regular cigarettes have also focused on people who are already planning to quit, which is a limitation since this ignores the substantial number of people who do not have any immediate plans to quit. This population tends to smoke more cigarettes per day, and they often have the highest risk for poor health outcomes from smoking.
Several studies have found that giving nicotine replacement therapy to people who are not planning to quit increases the number of people who quit. Two recent studies help shed some light on whether e-cigarettes might be an option to consider for people who are not yet ready to make attempt quitting. Both studies used data collected from the USA longitudinal Population Assessment of Tobacco and Health (PATH) study between 2014 and 2019. PATH is a federally sponsored long-term study of tobacco-use patterns and health outcomes in youth and adults in the United States.
The first study published in Addictive Behaviors found that among adults who smoked cigarettes daily with no plans to ever quit, subsequent uptake of daily e-cigarette use was associated with an increase in the percentage reporting plans to quit smoking. The second study published in JAMA Open Network found that among adults who smoked cigarettes daily, of those who did not initially use e-cigarettes and had no plans to ever quit smoking, subsequent daily e-cigarette use was associated with an eight-fold higher rate of quitting traditional cigarettes compared to those who did not use e-cigarettes at all.
Taken together these findings suggest that the uptake of daily use of electronic cigarettes may enable some people who smoke and are unmotivated to stop smoking cigarettes completely. For health professionals, these findings reinforce the need to not give up on patients who are resistant to stopping cigarettes. For people who smoke but are unmotivated to quit, the opportunity to at least try a nicotine replacement option such as nicotine patches or e-cigarettes may lead to future efforts to reduce and eventually stop smoking cigarettes.
I had a gymnastic coach when I was young who taught me to remove the phrase ‘I can’t’ from my vocabulary. Rather, I was instructed to say, “I am unable to do that difficult trick at this time.” We should adopt the same strategy here. We should not have the attitude that some people cannot quit—they just haven’t yet. We need to find the right mechanism for our patients to do that hardest thing they’ve ever tried: Quit.
