April 28, 2023 – Every day, Sonia Sharma meets people like Natalie H. who are trying to quit vaping.
Natalie, a member of the nicotine addiction support group at the University of California San Francisco’s Fontana Tobacco Treatment Center, switched from traditional cigarettes to vaping but found the electronic version just as addictive and eventually decided to quit using nicotine completely.
“I went from being an occasional cigarette smoker, a few a month, to a daily vaper,” said Natalie, who preferred not to give her last name to protect her privacy. “Vaping made my nicotine addiction worse, not better.”
“We have people tell us they vape before their feet hit the ground in the morning,” said Sharma, a physician assistant who co-leads Natalie’s support group at the university. She has met people who had smoked four to five cigarettes a day, switched to e-cigarettes to quit smoking, then vaped the equivalent of a pack a day. Others had switched to vapes to quit but ended up both vaping and smoking again. And others picked up vaping without ever smoking. They want to quit, she said, but are not sure how.
Researchers from the National Institutes of Health in 2020 reported that 5.66 million U.S. adults vaped. A little over 57% of people said they started using e-cigarettes to quit smoking traditional cigarettes. Another study in 2021 based on survey data found that about 60% of e-cigarette users wanted to quit their vaping habit.
Vaping has been sold as a way to help people kick their smoking habit. Research is inconclusive on this claim. But unlike cessation tools like nicotine gums or lozenges, using vapes to quit is uncharted territory. Vapers lack guidance on how to use the devices to quit, and they have even less direction on what to do if they get addicted to the vapes themselves.
A New Addiction?
Monica Hanna, assistant director of the Nicotine and Tobacco Recovery Program at RWJBarnabas Health’s Institute for Prevention and Recovery in New Jersey, said she has witnessed a higher level of nicotine addiction in the vapers with whom she has worked.
“When someone takes a hit from a vaping device, it doesn’t generate the burn it would from traditional tobacco,” she said. “This causes people to take a deeper pull, and when they take a deeper pull, they establish a higher level of nicotine dependence over time.”
A 2019 study of nearly 900 people published in The New England Journal Medicine found that smokers who used vapes for cessation were almost twice as likely to have quit smoking cigarettes than those who used other nicotine replacement therapy. But 80% of people who switched to vaping were using e-cigarettes a year after they tried to quit smoking.
Given that potential for addiction, Nancy Rigotti, MD, director of Massachusetts General Hospital’s Tobacco Research and Treatment Center in Boston, said patients must use vapes “properly” for cessation. That means giving up smoking completely and quitting vapes as soon as patients are sure they will not go back to smoking tobacco.
“We are going to need to help these people to stop vaping,” said Rigotti, who is working with Achieve Life Sciences, a pharmaceutical company developing a prescription drug to treat nicotine addiction from vapes and cigarettes.
And many nicotine users who have tried vaping to quit smoking end up becoming dual users.
“It’s important to stress that health benefits [of switching to vaping] only occur if the switch to vapes is complete and permanent. So far, that appears difficult to do for most people who smoke, and in my anecdotal experience, it has not worked,” said J. Taylor Hays, MD, the former medical director of the Mayo Clinic’s Nicotine Dependence Center in Rochester, MN.
Besides challenges in communicating the current evidence, there is no established method to help vapers quit, according to Nigar Nargis, PhD, senior scientific director of tobacco control research at the American Cancer Society.
“There are some experimental methods like using social interventions, counseling, and some educational campaigns,” she said. “[Little] progress has been done in terms of clinical interventions.”
Unlike cessation products such as gums or patches, which have clear recommendations for duration of use, similar guidelines don’t exist for vapes, in part because the FDA hasn’t yet granted approval of vapes as a way to quit smoking.
Alex Clark, the CEO of the Consumer Advocates for Smoke-free Alternatives Association, a nonprofit group that supports vaping, said people could vape for longer and still benefit from making the switch from traditional cigarettes.
“The most important thing is that people start replacing cigarettes with a smoke-free product and continue until they’ve completely switched,” said Clark, whose group accepts donations from the e-cigarette industry. “Following switching, people are encouraged to continue with the product for as long as they feel necessary.”
But 2013 guidelines from the FDA advised makers of nicotine replacement therapies – including gums, patches, and lozenges – to include labeling that advises users to complete treatment. According to the agency, if a person feels like they “need to use [the nicotine replacement therapy product] for a longer period to keep from smoking, talk to your health care provider.”
Hays, who is now an emeritus professor at the Mayo Clinic, said he would not recommend patients try vaping as a way to quit, since there are more proven techniques, such as patches and gums. If a patient insists, vaping could be considered under the medical guidance of a cessation professional.
He also said people should buy products only from large companies that are likely to have “reasonable quality control.” Hundreds of vaping devices are on the market, and they are not all equivalent, he said.
But when an e-cigarette user wants to quit vaping, guidance might boil down to using traditional tobacco cessation methods like the gums and lozenges, because few tools exist to help people with a vaping-specific addiction.
The long-term health outcomes of vaping are also unclear, and decades will pass before scientists are able to make conclusions, according to Thomas Eissenberg, PhD, co-director of Virginia Commonwealth University’s Center for the Study of Tobacco Products in Richmond, VA.
“I don’t think anyone knows what the long-term effects of heated propylene glycol and vegetable glycerin and flavors intended as food ingredients are, especially when these compounds are inhaled hundreds of times a day, week after week, year after year,” he said.