Which is the Role of Electronic Cigarettes in the Fight Against Smoking?

Harmful or Potentially Harmful Components (HPHCs) which are generated by the tobacco combustion and are present in cigarettes smoke are the main cause of smoking-related diseases whilst the nicotine addiction is the reason why people smoke but has a limited impact on tobacco-related morbidity and mortality [1,2]. 

Tobacco harm is posed by about 70 certain caricinogenes and by over 7000 toxicants that are present in cigarette smoking [3-8]. 

Despite this certainty and despite the fact that 7 million people die every year in the world as a result of smoking, reducing the damage deriving from the burning of tobacco still remains a controversial topic. 

About a year ago we asked ourselves whether it was still possible to go without risk reduction strategies and without the use of electronic cigarettes (E-cigs) in the fight against smoking [9]. 

Meanwhile, in Great Britain, since some years, E-cigs had taken on a very significant role in the fight against cigarette smoking [10]. 

Lately, very significant and completely independent studies have produced very convincing answers to this question. 

Already at the end of 2022, a systematic review by Cochrane Library examined 40 randomized studies with a total of 22,052 participants, concluding that there was high certainty evidence that E-cigs with nicotine increased cessation rates compared to nicotine dispensed in pharmacological way [11], and that has been confirmed in the latest available update of such review [12]. 

Nicotine is the most used drug in the world for managing the addiction of smokers trying to quit. Data from a US survey, showed that during a 2-year follow-up (the longest period measured so far), the use of E-cigs was substantially free of adverse events and there was no evidence of significant harm from nicotine taken via an electronic device [13]. 

In February 2023, in their Commentary in Nature Medicine, Warner KE et al.  pointed out that both in the United Kingdom and in the United States an increase in smoking cessation of 10-15% was associated with the use of E-cigs [14]. Those smokers who frequently used E-cigs were significantly more likely to quit smoking than smokers who did not vape [14]. Even the US Centers for Disease Control and Prevention reported that smokers were more likely to use E-cigs in their quit attempts than any other product, including Food and Drug Administration (FDA)-approved smoking cessation medications [14]. This paper also confirmed a 95% reduction in toxicants, usually produced by combustion products, in electronic aerosol [14]. 

In September 2023, a new systematic review by the Cochrane Library was published and showed that E-cigs and some drugs such as varenicline and cytisine were more likely to help people quit smoking. According to this review, for every 100 people, 10 to 19 were likely to stop smoking using E-cigs; 12 to 16 using varenicline; and 10 to 18 using cytisine [15]. 

Supporting the usefulness of nicotine consumption in the absence of combustion, an in-depth review was recently published which found that the health risks associated with the use of Snus, in which nicotine is decoupled from tobacco smoke, are significantly lower than those associated with cigarette smoking. The use of Snus in Sweden has proven effective in reducing the incidence of lung cancer and cardiovascular diseases: diseases for which combustion is the main culprit. This has led to calls for a review of the EU ban on the marketing and sale of Snus which represents a form of harm reduction in heavy smokers with public health benefits [16]. 

These concepts are supported by the opinion of authoritative International experts who have recently reviewed the available evidence in terms of Tobacco Harm Reduction (THR). Correct information for adult smokers on smoke-free products is hoped for, precisely in the already quoted commentary published in Nature Medicine [14]. 

Further evidence on the fact that smoke-free systems can represent, for adult smokers, an effective application of the principle of harm reduction regards not only E-cigs but also Heated Tobacco Products (HTPs) which appear to be equally efficient in guaranteeing rates cessation rate of around 40%, at least in the short term [17]. 

We had already asked ourselves about the methods of using E-cigs in a clinical setting in 2015 [18]. We showed that in a smoking cessation setting it was possible to intervene to help heavy smokers resistant to quitting using a E-cigs supported by specific counseling according to the procedure called MB and protected but European trademark [18]. 

On the basis of such growing evidence, ignoring E-cigs and more generally a risk reduction proposal in the context of policies to help heavy smokers is no longer possible both on a clinical and a scientific level. 

It is believed that risk reduction proposals should be aimed at adult smokers resistant to the cessation proposal and that they should not be confused with policies to block tobacco smoking initiation aimed at adolescents and young adults.

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2. UK Health Security Agency (2020) 8 things to know about e-cigarettes.
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8. Food and Drug Administration (FDA) (2019) Harmful and Potentially Harmful Constituents (HPHCs).
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10. Office for Health Improvement and Disparities (OHID), UK. Nicotine vaping in England: 2022 evidence update. 
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12. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub8/full
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15. Lindson N, Theodoulou A, Ordonez-Mena JM, Fanshawe TR, Sutton AJ, et (2023) Pharmacological and electronic cigarette interventions for smoking in adults: component network meta-analyses. Cochrane Database of Systematic Reviews 9: CD015226.
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