JAMA Article on E-Cigarettes Makes Refreshingly Sound Recommendations to Clinicians

A new JAMA article by the Treatment Research Network of SRNT (the Society for Nicotine and Tobacco Research) discusses how clinicians should discuss e-cigarettes with patients who smoke cigarettes.

Artwork by Pawel Bugucki

A new commentary in JAMA, by a working group within the Treatment Research Network of SRNT, makes evidence-based recommendations to US clinicians on how to discuss e-cigarettes with their patients who smoke cigarettes. This commentary advances the dialogue in two incredibly important ways in my opinion.

Background

E-cigarettes are more effective for smoking cessation than nicotine replacement therapy according to the official Cochrane review of randomized controlled trials (RCTs) on the topic, as well as an umbrella review (a systematic review of systematic reviews). In Cochrane parlance, this is “high-certainty evidence,” meaning that the existing evidence is so strong and consistent that additional forthcoming studies are unlikely to change this conclusion.

Yet, a large majority of doctors have misperceptions about the health risks of e-cigarettes and of nicotine in general (Wackowski et al., 2022). The hostile stances of several US medical groups towards e-cigarettes (American Heart Association, American Lung Association, and American Cancer Society) surely doesn’t help this situation. As a result, any patient asking their doctor about using e-cigarettes to stop smoking has a good chance of being given counterproductive and even harmful advice.

The new JAMA commentary by the SRNT working group aims to correct the above problems by reviewing current evidence and making recommendations directly to clinicians on how to incorporate e-cigarettes into discussions with patients who smoke.

This is not the first such paper; for example, Dr. Nancy Rigotti published a NEJM editorial aimed at clinicians, arguing that the evidence has reached a “tipping point” and concluding, “It is now time for the medical community to acknowledge this progress and add e-cigarettes to the smoking-cessation toolkit.” Prior to that, 15 past presidents of SRNT published a commentary in AJPH calling for the public health community to recognize the potential of e-cigarettes.

But in my reading, this latest JAMA commentary is especially groundbreaking in that it advances the existing discussion in two very important ways. These have to do with the usual caveats that accompany endorsements of e-cigarettes for smoking cessation.

1. No More Caveat about Trying Other Quit Methods First

One of the big two caveats often made is that e-cigarettes should only be tried for smoking cessation after other methods have been tried (and not been successful). A representative quote is from the FDA’s webpage on Relative Risks of Tobacco Products (FDA is by no means the only one saying this, however; I’m just choosing this as a prominent example with a well-worded quote):

“Evidence-based, FDA-approved medications – including nicotine replacement therapy (NRT), bupropion, and varenicline” which “along with behavioral counseling, should be the first line of therapeutic treatment for adults seeking to quit smoking.” — FDA, Relative Risks of Tobacco Products

But why should someone have to try an inferior method first (or, to be fair to varenicline, an equally-effective method that there’s less interest in, not to mention the side effects)? Allowing e-cigarettes only as a last option risks prolonging a person’s total smoking duration (which is especially ironic given the second caveat below about dual use!).

Furthermore, what if requiring patients to try (and fail) other methods first may discourage them from believing they’ll ever be able to quit, and lower their motivation to undertake yet another quit attempt with e-cigarettes? There is some support for this idea from a French study on how adults who smoke perceive e-cigarettes:

“Previous NRT use increased the probability of being a ‘doubter of e-cigarettes’, whereas prior e-cigarettes [sic] use decreased the likelihood of belonging to the ‘doubters of e-cigarettes’ and ‘resistors’ groups.” — Al Zayat et al., 2025

Refreshingly, the new JAMA commentary explicitly overturns the usual push for people to try other traditional cessation aids first, saying:

“If, after a risk-benefit conversation, the patient prefers to try and e-cigarette to quit smoking, they should be supported in doing so. Patients should not be required to first try or fail an FDA-approved medication before using an e-cigarette for cessation because supporting cigarette cessation is the primary goal.” — Leavens et al., 2026, JAMA

This is a striking and refreshingly logical change from the status quo.

2. “No Dual Use” Caveat Is Softened

The second big caveat often made about quitting with e-cigarettes is that it must be complete switching, not dual use. Again, the FDA has a well-worded quote describing this caveat, though the FDA is far from the only one cautioning against dual use:

However, it is important that they switch completely from cigarettes to e-cigarettes to get the full health benefit. Long periods of dual use of cigarettes and e-cigarettes can result in harms to health similar to, or in addition to, the harms from exclusive use of cigarettes. — FDA, Relative Risks of Tobacco Products

The problem is that the concerns about dual use being worse than smoking are based on evidence that is, at best, ambiguous, and at worst, misleading. The evidence is mostly based on cross-sectional studies that compare dual-users to exclusive smokers (without regard to their starting point) and find dual users are “worse off” on some measure (e.g., heavier smoking, higher dependence). This is an “apples to oranges” comparison but the comparable or worse outcomes of dual use are blamed on vaping.

In stark contrast, longitudinal studies of dual use that do account for each person’s starting point (e.g., how much they smoked before starting dual use) show that people who start dual use often reduce their cigarette consumption, which reduces the associated risk such as levels of harmful biomarkers (e.g., Chen et al., 2026).

I have a lot to say about dual use; I went more into detail on Substack here and on YouTube here. I’ll probably write another post soon about recent developments in research on dual use.

Some people may also need a longer period of dual use as they gradually taper down smoking and switch to e-cigarettes. In fact, a recent pilot trial showed that using e-cigarettes to substantially reduce cigarette consumption predicts later switching (Dahal et al., 2026). While it’s true that zero smoking is best, there is something to be gained by reducing cigarette consumption for those who have difficulty stopping completely. Telling people that all dual use should be avoided and is worse than exclusive smoking could discourage people from starting on the transition process.

Again, the JAMA authors soften and contextualize this caveat in a way that fully reflects the evidence base without either exaggerating or dismissing the harms:

Counsel patients to fully switch as quickly as possible. They may experience a period of using both products (ie, dual use) during the transition to complete smoking cessation, but transitioning away from cigarettes as quickly as possible should be encouraged to reduce the dangers associated with continued cigarette smoking at any level. Leavens et al., 2026, JAMA

Again, this is a striking change because it acknowledges that dual use isn’t always something to be discouraged, but in fact can be an important part of the transition away from cigarettes. It’s a much more nuanced understanding of dual use that reflects the totality of evidence.

Bonus: Jamie Hartmann-Boyce’s Commentary

Dr. Jamie Hartmann-Boyce of the Cochrane reviews on this topic published a commentary alongside this article. She discusses the tensions that clinicians face when their patients ask about e-cigarettes. Her overall theme is about distinguishing “values” from the evidence, which inherently argues that the evidence for e-cigarettes is sound but that opposition comes from values.

For example, she raises the value-based issue of whether the goal is to eliminate all “nicotine addiction” or simply reduce the harms of smoking-related diseases:

Quitting smoking is hard, most attempts fail, and “swapping one addiction for another” could reduce risk in people who cannot quit nicotine altogether. — Hartmann-Boyce, JAMA

She concludes that values of both the patient and the clinician should be explicitly discussed in the decision-making process and calls for more transparent communication of evidence:

In this murky terrain, the best path forward must include intellectual honesty. E-cigarettes are not a magic bullet for smoking cessation, but unfortunately no such thing exists… Intellectual honesty means presenting evidence transparently, including uncertainties and industry complications. It also means explicitly acknowledging and discussing values, both of the patient and the physician, so that patient autonomy can be supported… — Hartmann-Boyce, JAMA

Beyond “The Medical Route”

My remaining comments are not meant at all to be a criticism of the JAMA article, which I obviously think is excellent and whose scope is intentionally limited to the “medical use” of e-cigarettes. But I feel it’s important to emphasize that the medical pathway is not, and should not be, the only way that e-cigarettes are recognized as a benefit to population health.

First, there’s the concept of uptake or reach, which is very distinct from efficacy within an RCT. Efficacy within an RCT in a head-to-head comparison doesn’t always translate well into real-world uptake of that product or method. For example, “cold turkey” is one of the least effective ways to quit in a head-to-head comparison, but (before e-cigarettes, at least) this was nevertheless the most widely-used method. Another example is varenicline, which despite being similarly effective to e-cigarettes in RCTs (both vs. NRT; Lindson et al., 2023), has much lower real-world uptake (~8% vs. ~40%, respectively, Foxon & Niaura, 2025).

E-cigarettes are not only effective in head-to-head RCT comparisons, but also the most widely used quit aid by far in both the US (Foxon & Niaura, 2025) and UK (Jackson et al., 2025). In other words, e-cigarettes are superior (or at least tied) in both respects: RCT efficacy vs. NRT and substantially higher real-world uptake and. It’s no wonder, then, that e-cigarettes’ impact (based on a score incorporating both of these factors) dwarfed any other method (~38 vs. <2; Jackson et al., 2025).

A big reason for this success is that someone can use (and benefit from) e-cigarettes either with or without intending to quit. At any given time, only ~15% of adults who smoke are planning to quit in the next month (Kim et al., 2024), so the traditional smoking cessation aids are only relevant to this small fraction. E-cigarettes, on the other hand, can help people stop smoking even if they didn’t plan to (“accidental switching”; Kasza et al., 2021; Carpenter et al., 2023; Kim et al., 2024).

A person who smoked once told me, “I can quit any time I want; I just don’t want to.” He wouldn’t want medical help to quit, but he would have benefited from using nicotine in a safer form.

Finally, as I mentioned in the beginning, there’s the matter of “gatekeeping” of smoking cessation in the medical route. Between doctors’ misperceptions and the hostile stance of several prominent medical groups, patients seeking advice about e-cigarettes have a good chance of being misinformed, discouraged from trying e-cigarettes, or worse, told to go back to smoking after they’ve switched.

But hopefully this JAMA commentary — in a prominent medical journal with clear and sound recommendations to clinicians — will help overcome that opposition and correct misperceptions.