Research consistently shows e-cigarettes help smokers quit. When will U.S. policy catch up?

A sweeping new overview of the evidence on e-cigarettes and smoking cessation, published in the journal Addiction by researchers at the University of Oxford and Queen Mary University of London, should put to rest any remaining doubts over whether e-cigarettes help smokers quit. They do.

The paper synthesized 14 systematic reviews encompassing hundreds of primary studies. Every single comparison pointed in the same direction. Nicotine e-cigarettes outperformed every other cessation intervention tested.

Compared with nicotine replacement therapies (NRT) such as gums and patches, e-cigarettes showed improved quit rates ranging from 17 to 67 percent. Compared with placebo or behavioral support alone, the advantage was even bigger. The authors concluded that claims that the evidence is “mixed” on this question are simply not supported by the data.

The analysis followed the same methodology as the Cochrane Review, which is itself considered one of the leading authorities on evidence-based medicine, and has consistently found that e-cigarettes are more effective than NRT. Back in 2024, an editorial in the New England Journal of Medicine, commenting on a large randomized controlled trial that found e-cigarettes nearly doubled quit rates compared with standard care, concluded that the evidence has now reached a tipping point and that the American medical community must acknowledge e-cigarettes are effective cessation tools.

Peter Shields, Emeritus Professor of Medical Oncology at Ohio State University, agrees. Responding to the Oxford review, he said the evidence from Cochrane and others is “very consistent,” but that in the United States, this work is being ignored. “Too commonly, vaping is still viewed as something dangerous that should not be used as a smoking cessation tool,” said Shields.

For decades, the tools available to help smokers quit, such as NRT, have been inadequate, with success rates often measuring in the single digits. But e-cigarettes, one of the most promising innovations for helping smokers escape cigarettes, have been consistently met with obstruction, regulatory paralysis, and deeply misleading public messaging from the very agencies charged with protecting public health.

The Food and Drug Administration (FDA) has spent years denying market authorization to thousands of domestic e-cigarette products and failing to inform adult smokers of the potential benefits of switching to vaping. While the FDA squeezed out domestic e-cigarette manufacturers, illicit vapes from companies that have no inclination to cooperate with the agency on ensuring product quality and consumer safety standards flooded in to fill the gap. While Americans who already vape may have few qualms with where their products are coming from, it’s those who still smoke and are fearful of trying something new who suffer from the FDA’s obstinacy.

A majority of smokers still incorrectly believe vaping is no safer than smoking, a damaging misconception that the FDA and Centers for Disease Control and Prevention (CDC) have done precious little to correct. In reality, the largest evidence review on e-cigarettes ever conducted found they are dramatically safer than cigarettes. 

The cost of this messaging failure is measured in the lives of those smokers who would otherwise have quit using cigarettes but failed to do so. Economist Alex Tabarrok has described the FDA’s snail-like pace in pharmaceutical drug approvals as having created an “invisible graveyard,” because those who would benefit from those drugs sometimes die waiting for their approval. The same is true for the FDA’s approach to e-cigarettes.

When smokers who want to quit believe that switching to an e-cigarette offers no health benefit, they have no incentive to make the switch. The United Kingdom, by contrast, serves as an example of a country that has embraced the evidence backing e-cigarettes as safer alternatives. The National Health Service actively promotes e-cigarettes to smokers and has distributed free vape kits as part of its “swap to stop” program. In 2024, the number of vapers in the U.K. surpassed the number of smokers for the first time.

If we would like to see similar positive health outcomes in the United States, the FDA must first accelerate market authorization for e-cigarettes that appeal to smokers, which are, for the most part, products in non-tobacco flavors, and stop playing whack-a-mole with an illicit market of its own making. Second, the FDA must stop hedging and start communicating clearly to smokers and healthcare providers that switching from cigarettes to e-cigarettes represents a significant reduction in health risk. Third, professional medical societies need to update their clinical guidance to reflect the evidence that e-cigarettes work, and clinicians should discuss them with patients who smoke.

Many of America’s 25 million smokers haven’t tried e-cigarettes because they’ve been told that there’s no point. The only thing standing between smokers and a tool that could save their lives is an institutional culture of regulatory timidity and the public health community’s reluctance to embrace any non-pharmaceutical or therapeutic path for cessation.

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