Safer Solutions: New guidance urges doctors to include tobacco harm reduction in smoking cessation
“Special communication” publications in medical journals rarely capture much attention. But one such item, published in the Journal of the American Medical Association in July, is worth acknowledging because it represents a major step forward in supporting health professionals who want to help their patients quit smoking.
Authored by two dozen clinicians, researchers, and public health experts, this commentary provides clear, actionable guidance for clinicians on including e-cigarettes as part of their toolkit to help people quit smoking. It states that “e-cigarettes with nicotine are less harmful than cigarettes and have been shown to be more effective for smoking cessation than US Food and Drug Administration-approved nicotine replacement therapies,” and recommends that clinicians “integrate e-cigarettes into conversations on the risks and benefits of all evidence-based pharmacologic treatments for smoking cessation.”
Before we get deeper into the recommendations, let’s talk about why this is such a groundbreaking moment. Most Americans don’t know that vaping nicotine is significantly less harmful than smoking cigarettes—the most deadly way to consume nicotine. A similar dynamic is at work with health providers. Many clinicians also hold incorrect beliefs about the health risks of smoking cigarettes compared to vaping nicotine. In 2020, a national survey of U.S. doctors found that more than 80 percent erroneously believe nicotine directly causes cancer. A 2026 survey documented that about a quarter of participating doctors still mistakenly believe nicotine causes cancer and that e-cigarettes are worse for health than smoking cigarettes.
As a result, when people struggle to quit smoking via traditional means (e.g., counseling, nicotine patches and lozenges, medications), their doctors are unlikely to suggest switching to vaping as a risk-reducing strategy. And without fact-based guidance from trusted doctors, they are less likely to discover on their own that such a switch could improve their health—or even save their life.
These misconceptions are bolstered by communications from public health organizations that lack necessary nuance and cast reduced-risk nicotine products in an almost wholly negative light. Some trusted health organizations make absolutist statements like “e-cigarettes may seem safe to use, but they are not,” thereby erasing the nuance of relative risk. Others stress that “vaping is not a safe or healthy alternative to smoking,” failing to mention that a switch from smoking to vaping represents a real reduction in health risk—especially for people for whom quitting smoking is otherwise difficult or even impossible. Still others downplay the hard work that switching from smoking to vaping represents, insisting that, “switching to use of [e-cigarettes] is not quitting.” When such misleading claims are just a Google search away, they continue to feed into misperceptions by the public and clinicians alike.
That context brings us back to the new clinical guidance. It is clear-eyed about the burden of smoking, which is the leading cause of preventable disease and death in the United States. It also notes that “most U.S. adults who smoke want to quit” and that while more than half try to quit every year, fewer than 10 percent are successful. That’s a long, hard road for people who smoke, and another reason it’s so important for clinicians to have the full arsenal of quit tools available, including e-cigarettes, which many studies identify as a more successful off-ramp from smoking compared to traditional quit tools.
The new clinical guidance is also frank about what we do and do not know about the risk profile of e-cigarettes relative to smoking. It states that, “e-cigarettes expose users to fewer carcinogens and other toxicants.” It also acknowledges that data on the effects of long-term e-cigarette use is limited while noting that e-cigarettes have been sold and used for almost two decades without “population-level evidence of significant harm to health (e.g., cancer, lung disease).”
On misinformation, the authors specifically mention the 2019 lung injuries that many health professionals and members of the public still falsely associate with nicotine vapes. Here at Safer Solutions, we’ve written about this stubbornly persistent piece of misinformation repeated by journalists and trusted public health organizations alike.
Finally, the authors in the workgroup make clear recommendations to clinicians:
- Include nicotine e-cigarettes as one of the tools offered to help adult patients quit without requiring that they “first try or fail an FDA-approved medication.”
- Address misperceptions about e-cigarettes and relative risk.
- Center the patient by asking questions about their goals, and support the patient if they choose to try e-cigarettes as a quit tool.
This clinical guidance and its straightforward recommendations will not change patient care overnight. Changing misperceptions takes time, and accurate communication from public health organizations would certainly help things along. But this clarion call from a diverse group of respected experts represents a real breakthrough in smoking cessation. As this guidance trickles down, we hope it will result in more empowered patients and clinicians, better health, and longer life for people who currently smoke.
Read more on this new guidance from our colleague Jeff Smith.