Safer Solutions: When will the facts about tobacco harm reduction trickle down to veterans?
While veterans’ smoking rates have declined, smoking remains a persistent, deadly issue: About 22 percent of veterans are “current smokers”—twice the rate of Americans overall. The Veterans Health Administration (VA) spends close to $3 billion per year on smoking-related care, and the mortality rates for veterans who smoke are 1.73 times higher than those of non-smoking veterans.
A 2022 study found that despite robust smoking cessation programs available through the VA, “long-term abstinence is difficult to achieve,” even in veterans with lung cancer diagnoses. Some of the veterans who struggle most to quit are those with post-traumatic stress disorder, which is highly prevalent among veterans and associated with unusually high rates of unsuccessful quit attempts. This picture makes the VA a crucial actor in reducing the harms of smoking among our military veterans.
Veterans and their healthcare providers must be able to explore all pathways that offer lower-risk alternatives to smoking, including switching to smokeless nicotine products. But today, official information, advice, and access at the VA lags behind the evidence supporting these harm reduction options.
The Food and Drug Administration (FDA) clearly states that smoked tobacco is “the most harmful type” of tobacco product and that “[n]on-combusted products—such as e-cigarettes … generally have lower health risks than cigarettes…” The FDA also says that while quitting all forms of tobacco products outright has the greatest benefit for adults who smoke, adults who “fully switch … to a lower-risk alternative can generally reduce their health risk and exposure to … cancer-causing chemicals.” In other words, a harm reduction approach can offer risk reduction and better health to people who struggle to quit nicotine use completely. That’s why the FDA has authorized the sale of 20 nicotine pouch products and 39 e-cigarette products and devices to date.
On the other hand, the VA does not yet institutionally endorse reduced-risk options for veterans who struggle to quit smoking. As a clinical social worker serving military and veteran populations wrote last year, “[t]he VA publishes misinformation suggesting that vapes cause cancer. While vapes are not entirely risk-free, no reliable evidence demonstrates that they cause cancer … Ignoring established science and refusing to adopt technological advances that could save veterans’ lives is a failure in our commitment to those who served.”
The mismatch between the evidence and official VA statements on reduced-risk products is significant because the VA provides healthcare to more than 9 million veterans. It’s also at odds with the VA’s support for harm reduction in illicit drug use, where the agency takes a pragmatic approach to helping veterans improve their health and reduce their risks even if they don’t completely quit using drugs.
But emerging voices within the VA and the veteran community are exploring tobacco harm reduction for veterans. During a 2024 R Street virtual event, a clinical psychologist with the VA said, “Anecdotally I’ve had much more success in smoking reduction by offering conversations around the use of … non-cigarette devices.”
A primary care physician and geriatrician who has led large-scale smoking cessation studies at the VA told R Street that the VA is making progress on cessation, attributing its 10-15 percent annual quit rate to medications, counseling, and making access to treatment as easy as access to cigarettes. “[T]here’s really solid science that when you compare e-cigarettes to nicotine replacement, e-cigarettes work better at getting people to quit…” While he does not suggest reduced-risk nicotine products as the first option for his patients, he does discuss them as a way to move away from combustible cigarettes.
Further, he said there is “lots of debate” at the VA about the potential role of harm reduction in smoking cessation. He noted that one problem with institutional acceptance of reduced-risk nicotine products is the erroneous narrative—prevalent in the media and among some national health organizations—that characterizes reduced-risk nicotine products as equally or more dangerous than smoking.
In the absence of official guidance on tobacco harm reduction from the VA, some veterans are taking a “do it yourself” approach. A 2020 study found that “the most popular reason for vaping among military beneficiaries is to try to quit smoking.” One retired Marine told R Street that when he left active duty, he switched from cigarettes to e-cigarettes and now has moved mostly to nicotine pouches. These products have helped him avoid cigarettes for more than 10 years. He pursued this path on his own, noting that “the VA could do a lot more to help veterans … get into something that’s safer.”
The VA does admirable work providing smoking cessation options to our nation’s veterans. A wider lens—one that includes evidence-based, reduced-risk nicotine products—could help further decrease smoking among veterans, save lives, improve health, and save taxpayer money. VA leadership at all levels should encourage an approach that includes traditional cessation methods and harm reduction options. That shift would translate to better health and more lives saved.