The question a smoker asks you has changed.
For twenty years the question was “should I switch to vaping?” and the answer most of us gave was some version of “we don’t know enough.” That answer expired on July 30, 2026. That day JAMA published “Nicotine E-Cigarettes for Cigarette Smoking Cessation: Recommendations to US-Based Clinicians,” written by the Harm Reduction Workgroup of the Society for Research on Nicotine and Tobacco. Twenty-four tobacco treatment and addiction researchers put their names on it. It’s the first set of US clinical recommendations to say, in plain language, that nicotine e-cigarettes belong in the cessation conversation alongside varenicline, bupropion, and nicotine replacement.
So the question now is “which e-cigarette?” One number from the trials, which the press coverage skipped, should shape the answer: how many people are still using the device a year later.
What the recommendations say
The guidance is narrower than the headlines. It applies to adults who currently smoke cigarettes. Not teenagers. Not people who have never used tobacco. For those adults, the workgroup recommends that clinicians present nicotine e-cigarettes as one evidence-based option and use shared decision-making to choose among them.
The practical steps are specific. Point patients toward FDA-authorized products rather than whatever the gas station sells. Encourage complete substitution, not long-term dual use. Pair the device with behavioral counseling, the same way you’d pair a patch with counseling. And correct the misconception that most patients and a fair number of clinicians still carry: nicotine isn’t what causes most smoking-related disease. The combustion by-products are.
The authors are careful to say what the recommendations are not. E-cigarettes are not risk-free. They are not FDA-approved cessation medications. The workgroup doesn’t claim otherwise.
The evidence underneath it. The efficacy data have been accumulating for a while. The 2023 ACC/AHA chronic coronary disease guideline summarized 29 randomized trials of e-cigarettes for smoking cessation, five at low risk of bias. In meta-analysis, nicotine e-cigarettes beat nicotine replacement therapy with a relative risk of 1.69, which worked out to a 4% absolute increase in quit rates. That’s a real effect. Annual quit rates among people who smoke are under 10%, so a 4 point absolute gain is meaningful.
The cardiology guideline already gave e-cigarettes a Class 2b recommendation three years ago, with level B-R evidence, for short-term use in patients with chronic coronary disease. The language was hedged: short-term use “may be considered,” although “the risk of sustained use and unknown long-term safety may outweigh the benefits.”
What happens at one year. In one of the trials the guideline cited, 80% of the people assigned to e-cigarettes who successfully quit smoking were still using the device at one year. In the nicotine replacement arm, 9% were still using the patch or gum at one year.
Eighty versus nine. That figure says nothing about safety. It measures dependence. Nicotine replacement therapy works as a bridge: you cross it, and then you’re off nicotine. E-cigarettes, for most people who succeed with them, work as a destination. You stop smoking and you keep vaping. For a lot of patients that trade is worth making. Cigarette smoke damages the endothelium, promotes atherosclerosis, and is prothrombotic. The cardiology guideline notes that nicotine e-cigarettes appear to affect endothelial function, vascular stiffness, and blood pressure less than combustible cigarettes. Less harm is less harm.
But “less harm than smoking” and “no harm” are different claims, and the long-term cardiovascular risk of a decade of vaping is unknown. The same guideline says the physiologic and toxicology data suggest e-cigarettes may increase cardiovascular risk. Nobody has followed a cohort of former smokers who vaped for fifteen years, because the products haven’t existed long enough.
So the clinician’s job just got harder, not easier. The old conversation had one decision: will you try to quit? The new one has two. Will you try to quit, and are you choosing a bridge or a destination?
What this changes at the bedside. I see this in cardiology clinic regularly. A patient with a stent, two years out, still smoking a pack a day. He’s tried the patch twice. He’s heard about vaping from a coworker who quit that way.
Before July, I’d have told him the data were mixed. That was true and it wasn’t useful. Now the conversation runs differently. Varenicline is still the most effective single agent we have, and the EAGLES trial of over 8,000 patients put the cardiovascular safety question to rest. That’s where I’d start. If he’s failed varenicline or won’t take it, an FDA-authorized e-cigarette with counseling is a legitimate next step. Then I’d say this: “If this works, there’s a good chance you’ll still be vaping a year from now. We don’t know what that does to your arteries over ten years. We do know what the cigarettes do.”
He gets to decide. That’s what shared decision-making means. It doesn’t mean I withhold the 80% figure because it might discourage him.
The workgroup got this right by naming complete substitution as the goal and dual use as the failure mode. The patient who smokes ten cigarettes a day and vapes the rest of the time hasn’t reduced his risk much. The one who vapes and never lights a cigarette again has.
Taking a smoking history used to mean one question. It means two now. The second one is “are you still using the device,” and most clinics haven’t started asking it.
What I teach at APP Cardiology Academy works from that second question backward: risk-factor counseling that treats the dependence a therapy leaves behind as part of the therapy’s profile, not a footnote. The cigarettes are the enemy. The device that replaces them still needs a chart note.