Vaping Superior to Nicotine Replacement Therapy, Yet Another Study Shows

The pile of studies confirming that nicotine vaping is an effective quit-smoking tool continues to grow. According to a clinical trial just published in the Annals of Internal Medicine, vaping was significantly more effective than nicotine replacement therapy (NRT) in helping “socially disadvantaged” adult smokers quit and stay smoke free for at least six months. The authors put their results in perhaps the strongest terms you’ll read in a peer-reviewed journal:

“Among a low SES [low socioeconomic status] population wanting to quit, VNPs [vaporized nicotine products] were more effective for smoking cessation than NRT [nicotine replacement therapy] alongside minimal behavioral support. This effect was found for all smoking cessation measures at all time points. Consequently, VNPs may have a role in promoting smoking abstinence among groups experiencing socioeconomic disadvantage as well as in the general population.”

As a clinical trial, this study provides some of the best evidence researchers can produce and points to a conclusion too long neglected by the public health community: vaping should be widely promoted as a smoking-cessation tool to the 30 million Americans who still use combustible tobacco.

Study recap

Participants were randomized to either the vaping group or NRT group. The study wasn’t double blinded since everyone knew they were vaping an e-cigarette or chewing nicotine gum; however, the researchers analyzing the results didn’t know who got which intervention until the end of the trial. Australia's National Drug and Alcohol Research Centre managed the study, while an independent organization handled key interviews to minimize the risk of bias. 

The study recruited over 1,000 adults from Sydney, Australia, and nearby areas, primarily through ads on Facebook and Instagram. These participants were daily smokers, at least 18 years old, eager to quit within two weeks, and receiving government benefits, a proxy for their status as socially disadvantaged. 

The NRT group got an 8-week supply of nicotine gum or lozenges in mint flavor, with the option to switch between them after four weeks. The VNP group received two vaping devices—a tank and a pod device—loaded with nicotine e-liquid in various strengths and flavors like tobacco, menthol, or fruit. Importantly, they could pick their favorite device and flavors for the second half of the supply. Both groups were mailed their products, given a quit date (day 8 after starting), and told about possible side effects. To support their quitting journey, everyone received encouraging text messages for five weeks with tips tailored to their treatment.

The researchers called participants twice in the first month to check if they were still smoking, whether they were using their products correctly, and if they had any side effects. Seven months later, participants did a final phone interview and were paid $40 for their time. Those who said they hadn’t smoked for six months took a carbon monoxide breath test to prove they were smoke-free, either in person or remotely, earning another $40. The test could detect recent smoking but not how long someone had been smoke-free. 

Results: vaping better by every metric

In the NRT group, 9.6% (about 50 people) quit smoking, while in the VNP group, 28.4% (about 148 people) quit. The difference was 18.7%, and there was a 99.9% chance that vaping worked better than NRT. Additional checks, called sensitivity analyses, backed this up, showing vaping was still more effective even when looking at the data differently. For example, one analysis showed 36.3% of the VNP group quit compared to 11.8% of the NRT group, with a 24.3% difference and over a 99% chance that vaping was better. Vaping also worked better for all groups, whether split by age, sex, nicotine addiction level, or mental health status. 

Quit rates were similar within each treatment group for those with or without mental health issues (9% vs. 10% for NRT, 26% vs. 30% for VNP). For other measures, like self-reported quitting (without a breath test), the VNP group did better across the board. However, among those still smoking at 7 months, neither group reduced their cigarette use significantly compared to the other. 

Side effects were less common with vaping: 237 people in the VNP group reported 355 issues, while 278 in the NRT group reported 442 issues. This means vaping had about 11.5% fewer people with side effects, with a very high chance (99%) this was true. Common issues included COVID-19, cough, headache, and nausea. Cough and headache were more common with vaping, while nausea was more frequent with NRT. Serious side effects were rare and similar in both groups, with no clear difference (1.43 times more in VNP, but not significant, with a 90% chance of no real difference).

Breathing problems, like cough or shortness of breath, didn’t differ between groups at the start, during check-ins, or at the end. Most people tried their assigned treatment: 91.6% in the NRT group and 97.5% in the VNP group, with no significant difference. But more people in the NRT group (23.2%) stopped using their treatment early compared to just 2.2% in the VNP group, a very significant difference (16.3 times more likely to stop with NRT). 

NRT users often quit because they disliked the taste or had side effects, while VNP users rarely stopped, citing unrelated health issues or stress. In the VNP group, most (69.6%) used both vaping devices. NRT users used about 42 pieces of gum or lozenges on average.

By the 7-month follow-up, 56.3% of people in the VNP group kept using their vaping products at least weekly compared to 30.9% in the NRT group. Among those who quit smoking, 34% of NRT users and 58.1% of VNP users were still using their assigned products. Of the 253 VNP users still vaping at 7 months, 36.4% got their e-liquid through a prescription. Overall, the study showed vaping helped more people quit smoking, with fewer side effects and better sticking with the treatment compared to NRT.

Replicating real vaping habits

The existing literature on nicotine vaping is vast, though much of it is useless because it doesn’t evaluate nicotine vaping as it’s used by real people. For example, some previous studies have erroneously defined a “relapse” to smoking as “even one or two puffs” of a cigarette, using that as evidence that vaping doesn’t help smokers quit. 

This trial avoided stacking the deck by realistically defining abstinence as smoking 5 or fewer cigarettes over the previous 6 months, “validated biochemically by an expired carbon monoxide (CO) level of ≤5 ppm.” They also measured secondary effectiveness outcomes, including a 50% self-reported reduction in cigarette consumption between the beginning and end of the study period. In other words, the researchers left room for normal human behavior and verified the key data provided by participants. 

By way of comparison, if you lose a significant amount of weight on a diet, having “even one or two bites” of a cookie isn’t evidence that you've relapsed to your old, unhealthy eating habits. The same standard applies here.

Critically–and I can’t stress this point enough–“the study design partially replicated the routine setting in the community by allowing device and flavor preferences.” Previous research has shown that giving adults access to a broad array of flavored nicotine increases the likelihood that they will quit smoking. 

This is why the FDA’s longstanding policy of effectively banning flavored vapes is inexcusable. It’s all the more outrageous because the FDA acknowledged in a 2020 internal evidence review that flavors help adult smokers quit. The tobacco-control busybodies will insist that flavors appeal to kids, but this simply isn’t true: teen vaping and smoking have hit historic lows, though illegal flavored vapes are widely available.

Conclusion: imperfect but solid evidence 

All studies have limitations, this one included. The researchers relied on participants to self-report their habits to a certain extent. While they used carbon monoxide levels to validate smoking cessation, the breath test they utilized only detects smoking over the previous 24 hours. The study also could have involved more people and followed them for a longer period, while allowing access to a wider selection of NRT and vaping products.  

Nevertheless, this was a well-designed trial. It joins some 90 other studies involving more than 20,000 people showing that nicotine vaping effectively helps adults quit smoking. Anybody who continues to claim that vaping hasn’t been sufficiently studied for safety and efficacy is misinformed or ethically challenged.