Doctor's Orders: Many Physicians Endorse Vaping As Safer Alternative to Smoking

When I first told my doctor that I took up vaping as a smoking-cessation tool in 2012, I expected a finger-wagging lecture about the dangers of nicotine. But that's not the response I got. “Good—keep using that thing, and stay off cigarettes,” he said casually. At the time, I thought my doctor was an outlier among his colleagues, but according to a recent study published in JAMA Network Open, a surprisingly large percentage (though still a minority) of physicians take a generally positive view of e-cigarettes.

The researchers surveyed 2,058 practicing physicians in seven specialties in two waves, from February to July 2018 and April to July 2019. Just over 60 percent of respondents said that all tobacco products were equally harmful and cessation was the best approach, but nearly 40 percent said their goal was to get patients to stop smoking, "even if it meant switching to less harmful forms of tobacco.” The majority of these doctors saw vaping as a viable option for smokers under their care:

“Physicians who believed that cigarettes were the most dangerous tobacco product were significantly more likely to report ever recommending e-cigarettes (34.1% vs 13.3%; P < .001).”

There is a sizable minority of harm-reduction advocates among practicing physicians, in other words. It's an encouraging conclusion because it suggests that many doctors reject the abstinence-only paradigm that dominates tobacco control research today.

What's more striking, however, is that harm-reduction advocates among physicians seem to have the most experience with tobacco given their specialty, status as former smokers themselves, or patient interest in e-cigarettes—the last of these being the most significant in prompting physicians to recommend e-cigarettes. Table 2 offered a helpful breakdown of which doctors recommended e-cigarettes to their patients:

• More than 33 percent of pulmonologists
• Nearly 25 percent of cardiologists
• 40 percent of physicians who had ever used an e-cigarette
• Just over 28 percent of doctors who had smoked at least 100 cigarettes

The authors paid lip service to the standard tobacco-control dogma—teen vaping rates are high; the long-term effects of vaping remain unknown—though they explained that e-cigarette use was linked to significantly higher quit rates than nicotine replacement therapy or behavioral therapy support in a 2020 systematic review. [1], [2] Doctors are likely evaluating this evidence in light of the specific needs and experiences of their patients, the study authors concluded:

In the absence of definitive evidence about e-cigarettes for cessation, it could be expected that physicians, who often find themselves in situations that may not be directly addressed in standard practice and treatment guidelines, took a pragmatic approach. This finding was consistent with previous qualitative studies showing that physicians were more inclined to recommend e-cigarettes to certain patients, including those who had multiple unsuccessful quit attempts.

We now have multiple studies showing that practicing physicians do what anti-smoking groups and health reporters refuse to do: draw evidence-based conclusions that help smokers lead healthier lives.

[1] Teen vaping rates are actually quite low. See this thread by biologist Charles Gardner for details.

[2] “Long-term effects unknown” is a dubious standard. It's necessarily true since we can't predict the future, but often used to ignore the existing evidence on vaping's risks and benefits. The long-term effects of COVID vaccination are “unknown,” but that doesn't mean an obese 60-year-old should risk catching SARS-CoV-2.