Electronic cigarettes for smoking cessation

Abstract

Rationale: Electronic cigarettes (EC) are handheld electronic vaping devices that produce an aerosol by heating a liquid. People who smoke, healthcare providers, and regulators want to know if EC can help people quit smoking, and if they are safe to use for this purpose. This review update was conducted as part of a living systematic review.

Objectives: To examine the safety, tolerability, and effectiveness of EC for helping people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments, and no treatment.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 March 2025, reference-checked, and contacted study authors.

Eligibility criteria: We included trials randomising people who smoked to an EC or control condition. We also included uncontrolled intervention studies where all participants received an EC intervention. Studies had to measure an eligible outcome.

Outcomes: Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). Important outcomes were biomarkers, toxicants/carcinogens, and longer-term EC use.

Risk of bias: We used the RoB 1 tool to assess risk of bias for each study and GRADE to assess evidence certainty.

Synthesis methods: We followed standard Cochrane methods for screening and data extraction. Where appropriate, we pooled data using random-effects models to calculate risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes. For continuous outcomes, we calculated mean differences with 95% CIs.

Included studies: We included 104 completed studies (14 new to this update), representing 30,366 participants, of which 61 were randomised controlled trials (RCTs). We rated 11 included studies as being at low risk of bias, 70 at high risk (including all non-randomised studies), and the remainder at unclear risk overall.

Synthesis of results: Nicotine EC result in increased quit rates compared to nicotine replacement therapy (NRT) (high-certainty evidence) (RR 1.55, 95% CI 1.28 to 1.88; I² = 0%; 9 studies, 2703 participants). In absolute terms, this might translate to an additional three quitters per 100 (95% CI 2 to 5 more). The rate of occurrence of AEs is probably similar between groups (moderate-certainty evidence (limited by imprecision)) (RR 1.00, 95% CI 0.73 to 1.37; I² = 58%; 7 studies, 2241 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.22, 95% CI 0.73 to 2.03; I² = 30%; 8 studies, 2950 participants; low-certainty evidence). Nicotine EC probably result in increased quit rates compared to non-nicotine EC (moderate-certainty evidence, limited by imprecision) (RR 1.34, 95% CI 1.06 to 1.70; I² = 0%; 7 studies, 1918 participants). In absolute terms, this might lead to an additional two quitters per 100 (95% CI 0 to 4 more). There is probably little to no difference in the rate of AEs between these groups (moderate-certainty evidence) (RR 1.01, 95% CI 0.95 to 1.08; I² = 0%; 5 studies, 840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 0.98, 95% CI 0.55 to 1.73; I² = 0%; 10 studies, 1717 participants; low-certainty evidence). Compared to behavioural support only or no support, quit rates may be higher for participants randomised to nicotine EC (low-certainty evidence due to risk of bias) (RR 1.78, 95% CI 1.42 to 2.25; I² = 13%; 11 studies, 6819 participants). In absolute terms, this represents an additional three quitters per 100 (95% CI 2 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomised to nicotine EC (RR 1.22, 95% CI 0.96 to 1.55; I² = 66%; 8 studies, 2485 participants; very low-certainty evidence) but the evidence is uncertain and, again, there was insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.93, 95% CI 0.67 to 1.29; I² = 0%; 15 studies, 4716 participants; very low-certainty evidence). Data from non-randomised studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons; hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit.

Authors' conclusions: There is high-certainty evidence that nicotine EC increase quit rates compared to NRT, and moderate-certainty evidence that they probably increase quit rates compared to EC without nicotine. Evidence comparing nicotine EC with behavioural support or no support also suggests benefit, but is less certain due to risk of bias inherent in the study designs. CIs were, for the most part, wide for data on AEs, SAEs, and other safety markers, with no evidence of a difference in AEs between nicotine and non-nicotine EC nor between nicotine EC and NRT, but low-certainty evidence for increased AEs compared with behavioural support/no support. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longer, larger trials are needed to fully evaluate safety. Included studies tested regulated nicotine-containing EC; illicit products and/or products containing other active substances (e.g. tetrahydrocannabinol (THC)) may have different harm profiles. The main limitation of the evidence base remains imprecision for some comparisons and for safety outcomes due to the relatively small number of RCTs contributing, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this is a living systematic review. We run and screen searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Funding: Cancer Research UK (PICCTR-2024/100012).

Registration: Original 2012 protocol available via DOI: 10.1002/14651858.CD010216. Updated 2023 protocol available via DOI 10.17605/OSF.IO/ZWGSK (https://osf.io/ZWGSK/). 2025 updates to protocol available via DOI: 10.17605/OSF.IO/59M4U (https://osf.io/59M4U/) and DOI: 10.17605/OSF.IO/UPGJC (https://osf.io/UPGJC/).

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PRISMA diagram for 2025 update

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Risk of bias graph

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Risk of bias summary

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Analysis 1.1: EC vs NRT ‐ Smoking cessation

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Analysis 1.2: EC vs NRT ‐ Adverse events

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Analysis 1.3: EC vs NRT ‐ Serious adverse events

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Analysis 7.1: Nicotine EC vs non‐nicotine EC ‐ Smoking cessation

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Analysis 8.1: EC vs behavioural support only/no support ‐ Smoking cessation

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Analysis 7.2: Nicotine EC vs non‐nicotine EC ‐ Adverse events

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Analysis 8.2: EC vs behavioural support only/no support ‐ Adverse events

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Analysis 7.3: Nicotine EC vs non‐nicotine EC ‐ Serious adverse events

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Analysis 8.3: EC vs behavioural support only/no support ‐ Serious adverse events

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Funnel plot. Comparison: Nicotine EC vs behavioural/no support. Outcome: Carbon monoxide (ppm)

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Funnel plot. Comparison: Nicotine EC vs behavioural/no support. Outcome: smoking cessation