What a breakthrough e-cigarette study illustrates about addiction

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E-cigaretteThe first large, systematic study of whether e-cigarettes help people to quit smoking was published on 30 January in the New England Journal of Medicine, and covered by The New York Times, the BBC and many other major outlets, writes psychologist Stanton Peele for Filter magazine. It is good to switch to less harmful addictions, while seeking to support people to abandon addiction.

The study, conducted among almost 900 smokers in England, compared e-cigarettes and nicotine replacement therapy (NRT) – patches, gum etc – to discover whether vaping is helpful for cigarette cessation. The answer, unequivocally, was yes. The study found e-cigs to be roughly twice as likely to help cigarette smokers to quit as NRT.

The figures were still relatively low – with 18 percent of smokers who switched to e-cigs remaining smoke-free after one year, versus 10 percent for NRT. But, given that 18 percent would extrapolate to almost seven million people if applied across the population of US smokers, that is not something to sneeze at.

Study confirms what is known about addiction

These results actually affirm everything we know, or should know, about addiction. (In this article, I’ll use the term “addiction” in the popular sense, to describe compulsive use, with or without harms – although there are persuasive arguments to define addiction as necessarily including serious negative consequences, which align with current American Psychiatric Association criteria for diagnosing substance use disorders.)

Inhalation and involving your hands are crucial elements in cigarette addiction for some.

E-cigarettes work better than NRT for preventing cigarette smoking because smokers can still follow familiar and pleasurable patterns of behavior.

A crucial ingredient in the overall drug experience to which a person becomes addicted are the favored rituals involved in administering a drug.

Thus some people addicted to injecting heroin don’t accept non-injectable opioid replacements (like methadone and buprenorphine), which is one rationale for heroin-assisted treatment. Likewise, inhalation and involving your hands are crucial elements in cigarette addiction for some.

The new study, in showing that many smokers will succeed better by vaping than by wearing a nicotine patch or chewing gum, suggested that replacing cigarettes without continuing these elements doesn’t work for roughly half of addicted smokers who are able to switch to other nicotine products.

The worried observation, published in a separate editorial inthe New England Medical Journal, that 80 percent of the study participants who had quit by using e-cigarettes were still vaping at one year, while only nine percent of the NRT group were still using NRT, misses the point – the fact that smokers find e-cigarettes preferable is the whole advantage of that treatment.

Neither e-cigarettes nor NRT cure addiction

Neither e-cigarettes nor NRT cure, or even halt, “addiction”, used in the sense I described. In both cases, the person remains dependent on the chemical effects of nicotine, only delivered in much safer form. Replacing something that is potentially lethal (like adulterated street heroin, or shared syringes) with something that is not (like safely administered heroin, or sterile syringes) is the very essence of harm reduction.

The fact that people who switch to other nicotine products may keep using them compulsively, however, is not necessarily a bad thing. Addictive experience can be essential for a person’s functioning, in either the short or the long run.

In The Meaning of Addiction I explain how addiction is not an inherent property of drugs (as in, “heroin is chemically addictive”).

People instead become addicted to the experience that the drug – or other addictive involvement – provides. That is, the “drug” – be it heroin, nicotine, alcohol, sex or gambling – provides feelings and sensations that are so welcome as to feel essential for the person.

The benefits these experiences provide may be long-term, as heroin may be for sexual assault survivors, or shorter-term – as opiates were for caged rodents, but not when they were removed to Rat Park; or for soldiers in Vietnam, but not when they returned home.

Rather than recognize this, we too often confuse addiction with directly induced medical problems. Addiction is not per se medically harmful, though some kinds of addiction are. But our culture’s view of compulsive use means that we too readily combine the ideas of “harmfulness” and dependence.

Survival is at stake

People who vape obviously haven’t quit nicotine. For some critics, this makes vaping a useless exercise. “Vaping may help some people quit cigarettes, but what about the nicotine?” When survival is at stake, this, again, misses the point.

If there is a way to continue nicotine use without killing yourself, anyone ought to consider that a positive outcome. Death is bad. And among the many reasons for death’s badness is that it prevents people from outgrowing addiction – as Maia Szalavitz, Gene Heyman and I show that most people do.

Giving people the space and time – even a lifetime – to overcome addiction is an incalculable existential gift. And the realization that addiction is typically outgrown ought to somewhat reassure those who are concerned about youth vaping.

As a backdrop to the regularity of natural recovery, keep in mind, however, that cigarette-smoking is the most resilient of substance addictions. NESARC, a massive survey (43,000 subjects) of Americans’ lifetime drug and alcohol use, shows that while most people overcome drug addictions over their lifetimes, smokers are the least likely to do so (84 percent of smokers do, versus 91 percent for alcohol, 97 percent for cannabis, and 99 percent for cocaine).

Moreover, the half-life (the point at which half of those who were ever dependent remitted) for each form of addiction was 26 years for tobacco, 14 for alcohol, six for cannabis and five for cocaine. (This, however, constitutes an additional argument for tobacco harm reduction, rather than one against it.)

For smokers, getting beyond the peak early period for relapsing is a significant landmark to achieve. In another analysis from NESARC, the risk of relapse for those who had quit smoking for a year or less was above 50 percent; for smokers who had quit for over a year, the risk of relapse rapidly decreased, stabilizing at around 10 percent after 30 years.

Concomitant addiction therapy

Providing replacement therapies can be life-preserving. Convincing people in the process that they have a lifelong disease is not.

Addiction replacement therapies can sometimes have negative effects, but this depends on how they are presented. In one remarkable study that followed people who quit smoking with and without NRT for several years, the most dependent smokers were two-to-three times as likely to relapse if they relied on NRT.

Putting our common-sense hats on, why would this be? Because, if you believe your quitting depends only on using a replacement, then ceasing to use that replacement will likely lead to relapse.

Concluding that you were able to overcome addiction on your own is less likely to lead you down this road; belief that your addiction is a disease over which you are powerless increases the chances of relapse.

We should therefore ask ourselves how to maximize the benefits of replacement therapies, while minimizing potential drawbacks. As Zach Rhodes described in Filter, providing replacement therapies like buprenorphine and methadone can be life-preserving. Convincing people in the process that they have a lifelong disease is not.

Concomitant addiction therapy – that is, therapy that assists, encourages and inspires people to overcome addiction – provides guideposts, goals and resources for people to permanently leave addiction behind, even while welcoming their safer addictive alternative.

Dependence is not always harmful, and it is useful and good to switch people from harmful to less harmful addictions. While embracing such lifesaving switches, we can continue, through help and our own agency, to seek the purpose and fulfilment that can give us the choice of abandoning addiction. Praying for some sort of miracle cure for addiction only sidetracks us from what is genuinely helpful.

In the meantime, let’s welcome the good news about e-cigarettes. Whether or not addiction may be harmful, death always is.

* Dr Stanton Peele is a psychologist who has pioneered, among other things, the idea that addiction occurs with a range of experiences and recognition of natural recovery from addiction. He developed the Life Process Program for addiction and has authored many books since the 1975 publication of Love and Addiction (co-authored by Archie Brodsky). His book Outgrowing Addiction: With Common Sense Instead of “Disease” Therapy (with Zach Rhoads) will be published by Upper Access Press in May 2019. 

* Filter magazine advocates for rational and compassionate approaches to drug use, drug policy and human rights.

What a Breakthrough E-Cigarette Study Illustrates About Addiction



E-cigarettes are effective at helping smokers quit – Study

A year-long, randomised trial in England showed that e-cigarettes were almost twice as successful as products like patches or gum for smoking cessation, writes Jan Hoffman for The New York Times. It has been one of the most pressing unanswered questions in public health: Do e-cigarettes actually help smokers quit? Now, the first, large rigorous assessment offers an unequivocal answer: Yes.

The study, published on 30 January in the New England Journal of Medicine, found that e-cigarettes were nearly twice as effective as conventional nicotine replacement products, like patches and gum, for quitting smoking.

The success rate was still low – 18 percent among the e-cigarette group, compared to 9.9 percent among those using traditional nicotine replacement therapy – but many researchers who study tobacco and nicotine said it gave them the clear evidence they had been looking for.

This is a seminal study,” said Dr. Neal L. Benowitz, chief of clinical pharmacology at the University of California, San Francisco, an expert in nicotine absorption and tobacco-related illnesses, who was not involved in the project. “It is so important to the field.”

The study was conducted in Britain and funded by the National Institute for Health Research and Cancer Research UK. For a year it followed 886 smokers assigned randomly to use either e-cigarettes or traditional nicotine replacement therapies. Both groups also participated in at least four weekly counseling sessions, an element regarded as critical for success.

The findings could give some new legitimacy to e-cigarette companies like Juul, which have been under fire from the government and the public for contributing to what the Food and Drug Administration has called an epidemic of vaping among teenagers. But they could also exacerbate the difficulty of keeping the devices away from young people who have never smoked while making them available for clinical use.

“There is an unavoidable tension between protecting kids from e-cigarettes and smoking cessation, which is also very important,” Dr. Benowitz said.

Tobacco use causes nearly six million deaths worldwide each year, including 480,000 in the United States, according to the Centers for Disease Control and Prevention. If tobacco use trends continue, the global death tally is projected to reach 8 million deaths annually by 2030.

E-cigarettes provide the nicotine smokers crave without the toxic tar and carcinogens that come from inhaling burning tobacco. But regulators in the United States, Britain and elsewhere have not approved them to be marketed as smoking cessation tools.

Full report in The New York Times, which allows a limited number of free access articles per month.

E-cigarettes are effective at helping smokers quit, a study says


A randomized trial of e-cigarettes versus nicotine-replacement therapy


E-cigarettes are commonly used in attempts to stop smoking, but evidence is limited regarding their effectiveness as compared with that of nicotine products approved as smoking-cessation treatments.


We randomly assigned adults attending UK National Health Service stop-smoking services to either nicotine-replacement products of their choice, including product combinations, provided for up to 3 months, or an e-cigarette starter pack (a second-generation refillable e-cigarette with one bottle of nicotine e-liquid [18 mg per milliliter]), with a recommendation to purchase further e-liquids of the flavor and strength of their choice. Treatment included weekly behavioral support for at least 4 weeks.

The primary outcome was sustained abstinence for one year, which was validated biochemically at the final visit. Participants who were lost to follow-up or did not provide biochemical validation were considered to not be abstinent. Secondary outcomes included participant-reported treatment usage and respiratory symptoms.


A total of 886 participants underwent randomization. The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58; P<0.001). Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]).

Overall, throat or mouth irritation was reported more frequently in the e-cigarette group (65.3%, vs. 51.2% in the nicotine-replacement group) and nausea more frequently in the nicotine-replacement group (37.9%, vs. 31.3% in the e-cigarette group).

The e-cigarette group reported greater declines in the incidence of cough and phlegm production from baseline to 52 weeks than did the nicotine-replacement group (relative risk for cough, 0.8; 95% CI, 0.6 to 0.9; relative risk for phlegm, 0.7; 95% CI, 0.6 to 0.9). There were no significant between-group differences in the incidence of wheezing or shortness of breath.


E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support. (Funded by the National Institute for Health Research and Cancer Research UK; Current Controlled Trials number, ISRCTN60477608.)


Peter Hajek, Ph.D., Anna Phillips-Waller, B.Sc., Dunja Przulj, Ph.D., Francesca Pesola, Ph.D., Katie Myers Smith, D.Psych., Natalie Bisal, M.Sc., Jinshuo Li, M.Phil., Steve Parrott, M.Sc., Peter Sasieni, Ph.D., Lynne Dawkins, Ph.D., Louise Ross, Maciej Goniewicz, Ph.D., Pharm.D. et al.

A randomized trial of e-cigarettes versus nicotine-replacement therapy



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