BACKGROUND Parental smoking is a leading source of secondhand smoke exposure for children, increasing risks of respiratory illness and future smoking. Cessation treatment delivery for parents remains rare in pediatrics. This study evaluates the population-level impact of an automated tobacco treatment system integrated into the electronic health record (EHR) in pediatric primary care.METHODS We conducted a retrospective observational study of parents whose children received care at 12 pediatric practices in a cluster-randomized trial (June 2021-August 2024). Six practices implemented an automated EHR-linked parent tobacco treatment system (screening, motivational messaging, automatic treatment connection including nicotine replacement therapy, SmokefreeTXT, and quitline referral through a previsit questionnaire); 6 implemented screening only. This analysis included all parents who completed questionnaires during routine care, excluding parents enrolled in the trial. We analyzed self-reported cessation rates among parents who reported smoking during the study period.RESULTS Among 55 567 parents with follow-up data (49 595 mothers; 5972 fathers), smoking rates were 4.3% vs 5.5% for mothers and 6.5% vs 8.3% for fathers receiving care with vs without the system. Among mothers who reported smoking during the study, cessation rates were significantly higher for those receiving care with the system (37.4% vs 33.5%, P = .044), representing a 3.9% improvement. Among fathers who smoked, there was no difference in cessation rates (29.6% vs 29.6%).CONCLUSIONS An automated tobacco treatment system was associated with significantly increased maternal smoking cessation in pediatric settings while showing no effect for fathers. This scalable approach could enhance pediatric preventive care by reducing household tobacco use.

Importance Cigarette smoking, maintained predominantly by nicotine dependence, is a long-term and relapsing behavior that continues to be a leading cause of preventable death and disease worldwide. E-cigarettes with nicotine are less harmful than cigarettes and have been shown to be more effective for smoking cessation than US Food and Drug Administration–approved nicotine replacement therapies. However, misperceptions of the harms of e-cigarettes are common, even among clinicians. This Special Communication is a position manuscript developed by a working group within the Treatment Research Network of the international Society for Research on Nicotine and Tobacco. The aims of the manuscript were to summarize the evidence on the use of e-cigarettes for smoking cessation and to provide recommendations for clinicians on how to engage in conversations with adult patients who currently smoke cigarettes. Specifically, advice is provided on (1) integration of e-cigarettes into patient-centered shared decision-making conversations on the risks and benefits of various pharmacologic smoking cessation treatments; and (2) practical guidance on the use of e-cigarettes for smoking cessation. Observations This Special Communication includes one overarching recommendation: integrate e-cigarettes into conversations on the risks and benefits of all evidence-based pharmacologic treatments for smoking cessation. In support of this recommendation, specific guidance is provided regarding how to discuss potential misperceptions and suggests questions to guide patient conversations. Finally, evidence-based best practices are provided for using e-cigarettes to quit smoking, which can be shared with patients. Conclusions and Relevance The significant burden of cigarette smoking, coupled with scientific evidence supporting e-cigarettes for smoking cessation, clearly indicates that it is appropriate to include e-cigarettes in discussions of evidence-based pharmacologic treatment for smoking cessation to reduce the harms of cigarette smoking. These recommendations are intended to provide evidence-informed guidance to clinicians regarding use of e-cigarettes for smoking cessation.

INTRODUCTION:Cigarette smoking is the world's leading preventable cause of death. With no new smoking cessation pharmacotherapy approved since 2006, the 29 million US adults who smoke need new treatment options. Cytisinicline, a partial agonist at α4β2 neuronal nicotinic acetylcholine receptors, is the name of a new dosing regimen of cytisine, a smoking cessation pharmacotherapy that has been sold for decades in Eastern Europe but is currently unavailable in the US. The Food and Drug Administration is evaluating a New Drug Application for cytisinicline. AREAS COVERED:We summarize the history, chemistry, pharmacodynamics, and pharmacokinetics of cytisine and cytisinicline and explain their different dosing regimens. Two Phase 3 randomized double-blind placebo-controlled trials have demonstrated cytisinicline's efficacy and safety for smoking cessation in US adults. We review the trial results in the context of previous evidence supporting cytisine and other cessation medications. EXPERT OPINION:Cytisinicline has a strong evidence base to support US licensure as a smoking cessation aid. If approved and its effectiveness in clinical practice confirms its clinical trial efficacy, cytisinicline will likely join varenicline and combination nicotine replacement as a first-line smoking cessation treatment option. It may also aid cessation of electronic-cigarette vaping or other nicotine-mediated dependence disorders.

INTRODUCTION:Lung cancer screening (LCS) is an optimal time to offer tobacco treatment to adults who smoke, but many cannot quit even with treatment. Replacing combustible cigarettes (CC) with e-cigarettes (EC) could be a harm reduction approach, but few older adults use EC. No study has examined EC harm reduction potential among individuals undergoing LCS. METHODS:In a pilot mixed-methods single-arm clinical trial, we assessed the feasibility and short-term effects of providing EC to older adults not planning to quit after completing a smoking cessation trial at LCS. Participants were asked to use tobacco-flavored NJOY Ace EC (5% nicotine) for 4 weeks. Assessments occurred at weeks 1, 2, 3, 4, and 8, with qualitative interviews at week 4. Primary outcomes were study feasibility and change in cigarettes/day (CPD) during EC provision. Secondary outcomes included breath carbon monoxide (CO) and EC use. RESULTS:From 9/2024-2/2025, we enrolled 15 participants (54% of eligibles; mean age = 66.1 years, 40% female); 14 (93%) completed the study. Over the 4-week EC provision, mean CPD and breath CO declined significantly (CPD = 16.9 [SD:7.2] to 10.4[SD: 7.0], P<.001; CO: 19.4[SD:11.0] to 12.3[SD: 8.5], P=.04). Mean CPD remained stable post-EC provision. At week 4, participants used EC on 5.5 (SD:2.4) days/week; 2 participants (13%) used only EC, 12 (80%) were dual users, and 1 (7%) used only CC. CONCLUSIONS:This pilot trial showed the feasibility of recruiting older adults unable to quit smoking after LCS to use EC and suggested the short-term efficacy of EC to reduce CC consumption and CO exposure. IMPLICATIONS:This pilot study demonstrates the feasibility and promising short-term effects of switching older adults who smoke and did not quit at LCS to use EC. Participants' cigarette consumption and CO exposure declined over 4 weeks of EC provision, but most participants became dual users (EC and CC). Qualitative interviews illustrated benefits and challenges of switching. The findings deserve confirmation in a larger sample, but suggest that longer EC provision and behavioral support might help this group to completely replace CC use and gain the full harm reduction benefits associated with switching to EC.

Tobacco use is the leading cause of preventable death globally, claiming more than 7 million lives each year. The burden of disease is highest in low- and middle-income countries, where more than 80% of the world's 1.3 billion tobacco users reside. The World Health Organization (WHO) defines six proven strategies to reduce tobacco use, referred to by the acronym MPOWER, with one of the strategies being to offer tobacco users help with quitting. Many low- and middle-income countries provide tobacco-cessation services; however, only 31 meet the WHO best practice, defined as providing both cost-covered behavioral interventions and pharmacotherapy. In this article, case studies from India and Vietnam illustrate how cross-country differences in tobacco-related sociocultural norms, tobacco-use patterns (e.g., smokeless tobacco or water pipes), the tobacco-control regulatory environment, industry influence, and health care system financing shape treatment access and uptake. These cases further show that cost-effective population-level strategies, including quitlines, digital interventions, and systemwide screening for tobacco use paired with clinician advice to quit, are essential for expanding treatment reach. Combining these interventions with pharmacotherapy products that are included on the WHO Model List of Essential Medicines (e.g., cytisine and nicotine-replacement therapy) further improves cessation outcomes. System-level models, such as the Ask-Advise-Connect model (ask about tobacco use, advise to quit, connect to cessation help), offer a feasible, low-burden pathway for integrating cessation care into routine practice. Ultimately, curbing the rising global burden of tobacco-related disease requires establishing comprehensive cessation support as a universal standard of care, which would ensure equitable access for those most affected.

Importance:Cigarette smoking, maintained predominantly by nicotine dependence, is a long-term and relapsing behavior that continues to be a leading cause of preventable death and disease worldwide. E-cigarettes with nicotine are less harmful than cigarettes and have been shown to be more effective for smoking cessation than US Food and Drug Administration-approved nicotine replacement therapies. However, misperceptions of the harms of e-cigarettes are common, even among clinicians. This Special Communication is a position manuscript developed by a working group within the Treatment Research Network of the international Society for Research on Nicotine and Tobacco. The aims of the manuscript were to summarize the evidence on the use of e-cigarettes for smoking cessation and to provide recommendations for clinicians on how to engage in conversations with adult patients who currently smoke cigarettes. Specifically, advice is provided on (1) integration of e-cigarettes into patient-centered shared decision-making conversations on the risks and benefits of various pharmacologic smoking cessation treatments; and (2) practical guidance on the use of e-cigarettes for smoking cessation. Observations:This Special Communication includes one overarching recommendation: integrate e-cigarettes into conversations on the risks and benefits of all evidence-based pharmacologic treatments for smoking cessation. In support of this recommendation, specific guidance is provided regarding how to discuss potential misperceptions and suggests questions to guide patient conversations. Finally, evidence-based best practices are provided for using e-cigarettes to quit smoking, which can be shared with patients. Conclusions and Relevance:The significant burden of cigarette smoking, coupled with scientific evidence supporting e-cigarettes for smoking cessation, clearly indicates that it is appropriate to include e-cigarettes in discussions of evidence-based pharmacologic treatment for smoking cessation to reduce the harms of cigarette smoking. These recommendations are intended to provide evidence-informed guidance to clinicians regarding use of e-cigarettes for smoking cessation.

The increase in HIV pre-exposure prophylaxis (PrEP) uptake presents both challenges and opportunities. The process of initiating and continuing PrEP brings the medical care establishment into direct and ongoing contact with a young population that is often otherwise unengaged with health-care systems. The groups at highest risk for HIV acquisition, including PrEP recipients, have high rates of tobacco use, which remains the leading cause of preventable death in the world. However, there has been little attention paid to tobacco use and cessation treatment in the context of PrEP care. PrEP guidelines and tobacco use treatment guidelines do not mention the issue of tobacco use in PrEP recipients, and medical literature pertaining to this subject is virtually non-existent. Public health investments that focus on reducing the immediate risk of HIV acquisition have not been accompanied by sufficient investment aimed at mitigating the long-term harms of tobacco use within the same target population. This Viewpoint discusses easy and efficient strategies that might be used to promote tobacco use cessation in PrEP care settings and encourages health-care providers and policy makers to seize this opportunity.

Importance:Integrating smoking cessation interventions within lung cancer screening (LCS) programs may significantly reduce smoking-related morbidity and mortality. Data on costs and cost-effectiveness of smoking cessation interventions in the context of LCS can foster the dissemination of effective treatments. Objective:To evaluate the cost-effectiveness from a health system perspective of 8 smoking cessation treatment strategies evaluated in the context of the Screen Aiding Screening Support In Stopping Tobacco (ASSIST) trial among patients undergoing LCS in 1 large health care system. Design, Setting, and Participants:The Screen ASSIST trial used a 3-way factorial design testing the effectiveness of 8 combinations of smoking cessation treatments at a health system in Massachusetts with 11 participating LCS sites. In this economic evaluation, costs and cost-effectiveness were evaluated prospectively and contextualized through sensitivity analyses. Participants included English-speaking and Spanish-speaking patients who smoked and were scheduled for LCS between April 2019 and July 2023. Interventions:Participants were randomized to 4 vs 8 counseling sessions, 2 vs 8 weeks of nicotine replacement therapy (NRT), and screening for social determinants of health (SDH) vs no screening. Main Outcomes and Measures:The primary effectiveness outcome was self-reported 7-day smoking abstinence at 6 months. Cost measures included both start-up and operating costs, with incremental cost per quit (ICQ) calculated relative to usual care. Results:Screen ASSIST had 642 participants (mean [SD] age, 64.0 [6.5] years; 358 female [55.8%]; mean [SD] 36.8 [19.4] pack-years; mean [SD] 16.2 [8.2] cigarettes per day). Start-up costs for the program were $131 371, primarily for electronic health record programming ($124 903). Operating costs for the intervention conditions ranged from $196 272 to $274 865 for 642 participants. The ICQ of 8 counseling sessions, 2 weeks NRT, and no SDH screening was $3050 (95% CI, $1286-4815), the most cost-effective condition. Per-patient costs and ICQ would be lower in health systems serving larger patient populations. Conclusions and Relevance:In this economic evaluation of smoking cessation treatment in LCS, 8-session counseling combined with 2 weeks of NRT was a cost-effective strategy, with a favorable ICQ relative to usual care and other treatment strategies evaluated. These findings are relevant for health systems considering integrating smoking cessation programs with LCS services.

BACKGROUND:Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update of a review first published in 2014. OBJECTIVES:To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke achieve long-term smoking abstinence. SEARCH METHODS:We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 February 2021, together with reference-checking and contact with study authors. SELECTION CRITERIA:We included randomized controlled trials (RCTs) and randomized cross-over trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. To be included, studies had to report abstinence from cigarettes at six months or longer and/or data on adverse events (AEs) or other markers of safety at one week or longer. DATA COLLECTION AND ANALYSIS:We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included changes in carbon monoxide, blood pressure, heart rate, blood oxygen saturation, lung function, and levels of known carcinogens/toxicants. We used a fixed-effect Mantel-Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data from these studies in meta-analyses. MAIN RESULTS:We included 56 completed studies, representing 12,804 participants, of which 29 were RCTs. Six of the 56 included studies were new to this review update. Of the included studies, we rated five (all contributing to our main comparisons) at low risk of bias overall, 41 at high risk overall (including the 25 non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.69, 95% confidence interval (CI) 1.25 to 2.27; I2 = 0%; 3 studies, 1498 participants). In absolute terms, this might translate to an additional four successful quitters per 100 (95% CI 2 to 8). There was low-certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar) (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs occurred rarely, with no evidence that their frequency differed between nicotine EC and NRT, but very serious imprecision led to low certainty in this finding (RR 1.37, 95% CI 0.77 to 2.41: I2 = n/a; 2 studies, 727 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.70, 95% CI 1.03 to 2.81; I2 = 0%; 4 studies, 1057 participants). In absolute terms, this might again lead to an additional four successful quitters per 100 (95% CI 0 to 11). These trials mainly used older EC with relatively low nicotine delivery. There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 0.60, 95% CI 0.15 to 2.44; I2 = n/a; 4 studies, 494 participants). Compared to behavioral support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.70, 95% CI 1.39 to 5.26; I2 = 0%; 5 studies, 2561 participants). In absolute terms this represents an increase of seven per 100 (95% CI 2 to 17). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was no evidence that the rate of SAEs differed, but some evidence that non-serious AEs were more common in people randomized to nicotine EC (AEs: RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants; SAEs: RR 1.17, 95% CI 0.33 to 4.09; I2 = 5%; 6 studies, 1011 participants, very low certainty). Data from non-randomized 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 use. Very few studies reported data on other outcomes or comparisons and hence evidence for these is limited, with confidence intervals often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS:There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to ECs without nicotine and compared to NRT. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the size of effect, particularly when using modern EC products. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, though evidence indicated no difference in AEs between nicotine and non-nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect any clear evidence of harm from nicotine EC, but longest follow-up was two years and the overall number of studies was small. The evidence is limited mainly by imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information, this review is now a living systematic review. We run 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.

Chronic tobacco use is the leading preventable cause of 18 cancer types, heart and pulmonary disease, and premature death in the United States. The average cigarette contains approximately 10 to 15 mg of nicotine, a highly addictive chemical and the primary driver of chronic tobacco use. High-quality clinical trials have repeatedly shown that reducing nicotine content in cigarettes by approximately 95% lowers exposure to toxicants and carcinogens by decreasing the number of cigarettes smoked and increasing quit attempts and cessation. It is estimated that limiting nicotine in combustible cigarettes to such minimally addictive levels would result in nearly 13 million additional Americans quitting smoking within 1 year, powerfully benefiting public health. Therefore, we urge the FDA to move forward in finalizing the recently proposed nicotine product standard limiting nicotine concentration to 0.7 mg/g within combustible cigarettes and other selected combustible tobacco products. Specific populations may benefit disproportionately from a limit on nicotine levels, and it is important to consider such impacts. Therefore, it is vital that the FDA and other federal and local health agencies engage with broad stakeholders to ensure that all Americans benefit equally. Additionally, increased support for evidence-based smoking cessation therapies and education surrounding the continuum of risk of nicotine products will be essential for supporting individuals who want to quit and maximizing the public health benefits of the nicotine product standard. If implemented, this policy would constitute one of the most impactful cancer prevention, anti-addiction, and anti-chronic disease policies in American history.

INTRODUCTION:Individuals with psychiatric disorders experience substantial tobacco-related morbidity and mortality. Concerns persist that smoking cessation may exacerbate depression and anxiety, potentially limiting treatment efforts in psychiatric settings. This study examined whether sustained smoking abstinence following psychiatric hospitalization is associated with changes in depressive and anxiety symptoms. METHODS:This secondary analysis used data from the Helping HAND 3 RCT of a smoking cessation intervention among psychiatric inpatients. Participants (N=224) with elevated baseline depression and/or anxiety symptoms on the PROMIS Depression and Anxiety Short Forms 8a were assessed at 1-, 3-, and 6-months post-discharge. Self-reported continuous abstinence (vs. continuous smoking) was examined as a predictor of depressive and anxiety symptoms using linear mixed models. RESULTS:Continuous abstinence was associated with significant reductions in depressive (β = -3.88, 95% CI: -7.29, -0.47, p = .026) and anxiety symptoms (β = -5.06, 95% CI: -8.11, -2.02, p = .001) across follow-up. Significant abstinence-by-time interactions indicated that longer durations of abstinence were associated with greater symptom improvements. At 6 months, abstinence, compared to continued smoking, was associated with large reductions in depression (Cohen's d = 1.10) and anxiety (Cohen's d = 1.21). Participants who remained abstinent improved from markedly elevated baseline symptom levels to near population norms. CONCLUSIONS:Sustained smoking abstinence following psychiatric hospitalization is associated with substantial improvements in depression and anxiety. These findings challenge concerns that tobacco cessation worsens psychiatric symptoms and suggest that integrating evidence-based cessation interventions into routine psychiatric care could improve overall treatment outcomes without compromising symptom stability.

Vaping regulation is a global challenge. We discuss evidence on health risks, smoking impacts and policy goals, and advocate for pragmatic, proportionate regulation that reduces smoking harms while minimizing youth uptake and unintended consequences.

Objectives: We aimed to understand tobacco use and treatment patterns among adults starting care in a Chennai HIV clinic. Methods: Cross-sectional survey of adults initiating HIV care with biochemical verification of tobacco exposure. Results: Among 154 adult patients (10/2019-12/2021) initiating HIV care, 37.7% (n = 58) self-reported current tobacco use (13.6% [n = 21] smoking, 17.5% [n = 27] smokeless tobacco [SLT], 6.5% [n = 10] dual use) and 7.8% (n = 12) reported former use (5.8% [n = 9] smoking, 1.3% [n = 2] SLT, 0.6% [n = 1] dual), none reported using cessation medications, two reported counseling. Cotinine levels indicating current use varied by tobacco product (smoking: 66.7% had cotinine ≥ 50ng/ml; SLT: 70.4%; dual: 80.0%, no current tobacco: 44.8%, p = 0.02). Conclusion: Smoking and SLT use are common and underreported and evidence-based cessation treatment use was rare prior to HIV care initiation.

Postpartum smoking relapse within the first year affects up to 90

INTRODUCTION:Most adults with opioid use disorder (OUD) smoke cigarettes, and cessation rates with FDA-approved medications are low. Switching to e-cigarettes (EC) is an effective cigarette reduction method in adults without OUD but has not been rigorously evaluated in adults with OUD. METHODS:Adults (N=41) in OUD treatment who smoked >5 cigarettes/day (CPD), used EC <3 of prior 30days, and did not want to quit smoking, were randomized to receive an 8 week supply of NIDA's standardized research EC immediately (SREC, n=22) or after an 8-week delay (waitlist control; WLC, n=19). Participants reported past 24-hr CPD and EC use in daily texts for 8 weeks and research assessments and biochemical monitoring (e.g., carbon monoxide [CO]) every 2 weeks for 8 weeks. RESULTS:Participants had a mean age of 50, were 76% male, 88% white. From Baseline (BL) to Week 8, the change in CPD differed significantly between groups (p=0.001) with a larger decrease in CPD in SREC vs. WLC (SREC 15.3 at BL to 7.2 CPD at W8, WLC 14.2 to 12.8). There was a significant reduction in breath CO levels within SREC across the 8-weeks (from 22.9 at BL to 12.5 at W8, p<0.001), that was larger than WLC (23.7 vs. 20.3, p=0.042) (group x time p=0.071). No group differences were observed on nicotine dependence, withdrawal, or OUD stability (p's>0.05). CONCLUSIONS:Provision of ECs to people with OUD who smoke, not planning to quit, resulted in reduced combusted tobacco use, exposure and no worsening withdrawal, dependence, or OUD stability.

Introduction Lung cancer screening (LCS) provides an opportunity to offer tobacco cessation treatment, but most people who smoke are unable to quit, even with support. They might benefit from switching to electronic cigarettes (EC), but their perceptions and interest in EC use are unknown. Methods Adults who participated in a smoking cessation clinical trial offered at LCS and still smoked at trial completion were surveyed about their interest in trying EC (primary outcome). Independent variables were EC use history and perceptions of health risks and benefits of EC vs combustible cigarettes (CC). Logistic regression models tested the association of EC use and perceptions with interest in trying EC, adjusting for covariates. Results 204/359 eligible participants (56.8%) completed the survey. 56.4% had never tried EC, and 30.9% were interested in trying EC in the future. 60.3% believed EC to be as or more harmful than CC, but 60.8% thought that EC were likely to help people cut down smoking. Interest in trying EC was positively associated with previous EC experience (OR: 2.08, 95%CI:1.1–3.9), and the belief that EC were less harmful than CC (OR: 8.9, 95%CI: 3.2–24.9), or that EC can help people cut down on smoking (OR: 8.6, 95%CI: 3.5–21.2). Conclusions Adults undergoing LCS who smoke after cessation treatment ends believe that EC can help people cut down, but they overestimate EC health risks. A positive perception of EC is associated with greater interest in trying EC. Education to correct EC misperceptions might increase interest in trying EC as a harm reduction tool among those who smoke.

Importance: Electronic cigarette use (vaping) among adolescents and young adults is common. Few treatments have been tested in this population. Objective: To evaluate the efficacy of varenicline for nicotine vaping cessation in youth who do not smoke tobacco regularly. Design, setting, and participants: A 3-group randomized clinical trial compared 12 weeks of double-blind varenicline vs placebo, each added to brief, remotely delivered behavioral counseling and compared with single-blind enhanced usual care, with monthly follow-up to 24 weeks. The trial was conducted among youth, aged 16 to 25 years, who vaped nicotine daily or near daily, did not regularly smoke tobacco, and wanted to reduce or quit vaping, in a single US state from June 2022 to May 2024. Data collection ended May 28, 2024. Interventions: Participants were randomized (1:1:1) to 12 weeks of varenicline titrated to 1 mg twice daily over 7 days (standard titration), weekly counseling, and referral to text messaging vaping cessation support (This is Quitting [TIQ]) (n = 88); identical placebo, weekly counseling, and referral to TIQ (n = 87); or enhanced usual care (referral to TIQ only) (n = 86). Main outcomes and measures: Biochemically verified continuous vaping abstinence for the last 4 weeks of varenicline treatment vs placebo (primary outcome). Secondary outcomes included bioverified continuous abstinence from weeks 9 through 24 in the varenicline and placebo groups. Additional analyses compared varenicline group and placebo group with enhanced usual care. Results: Of 261 randomized participants (mean age, 21.4 years; 53% female), 254 completed the trial (97.3%). For varenicline and placebo, continuous abstinence rates were 51% vs 14% during weeks 9 through 12 (adjusted odds ratio [aOR], 6.5 [95% CI, 3.0-14.1]; P < .001) and 28% vs 7% during weeks 9 through 24 (aOR, 6.0 [95% CI, 2.1-16.9]; P < .001). Varenicline had higher continuous abstinence rates vs enhanced usual care during weeks 9 through 12 (51% vs 6%; aOR, 16.9 [95% CI, 6.2-46.3]) and during weeks 9 through 24 (28% vs 4%; aOR, 11.0 [95% CI, 3.1-38.8]). Continuous abstinence rates were not significantly different between the placebo and enhanced usual care groups. Study medication was generally well tolerated. Two varenicline participants (2%) and 1 placebo participant (1%) discontinued study medications due to adverse events. No drug-related serious adverse events occurred. Treatment-emergent adverse events were reported by 76 (86%) in the varenicline group, 68 (79%) in the placebo group, and 68 (79%) in the enhanced usual care group. Conclusions and relevance: Varenicline, combined with behavioral counseling, increased vaping abstinence in youth who vape nicotine and do not regularly smoke tobacco.

RATIONALE:There is limited guidance on how to stop using nicotine-containing vapes (otherwise known as e-cigarettes) and ensure long-term abstinence, whilst minimising the risk of tobacco smoking and other unintended consequences. Treatments could include pharmacological interventions, behavioural interventions, or both. OBJECTIVES:To conduct a living systematic review assessing the benefits and harms of interventions to help people stop vaping compared to each other, placebo or no intervention. To assess how these interventions affect the use of combustible tobacco, and whether effects vary based on participant characteristics. SEARCH METHODS:We searched CENTRAL, MEDLINE, Embase, PsycINFO, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform from 1 January 2004 to 1 July 2025. We also searched the references of eligible studies and abstracts from the Society for Research on Nicotine and Tobacco conferences, and contacted study authors. ELIGIBILITY CRITERIA:We included randomised controlled trials (RCTs) recruiting people of any age using nicotine-containing vapes, regardless of tobacco smoking status. Studies had to test an intervention designed to support people to quit vaping, and plan to measure at least one of our outcomes. OUTCOMES:Critical outcomes: vaping cessation at six months or longer; change in combustible tobacco use at six months or longer; number of participants reporting serious adverse events (SAEs) at one week or longer. RISK OF BIAS:We used Cochrane's RoB 1 tool to assess risk of bias in the included studies. SYNTHESIS METHODS:We followed standard Cochrane methods. We grouped studies by comparisons and outcomes, and calculated individual study and pooled effects, as appropriate. We used random-effects Mantel-Haenszel methods to calculate risk ratios (RRs) with 95% confidence intervals (CIs) and random-effects inverse variance methods to calculate mean differences (MDs) and 95% CIs. We used GRADE to assess the certainty of evidence for our critical outcomes. INCLUDED STUDIES:Fifteen studies (six new to this updated version) involving 5800 participants are included. Fourteen studies included some participants who had previously smoked tobacco; in seven studies, participants were not smoking at baseline. Twelve studies only included participants aged 18 or older (five exclusively included people between 18 and 29); two included some participants under 18 years; and one included 13- to 17-year-olds only. Fourteen studies were conducted in the USA and one in Italy. We judged five studies at low, six at high, and four at unclear risk of bias. SYNTHESIS OF RESULTS:Pharmacological interventions Studies assessed our critical outcomes in relation to combination nicotine replacement therapy (NRT), cytisine, and varenicline compared to placebo or no/minimal support. For combination NRT versus no/minimal support, there was no clear evidence of benefit for vaping cessation rates at six months or longer, with the CI incorporating the possibility of reduced and increased cessation rates (very low-certainty evidence due to imprecision and risk of bias; RR 0.96, 95% CI 0.73 to 1.25; I² = 0%; 2 studies, 214 participants). One study investigating cytisine versus placebo did not report vaping cessation at six months or longer. When compared to placebo, varenicline increased vaping cessation rates at six months, but evidence was of low certainty due to imprecision (RR 2.71, 95% CI 1.33 to 5.49; I2 = 48%; 2 studies, 315 participants). One study comparing combination NRT versus no/minimal support reported combustible tobacco cessation. There was no clear evidence of higher tobacco cessation in either arm, and CIs were imprecise. The evidence was of very low certainty due to imprecision and risk of bias (RR 0.99, 95% CI 0.71 to 1.37; 198 participants). Zero participants reported SAEs in the two studies investigating combination NRT versus no/minimal support (706 participants; very low-certainty evidence due to risk of bias and imprecision) and in the one study investigating cytisine versus placebo (159 participants; low-certainty evidence due to imprecision). Four studies evaluating varenicline versus placebo measured SAEs, with zero events reported in two studies. Thus, our effect estimate was based on two studies (RR 2.82, 95% CI 0.45 to 17.59; 304 participants; low-certainty evidence due to imprecision). Behavioural interventions Studies assessed our critical outcomes in relation to reducing nicotine/vaping behaviour and text message-based interventions compared to no/minimal support. There was no clear evidence that nicotine/vaping reduction increased vaping cessation at six months compared to minimal support (RR 3.38, 95% CI 0.43 to 26.30; 1 study, 17 participants; very low-certainty evidence due to imprecision and risk of bias). There was low-certainty evidence (due to indirectness) that text message-based interventions may increase vaping cessation rates compared to no/minimal support in 13- to 24-year-olds specifically (RR 1.32, 95% CI 1.19 to 1.47; I2 = 0%; 2 studies, 4091 participants). There was very low-certainty evidence (due to indirectness and imprecision) that text message-based interventions for vaping cessation may result in little to no difference in smoking uptake (RR 1.04, 95% CI 0.81 to 1.33; 1 study, 1036 participants) or cessation (RR 1.03, 95% CI 0.90 to 1.19; 1 study, 793 participants) compared to no/minimal support. The one study investigating nicotine/vaping behaviour reduction versus minimal support did not report SAEs. Three studies investigating text message-based interventions reported SAEs; however, zero events were reported (2082 participants; low-certainty evidence due to imprecision). AUTHORS' CONCLUSIONS:Low-certainty evidence suggests that text message-based interventions to help people stop nicotine vaping may help more youths and young adults to successfully stop compared to no/minimal support, with very uncertain evidence regarding their effect on smoking behaviours. Low-certainty evidence suggests that varenicline may help people quit vaping. Data exploring the effectiveness of combination NRT, cytisine, and nicotine/vaping behaviour reduction are inconclusive due to risk of bias and imprecision. Most studies that measured SAEs reported that none had occurred; however, more data are needed to draw clear conclusions. Studies that have investigated these interventions for quitting smoking have not demonstrated serious concerns about SAEs. It is important that future studies measure combustible tobacco outcomes so the complete risk profile of relevant interventions can be considered. Further RCTs are underway. To ensure this review continues to provide up-to-date information to decision-makers, we will maintain it as a living systematic review by running searches monthly and updating the review when relevant new evidence that will strengthen or change our conclusions emerges. FUNDING:Cancer Research UK (PICCTR-2024/100012); National Institute for Health and Care Research (NIHR206123). REGISTRATION:Protocol (2024) DOI: 10.1002/14651858.CD016058 Original review (2025) DOI: 10.1002/14651858.CD016058.pub2.