For decades, public health messaging around smoking cessation has revolved around a simple binary: quit completely or fail. Yet real-world data have consistently shown that many smokers struggle to stop abruptly, even with access to traditional nicotine replacement therapies (NRT) such as patches or gum. Against this backdrop, the growing body of evidence supporting safer nicotine alternatives—particularly vaping—has reshaped how harm reduction is understood. Today, the question is no longer whether these products reduce harm compared to smoking, but why policymakers and institutions are still reluctant to fully embrace what the science already shows.
The myth of dual use
The combined use of cigarettes and safer alternatives, coined “dual use,” has long been viewed negatively within tobacco control. Critics often assume that smokers who vape while continuing to smoke simply become stuck in a permanent pattern of combined use, gaining little or no health benefit and delaying cessation indefinitely. This assumption has driven policies and messaging that discourage dual use outright, framing it as a failure rather than a transitional phase. However, this perspective is increasingly challenged by empirical evidence showing that, for many smokers, dual use is not an endpoint but a stepping stone—one that can reduce immediate harm and increase the likelihood of quitting cigarettes altogether.
New research from Queen Mary University of London sheds more light on the topic. Drawing on a year-long clinical trial involving 886 adult smokers attempting to quit, researchers found that people who used e-cigarettes alongside cigarettes—often labelled “dual users”—absorbed fewer toxic substances from cigarette smoke and were more likely to quit smoking entirely than those who continued smoking alone. Published in Nicotine & Tobacco Research, the study directly challenges the claim that dual use undermines cessation efforts or entrenches smoking.
Instead, the findings suggest the opposite. Smokers who vaped while gradually cutting down cigarettes were more likely to achieve abstinence both in the short term and after a full year. Even among participants who did not quit completely, dual use significantly reduced the number of cigarettes they smoked and their exposure to harmful chemicals. This aligns with biomarker studies showing that most smoking-related harm comes from combustion, not nicotine itself, and that replacing even part of one’s cigarette intake with non-combustible alternatives produces measurable health benefits.
Why public health got dual use wrong
Crucially, the study also helps explain why vaping appears to work where many other cessation tools fall short. In line with previous reports, researchers observed that vapes suppressed cravings more effectively than conventional NRT, allowing smokers to manage withdrawal while changing behavioural habits. Most participants began using higher nicotine strengths and gradually stepped down over time, with around 10 percent using nicotine-free liquids by the end of the study. This pattern reflects a harm-reduction pathway rather than a permanent dependency, countering fears that vaping locks users into lifelong nicotine use.
Once again, flavour choice emerged as another important factor. Tobacco-flavoured e-liquids were unpopular and less associated with long-term success, while participants who switched to non-tobacco flavours, such as fruit, were more likely to remain smoke-free. This finding echoes earlier research showing that flavour variety plays a key role in helping smokers disassociate nicotine use from cigarettes. Attempts to restrict flavours, often justified on youth-protection grounds, may therefore inadvertently undermine adult cessation.
The implications are significant. Roughly 12 percent of UK adults still smoke, and many belong to populations with higher dependence, lower incomes, or multiple health vulnerabilities. For these smokers, abrupt cessation is often unrealistic. The Queen Mary study reinforces what harm-reduction advocates have long argued: vaping, including temporary dual use, can serve as a pragmatic stepping stone away from cigarettes rather than a barrier to quitting.
Looking into the long term effects of vaping
Alongside evidence of effectiveness, ongoing research continues to refine understanding of long-term safety. A major new project at the University of Birmingham—the EVALUATE study—is examining how prolonged vaping affects lung and immune health among former smokers. Led by Dr Aaron Scott and funded by £1.46 million from the UK Medical Research Council, the study is following 200 participants recruited through NHS smoking cessation services. Half are using e-cigarettes, while the remainder rely on traditional NRT, with outcomes compared to a control group of never-smokers and never-vapers.
Researchers are analysing changes in immune and lung cells, inflammation markers, airway health, and gene and protein expression over 12 months. Earlier work by Dr Scott’s team suggested that some chemicals formed when e-liquids degrade could affect immune cells, even without nicotine. Rather than undermining harm reduction, this research reflects scientific maturity: identifying residual risks, quantifying them, and comparing them directly to the well-established harms of continued smoking.
Importantly, no credible health authority disputes that smoking is vastly more dangerous than vaping. Reviews by Public Health England, the Royal College of Physicians, the U.S. National Academies of Sciences, Health Canada, and many others, all converge on the conclusion that non-combustible nicotine products expose users to a fraction of the toxicants found in cigarette smoke. And population-level data of course reinforce this. Countries that have embraced vaping and other safer alternatives, such as the UK, New Zealand, Sweden, and Norway, have seen smoking rates fall faster than those relying on abstinence-only approaches.
The global context makes this evidence even more urgent. While the World Health Organization reports that overall tobacco use has declined from 1.38 billion people in 2000 to around 1.2 billion today, smoking remains stubbornly high in many regions. At the same time, vaping has grown to over 100 million people worldwide. The policy choice is not between nicotine use and a nicotine-free world, but between safer nicotine use and continued mass exposure to combustible tobacco.
The science policymakers keep ignoring
For harm-reduction advocates, the emerging consensus is clear. We now have sufficient data to say that vaping and other novel nicotine products help smokers quit, reduce toxic exposure when quitting is incomplete, and contribute to rapid declines in smoking prevalence at the population level. Continued research into long-term effects is essential—but it should inform smarter regulation, not justify blanket restrictions or moral panic.
Public health has successfully adopted harm reduction in other fields, from opioid substitution therapy to needle exchange and HIV prevention. Smoking—the leading preventable cause of death globally—deserves the same evidence-based pragmatism. The science no longer supports treating safer nicotine products as a threat. On the contrary, it increasingly shows they are one of the most powerful tools available to end the cigarette epidemic.
