Mixed Opinions About Dual Use – Based on What Facts?

Dual use—smoking and vaping simultaneously—has long been the subject of debate. While opponents argue that it extends nicotine addiction without ever leading to complete cessation, tobacco harm reduction (THR) experts highlight that it is often a transitional phase, potentially leading to exclusive vaping.

Diane Caruana

December 10, 2024

Dual use of vapes and cigarettes sparks debate. Proponents argue that vaping reduces harm by lowering cigarette consumption, citing studies showing improved health. However, critics counter that dual use maintains nicotine addiction, leaving users in a limbo of perpetual nicotine addiction, and therefore never fully quitting smoking.

Several real-world examples of smokers who went on to become dual users and eventually transition to exclusive vaping, indicate that ultimately some users end up preferring vapes, due to a number of factors.

Research reveals mixed findings, with some studies showing dual users are as likely, or more likely, to quit as exclusive smokers, and others suggesting that dual use may pose health risks equal to or greater than smoking alone. A recent systematic review and meta-analysis investigated the prevalence of dual use of combustible tobacco and e-cigarettes among pregnant women, a group who is very likely to engage in dual use given their likelihood to want to quit smoking.

Titled, “Prevalence of dual use of combustible tobacco and E-cigarettes among pregnant smokers: a systematic review and meta-analysis,” the study conducted comprehensive searches across PubMed, Embase, Web of Science, and Cochrane. A total of 18 studies were selected, involving 5,983,363 pregnant women who met inclusion criteria. Overall, prevalence of dual use among the pregnant women was at 4.6%, with some regional variations being observed, and a meta-regression revealed a reduction in dual use prevalence from 2019 to 2023.

It is important to highlight that while smoking is of course linked to known adverse outcomes, there are no known specific health outcomes related to vaping. Therefore it is the lack of long term data available on vaping and dual use during pregnancy that raises concerns among researchers – the cliche “fear of the unknown.” Hence such studies on prevalance rates do not tell us much.

Harm reduction or perpetual nicotine addiction?

Meanwhile renowned THR experts like Clive Bates argue that dual use reduces smoking rates and therefore health risks, supporting harm reduction. For instance, many users unintentionally quit smoking by gradually starting to favour vaping over smoking. Similarly, respiratory expert Dr. Riccardo Polosa, emphasizes that reduced cigarette consumption, even if complete cessation isn’t achieved, still provides significant health benefits.

A study by renowned cardiologist and THR researcher Dr. Konstantinos Farsalinos, found that dual users reduced their cigarette intake significantly after taking on vaping, from an average of 20 cigarettes daily to about 4. The survey which included 19,441 participants identified 3,682 dual users. After matching them with 3,530 non-smoking vapers based on age and gender, their responses were compared. Both groups included former smokers.

Farsalinos and his team found that while dual users had longer smoking histories and reduced their cigarette intake significantly after taking on vaping, they were less likely to use advanced vape devices or consume liquid daily compared to non-smoking vapers. Dual users were also more likely to use vpes occasionally rather than daily, and have higher risk perceptions of vaping.

Many dual users eventully become exclusive vapers

Meanwhile, several real-world examples of smokers who went on to become dual users and eventually transition to exclusive vaping, indicate that ultimately some users end up preferring vapes, due to a number of factors. Firstly, in a pattern revealed by many studies, many of these users start enjoying the vape flavours available, eventually preferring them over the taste of cigarettes – a factor which becomes a main motivator to stick to vaping. Other reasons include the fact that they do not smell of cigarettes anymore, of course the experienced health imporvements, especially respiratory ones, and also the evolving quality of vaping products, especially for technology lovers.

While critics of dual use often express concerns about its health impacts, assuming that double the product, double the risk, THR experts believe that given the proven relative safety of vaping, when using both vapes and cigarettes, one is still reducing harm, even if in a smaller way. The existing fear-based rhetoric around vaping risks may slow individuals’ progress in quitting smoking entirely, whereas supporting dual users through vaping, rather than condemning the practice, can foster gradual smoking reduction, marking an incremental yet meaningful public health victory.