Ending Tobacco and Nicotine Addiction
Quitting through vaping vs. nicotine replacement, bupropion, or varenicline.
Updated August 8, 2025 | Reviewed by Davia Sills
When I was in medical training in the 1970s, 40 percent of adults in the U.S. smoked cigarettes. There were cigarette vending machines everywhere, cigarettes cost a low 40 cents per pack, making teen use easy, and people smoked everywhere, from theaters to airplanes. The situation has markedly changed. Only 11 percent of U.S. adults were cigarette smokers in 2023. Who missed the message and still smokes?
Smokers and Mental Illness
Mental illness is a major driver of continued smoking and low cessation success. Among U.S. adults with any mental illness, 25 percent are current smokers—more than double the rate for those without mental illness. Patients with serious mental illness—especially schizophrenia or bipolar disorder —have substantially elevated smoking rates, in schizophrenia as high as 80 to 90 percent. One study reported that more than a third (37 percent) of subjects with major depression were current smokers.
FDA Considering Reducing Nicotine Content in Cigarettes
In 2022, the U.S. Food and Drug Administration (FDA) proposed a landmark public health policy mandating the reduction of nicotine content in cigarettes to minimally addictive levels. This initiative is supported by robust clinical evidence and hopefully would lower cigarette consumption, decreasing toxic exposure. If implemented, as I hope it is, nicotine reduction would represent one of the most transformative regulatory interventions in tobacco control since the 1964 Surgeon General’s Report.
Vaping as a Smoking Cessation Aid
The role of electronic nicotine delivery systems (ENDS), otherwise known as vapes, has evolved rapidly. Some researchers regard vaping as a harm-reducing, safer form of nicotine maintenance for cigarette smokers. Others compare vapes to methadone maintenance for people addicted to opioids.
Yet real evidence summarized in a 2025 Cochrane Review found that nicotine-containing e-cigarettes might help adult smokers reduce or eliminate cigarette use compared to nicotine replacement therapy (NRT) and non-nicotine vaping products. This conclusion is consistent with other recent 2025 studies, including the JUUL2 Actual Use Study by Goldenson and a JAMA Network Open article showing daily vaping was associated with a greater likelihood of long-term cessation when compared to smokers who were non-vapers or intermittent users.
A recent Annals of Internal Medicine study of low-socioeconomic-status (SES) smokers found that vaporized nicotine products (VNPs) led to a 28.4 percent six-month abstinence rate versus 9.6 percent for NRT—a nearly threefold decrease. This evidence has led some health agencies to cautiously endorse vaping as a secondary cessation tool for adult smokers who failed with NRT or varenicline (Chantix).
While observational results appear favorable, new studies and expert commentaries suggest vaping may not significantly promote tobacco cessation. The 2025 study by Quach et al. concluded that neither daily nor nondaily vaping was associated with an increased likelihood of quitting smoking.
Cigarette smoking experts like UCSF’s Stanton Glantz, Ph.D., Truth Initiative Distinguished Professor of Tobacco Control and Professor at the University of California in San Francisco, noted some analyses overestimated vaping benefits. After accounting for motivation to quit and sociodemographic variables, the benefits of vaping frequently diminished or even reversed. Additional studies of people with psychiatric illness or substance use disorders tend to show vaping doesn’t significantly enhance cessation outcomes. Dr. Glantz and his colleagues recently published papers demonstrating that e-cigarette smokers are less likely to quit smoking .
“The original idea was smokers would switch to e-cigarettes, but we’ve found they are actually becoming ‘dual users,’ smoking both cigarettes and e-cigarettes,” said Dr. Glantz. “The overall evidence is smokers who use e-cigarettes are less likely to quit by about 25 to 30 percent than smokers who don’t use e-cigarettes. We think one way that happens is you can use e-cigarettes in a lot of places where you can’t smoke [conventional cigarettes].”
Also, although e-cigarettes emit fewer toxic chemicals than cigarettes, scientists don’t know the full health effects of vaping. “Just because e-cigarettes are less dangerous than cigarettes doesn’t make them safe,” said Dr. Glantz.
Many people are not aware that cigarettes cause more heart and cardiovascular deaths than lung cancer deaths, since cigarette smoke makes blood clots more likely to form and impairs blood vessels’ ability to carry increased blood flow. Like conventional cigarettes, e-cigarettes generate ultrafine particles that reach the bloodstream through the lungs. More research is needed to understand whether e-cigarettes affect the cardiovascular system like tobacco cigarettes do.
Another issue is vaping addiction , which poses a significant clinical and public health concern. About 25 percent of youths use e-cigarettes, with 1.6+ million middle and high school students using e-cigarettes in 2024. A 2023 national survey by the Truth Initiative found that 73 percent of daily vapers aged 15–24 reported cravings, 63 percent unsuccessfully attempted to quit, and 44 percent self-identified as addicted to vaping. Nicotine delivery from popular devices such as Elf Bar, Breeze, and Mr. Fog-brand combustible cigarettes can produce rapid dependence in adolescents, whose brains are more sensitive to nicotine.
Recent clinical research supports varenicline as an effective pharmacologic aid for cigarette smoking and nicotine vaping cessation, particularly among adolescents and young adults. A 2025 trial by Harvard’s Eden Evins, M.D., M.P.H., Director of the MGH Center for Addiction Medicine, studied daily vapers aged 16–25, demonstrating varenicline led to a 51 percent quit rate at 12 weeks and 28 percent more quitting at 24 weeks, a very good result.
Our anti-cigarette success was due to tobacco control interventions, including taxation, smoke-free laws, stigmatizing media campaigns, cessation services, and regulatory restrictions. In addition to nicotine replacement, bupropion (Zyban) reduces cravings and helps end smoking. Varenicline is the most effective cessation treatment for cigarette smoking or nicotine vaping addiction.
Considerable evidence supports vaping’s role in harm reduction compared to cigarette smokers using NRT. Yet other reliable data suggest vaping can prolong nicotine device dependence. In clinical practice, vaping should not be a first-line recommendation for adult tobacco cessation. Patients with mental illness, substance use disorders, or adolescents should be strongly counseled against starting or continuing vaping due to high addiction potential and low cessation rates in these populations.
Quach NE, Pierce JP, Chen J, Dang B, Stone MD, Strong DR, Trinidad DR, McMenamin SB, Messer K. Daily or Nondaily Vaping and Smoking Cessation Among Smokers. JAMA Netw Open. 2025 Mar 3;8(3):e250089. doi: 10.1001/jamanetworkopen.2025.0089. PMID: 40042845; PMCID: PMC11883493.
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Evins AE, Cather C, Reeder HT, Evohr B, Potter K, Pachas GN, Gray KM, Levy S, Rigotti NA, Iroegbulem V, Dufour J, Casottana K, Costello MA, Gilman JM, Schuster RM. Varenicline for Youth Nicotine Vaping Cessation: A Randomized Clinical Trial. JAMA. 2025 Jun 3;333(21):1876-1886. doi: 10.1001/jama.2025.3810. PMID: 40266580; PMCID: PMC12019676.
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Mark S. Gold, M.D., is a pioneering researcher, professor, and chairman of psychiatry at Yale, the University of Florida, and Washington University in St Louis.
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