A combination of behavioral counseling and pharmacotherapy can more than double the chances of a successful smoking cessation attempt.(1) According to the 2020 Surgeon General’s report, less than one-third of adults who smoke utilize smoking cessation behavioral counseling or Food and Drug Administration (FDA) approved medications in their attempts to quit.(1, 2) In Israel, free behavioral therapy for smoking cessation, as well as subsidized smoking cessation pharmacotherapy, were introduced into the "Health Services Basket" in 2010 as part of the National Health Insurance Law.(3) Currently, Israel’s health maintenance organizations (HMOs) provide a range of smoking cessation support options, including group behavioral therapy, telephone support and guidance from family physicians. Despite these efforts, only around 2.5% of people who smoke in Israel seek smoking cessation support each year.(4)
Electronic nicotine delivery systems (ENDS), commonly referred to as electronic cigarettes or e-cigarettes(5) and known as ‘vaping’ products,(6) emerged in 2004 as an alternative for nicotine delivery and have been promoted as a viable method for smoking cessation.(7) These battery-powered devices incorporate a cartridge containing propylene glycol liquid, with or without nicotine.(7–9) The liquid is heated to generate aerosol, which is inhaled through a vaporization chamber.(7) Over the past two decades, they have undergone major evolutions and have been manufactured in a diverse range of shapes, sizes and types.(9)
In Israel, the prevalence of past 30-day e-cigarette use among tenth-grade students was 10% in 2022: 7.8% among Jewish students and 15.3% among Arab students.(3) A lower rate of 1.6% for using electronic nicotine delivery systems (either e-cigarettes or heated tobacco products) was reported among adults in 2021, 1.2% among Jewish adults and 2.8% among Arab adults (10)
Since the introduction of e-cigarettes to the market, they have been the subject of much controversy.(7) They are often considered as a “safer substitute” for combustible cigarettes,(9) and are endorsed for their potential role in harm reduction for people who smoke and are unable or unwilling to quit smoking.(11) Yet, the evidence regarding using them as a smoking cessation aid is mixed and they have not been proven to be effective for cessation at the population level.(5, 12) Despite evidence suggesting that e-cigarettes are potentially less harmful than combustible cigarettes, their long-term effects on human health are still unclear.(5) Additionally, people who switch fully to e-cigarettes remain addicted to nicotine, which might increase risk for relapse.(9) Furthermore, a substantial proportion of adult e-cigarette users do not quit smoking cigarettes, but continue to use both products (“dual use”).(13) Dual use has not been shown to be associated with reduced levels of exposure to harmful chemicals.(14)
Several systematic reviews, including Cochrane analyses, suggest that nicotine e-cigarettes may only benefit people who smoke and fully switch to using them for quitting combustible cigarette smoking.(6, 15–17) Integrating nicotine e-cigarettes into therapeutic approaches could enhance smokers' confidence in using them as a harm reduction strategy, promote proper usage (including advice on complete transition and eventual cessation of vaping), and discourage the use of illicit or unregulated alternatives.(18) However, more robust evidence is necessary to confirm their safety and effectiveness as smoking cessation aids and a harm-reduction tool.(6, 15–17) International guidelines on vaping vary, with some emphasizing smoking cessation benefits while others address broader concerns, including long-term risks beyond cessation.(19)
Differences in clinical guidelines arise from varying policies toward e-cigarettes in different countries.(20) Currently, the World Health Organization (WHO) does not endorse e-cigarettes as a viable method for smoking cessation,(5, 12) and in the United States (US), e-cigarettes are not approved by the FDA as smoking cessation aid.(1, 21) Conversely, several countries such as the United Kingdom (UK) endorse them for harm reduction and cessation. According to the National Institute for Health and Care Excellence (NICE) guidelines, while nicotine e-cigarettes are not licensed medicines, they fall under the regulation of the Tobacco and Related Products Regulations 2016.(22, 23) Hence, when smokers consult healthcare practitioners about using nicotine e-cigarettes as a cessation aid, the advice should include a discussion on their potential for smoking cessation.(22) A report commissioned by Public Health England (PHE) suggested that integrating vaping products with stop-smoking support should be accessible to all those who seek to quit smoking.(24) This UK initiative was recently launched in a new National Health System (NHS) scheme, encouraging smokers to switch from cigarettes to e-cigarettes by providing them with an e-cigarette starter kit alongside behavioral support.(25) In Canada, Health Canada's messaging on vaping for smoking cessation lacks clarity and fails to specify that e-cigarette devices are not approved cessation tools, despite the requirement for authorization for products making therapeutic claims.(26) The Belgian Superior Health Council recommends e-cigarettes as a smoking cessation aid.(19) Similarly, New Zealand promotes e-cigarettes as a harm reduction tools and encourages smokers to switch to vaping as a potentially less harmful alternative to smoking.(27, 28) However, in Israel, clinical guidelines from the Israel Family Physicians Medical Association do not recognize e-cigarettes as cessation tools; recommending instead that practitioners should guide smokers to use evidence-based treatments authorized and available through the "National Health Services Basket”.(29)
The controversy surrounding the role of e-cigarettes in harm reduction and smoking cessation may impact the clinical recommendations and support provided to people who smoke. Studies from various countries reveal diverse attitudes among smoking cessation practitioners and service providers. While some express concerns about the safety and efficacy of e-cigarettes and advocate for stricter regulations, others view them positively as a harm-reduction approach, considering them comparable to other cessation aids. However, most of these previous studies were conducted several years ago and reflect diverse attitudes from countries with varying regulatory guidelines, (30) (31) (32, 33) and none were conducted in Israel.
In summary, the role of e-cigarettes in smoking cessation is subject to scientific debate, with evidence suggesting their potential to aid smokers in quitting combustible cigarette use, despite concerns regarding continued nicotine addiction, health risks, and "dual use" scenarios.(34) Smoking cessation practitioners who directly engage with people who smoke, should discuss e-cigarettes with their patients, despite a dearth of empirical data informing their guidance.(31) There is limited research, and none from Israel, on the perspectives of smoking cessation practitioners regarding e-cigarettes as cessation aids, particularly in recent years, despite the increasing prevalence of e-cigarette use.
This study aims to: 1) explore smoking cessation counselors' knowledge, attitudes, and practices regarding e-cigarettes; and 2) identify factors associated with not recommending e-cigarettes as a harm-reduction strategy.