Barnes-Jewish Hospital | Washington University Physicians
breakthroughs from the lab


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By Jim Dryden

Most of the 40 million Americans who smoke cigarettes say they want to quit, and some move to e-cigarettes as a step toward quitting. However, a growing number of such people become dual nicotine users: They smoke traditional cigarettes and vape e-cigarettes, researchers at Washington University School of Medicine have found.

Rather than discontinuing their addiction, many end up substantially increasing the amount of nicotine they consume. The researchers found, however, that smoking-cessation treatments approved by the Food and Drug Administration (FDA) that focus on nicotine replacement and counseling can help dual users quit. In fact, such treatments seem to be effective in dual users as well as those who smoke traditional cigarettes exclusively. These findings were published in the journal Thorax.

“We recommend FDA-approved treatment such as nicotine replacement, the drug varenicline and counseling for cigarette smokers,” says Li-Shiun Chen, MD, MPH, ScD, psychiatrist at Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, and senior investigator of the study. “But we know that a growing number of people are using both cigarettes and e-cigarettes. The good news is that tobacco treatment still can help these people stop smoking and defeat their nicotine addiction.”

In an average year, about 70% of those who smoke will make an attempt to quit. Another 20% say they want to smoke less. But without treatment, such as nicotine replacement therapy and counseling, only about 5% quit successfully. For the study, Chen and colleagues reviewed de identified electronic health records of more than 110,000 smokers who were seen in outpatient clinics at Barnes-Jewish Hospital between 2018 and 2020. They found that the number of e-cigarette users tripled. Some apparently started vaping as a potential step to quitting, but many seemed to get stuck. Instead of quitting, they started vaping while also continuing to smoke traditional cigarettes.

A relatively small but growing percentage of the smokers who were studied became dual users during the course of the study. Some 0.8% reported dual use in the study’s first year, but that number had grown to 2.3% when data collection had concluded. The authors noted that the actual number of dual users was likely higher. The researchers found that about one in five (20.8%) of the dual users quit smoking within 12 months. That compared to a 16.8% quit rate among those who smoked only traditional cigarettes.

Treatment still seemed to be the key for dual users. When they received smoking-cessation treatment, almost one-third (29%) became nonsmokers 12 months later. About 17% of dual users who didn’t get treatment were able to quit.

The study’s first author, Brendan Heiden, MD, a surgical resident and cardiothoracic surgery research fellow, says that although quit rates were higher among dual users, about two-thirds remained smokers a year later, even after treatment. That, combined with the fact that little is known about the long-term health effects of e-cigarette use, means that he and Chen don’t recommend that people who want to quit smoking should start vaping.

“The current scientific consensus is that using both cigarettes and e-cigarettes is bad for you,” Heiden says. “Although current guidelines do not recommend vaping for smoking cessation, we did find that among the growing number of people who use both of these products, traditional FDA-approved tobacco treatment—such as nicotine-replacement therapy and behavioral support therapy—can help them quit.”

Originally published by Washington University School of Medicine at

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