A 2025 position statement from the Thoracic Society of Australia and New Zealand on the management of electronic cigarette use recommends nicotine replacement therapy (NRT) strategies that substitute the high-peak nicotine delivery of vaping with slower, sustained nicotine exposure to mitigate withdrawal symptoms. Combination NRT is emphasized as a preferred approach, typically consisting of a transdermal nicotine patch combined with a faster-acting buccal formulation such as nicotine gum, lozenge, or oral spray. The patch provides continuous baseline nicotine delivery, while rapid-acting formulations can be used as needed to control cravings and withdrawal. Suggested dosing examples include a 21 mg transdermal patch for adults (or 14 mg for individuals <45 kg) together with rapid-acting NRT used liberally for breakthrough cravings. Treatment selection and dosing should be individualized according to the patient’s level of nicotine dependence, with clinicians encouraged to assess dependence features such as time to first vape, frequency of use, cravings, and withdrawal symptoms. The guidance notes that NRT is commonly underdosed and recommends reassessment within 1 to 2 weeks to evaluate symptom control and adjust dosing or frequency of rapid-acting products if cravings or withdrawal persist. Combination NRT may be used in adolescents aged ≥12 years and adults when clinically appropriate, alongside counseling and behavioral support, with the aim of attenuating withdrawal, allowing gradual neuroreceptor down-regulation, and supporting sustained cessation of vaping. [1]
According to the TRC Pharmacist’s Letter, evidence-based pharmacologic strategies for vaping cessation are limited; therefore, treatment approaches are generally extrapolated from traditional smoking cessation. NRT is suggested as an initial pharmacologic option for adults who regularly use e-cigarettes, particularly those with nicotine dependence. Combination NRT (a long-acting patch with a short-acting product such as gum or lozenges) may be considered to address baseline cravings and breakthrough symptoms. Suggested starting doses may be estimated from nicotine exposure (Table 3); for example, adults using more than approximately 20 mg of nicotine per day may start with a 21 mg/day patch, while those using less may start with a 14 mg/day patch. Doses may be adjusted based on withdrawal symptoms, and tapering should follow product labeling. If NRT is insufficient or only partially effective, other smoking cessation medications such as varenicline or sustained-release bupropion may be considered alone or in combination with NRT, particularly for users with depression, with therapy initiated prior to the quit date. The guidance notes that dosing recommendations for vaping cessation are based on assumptions derived from cigarette smoking equivalency, and additional data are needed to define optimal pharmacotherapy and dosing for patients who use e-cigarettes. [2]
Vaping cessation is an emerging clinical challenge requiring structured behavioral and pharmacologic strategies tailored to the patterns of electronic cigarette (EC) use. ECs deliver nicotine through various devices and e-liquids containing propylene glycol, vegetable glycerin, flavorings, and often highly concentrated nicotine formulations such as nicotine salts or synthetic nicotine. These products are frequently marketed as safer alternatives to combustible cigarettes, yet they expose users to toxic substances and promote strong nicotine dependence. Dual use of ECs and conventional cigarettes is common and is associated with increased risk of cardiovascular disease, stroke, COPD, and lung cancer. Because vaping patterns differ from traditional smoking and often involve continuous “grazing” throughout the day, cessation strategies must account for variability in nicotine exposure and patterns of use. [3]
Behavioral treatment forms the foundation of vaping cessation. Motivational interviewing is emphasized as an effective patient-centered counseling approach that uses open-ended questioning, active listening, affirmation, and summarization to encourage patients to articulate their own motivations for quitting. Cognitive behavioral therapy (CBT) is often combined with this approach and focuses on identifying and modifying maladaptive beliefs about nicotine use while helping patients develop coping strategies, problem-solving skills, and relapse prevention techniques. Structured therapy sessions typically include mood assessment, agenda setting, psychoeducation, collaborative planning, and feedback. Behavioral counseling also supports medication adherence and improves overall cessation outcomes. Digital interventions such as text-message–based support programs may supplement counseling by providing coping strategies, information about risks and benefits of quitting, and reminders; in one randomized trial among young adults, such a program increased 30-day abstinence rates at seven months to 24.1% compared with 18.6% in controls, although the overall certainty of evidence for these digital interventions remains limited. [3]
Pharmacologic treatment is considered when patients demonstrate moderate to severe nicotine dependence, have experienced unsuccessful quit attempts, or develop significant withdrawal symptoms. Because specific guidelines for vaping cessation remain limited, clinicians typically extrapolate treatment approaches from established smoking cessation protocols. First-line pharmacologic options include nicotine replacement therapy (NRT) and non-nicotine medications, and these treatments are most effective when combined with behavioral support. [3]
Nicotine replacement therapy is used to reduce withdrawal symptoms and gradually taper nicotine exposure. Two main categories are used: slow-release transdermal patches and rapid-acting formulations such as gum, lozenges, sprays, or inhalers. Patches typically provide continuous nicotine delivery in doses of 21 mg, 14 mg, or 7 mg per day. Initial therapy often begins with higher doses (for example, a 21-mg patch) during the early cessation phase, followed by stepwise dose reductions during the maintenance phase. After approximately 6–12 weeks, clinicians generally taper the dose from 21 mg to 14 mg and then to 7 mg before discontinuation. The overall tapering process usually occurs over 8–12 weeks, though individual adjustments may be required depending on nicotine dependence. Maximum recommended dosing for patches is typically about 42 mg/day. Rapid-acting NRT formulations may be used concurrently for breakthrough cravings, with typical limits of approximately 15–20 gums or lozenges per day. During treatment, clinicians should monitor for nicotine toxicity symptoms such as nausea, vomiting, tachycardia, or dizziness and adjust dosing accordingly. [3]
A key challenge in vaping cessation is determining the appropriate NRT dose because EC nicotine delivery varies widely across devices and user behaviors. To estimate nicotine intake, clinicians are advised to collect detailed information about device characteristics (e.g., device type, brand, and capacity), e-liquid characteristics (nicotine type, concentration in mg/mL or percentage, and tank volume), and usage patterns (frequency of refills, amount of liquid consumed, and dual use with cigarettes). Nicotine intake can then be approximated by converting nicotine concentration percentages to mg/mL, multiplying by the volume of e-liquid consumed, and calculating the total nicotine exposure over time. This estimate can be converted into cigarette equivalents using the approximation that one cigarette delivers about 1 mg of nicotine, which helps guide NRT dosing decisions. For example, a patient using a 2% nicotine salt solution (20 mg/mL) who consumes 10 mL of e-liquid over four days would ingest approximately 200 mg of nicotine, corresponding to roughly 50 cigarette equivalents per day. In such cases, high-dose NRT such as two 21-mg patches per day (total 42 mg) may be considered, with optional short-acting NRT for cravings. [3]
Non-nicotine medications can also be incorporated into cessation strategies, typically alongside counseling and NRT when appropriate. Bupropion is commonly initiated 1–2 weeks before the target quit date. A typical regimen begins with 150 mg once daily for the first three days, followed by 150 mg twice daily (or 300 mg extended-release once daily). Treatment generally continues for 6–12 weeks, although longer durations may be used depending on response. Varenicline is also started prior to the quit date and titrated over the first week: 0.5 mg once daily for days 1–3, 0.5 mg twice daily for days 4–7, and then 1 mg twice daily beginning on day 8. Treatment is usually continued for 3–6 months. Clinical trials of varenicline combined with counseling in EC users have demonstrated higher abstinence rates compared with placebo, including approximately 40% vs 20% abstinence at 12 weeks and sustained benefits through 24 weeks. Cytisinicline represents another pharmacologic option and can be used either as a structured tapering regimen (initially frequent dosing followed by gradual reduction over approximately 25 days) or as a simplified regimen of 3 mg three times daily for 6–12 weeks. Some treatment protocols support gradual nicotine reduction strategies during therapy, such as reducing consumption by approximately 50% by week 4 and 25% by week 8 before complete cessation by week 12. [3]
Overall, the review emphasizes that successful vaping cessation requires individualized treatment planning that combines behavioral counseling with carefully titrated pharmacotherapy. Because nicotine exposure from ECs can vary dramatically between individuals, clinicians must estimate nicotine intake and adjust NRT dosing accordingly while supporting patients through gradual tapering strategies and relapse-prevention counseling. The authors highlight the need for further research and formal guidelines to optimize dosing strategies and treatment protocols for EC dependence. [3]
A 2021 systematic review and meta-analysis evaluated the effectiveness of electronic nicotine device systems (ENDS) compared to traditional nicotine replacement therapies (NRT) for smoking cessation. The research synthesized data from six randomized controlled trials (RCTs) involving traditional cigarette users, examining outcomes such as smoking cessation rates, smoking reduction, and associated harms. The primary outcome assessed was smoking cessation, defined as abstinence from traditional cigarette smoking for any period, reported either through self-reports or biochemical validation. Secondary outcomes included smoking reduction, adverse events, withdrawal symptoms, and participants' acceptance of therapy. The results indicated no significant difference in smoking cessation rates between users of e-cigarettes and NRT, with a pooled rate ratio (RR) of 1.42 (95% CI 0.97 to 2.09). Similarly, no significant difference was observed in the proportion of participants reducing smoking consumption or in the mean reduction of cigarettes smoked per day. The assessment of harms revealed no serious adverse events related to either e-cigarettes or NRT; however, the quality of evidence was deemed low due to the high risk of bias in the included studies and considerable methodological heterogeneity. The study concluded that more research is needed to establish the effectiveness and long-term safety of ENDS as smoking cessation aids compared to NRT. [4]
A 2016 case report describes the first published example of successful e-cigarette cessation using evidence-based tobacco dependence treatments (Table 4). The authors noted that no validated tool comparable to the Fagerström scale exists to assess dependence in e-cigarette or dual users, which complicates clinical evaluation as dual use becomes more common. They also described challenges in using NRT for e-cigarette cessation, particularly estimating appropriate dosing, because nicotine exposure from electronic nicotine delivery systems (ENDS) can be difficult to quantify due to variable labeling, refill practices, and potentially inaccurate patient-reported use. Clinicians may therefore need to monitor both NRT use and continued ENDS use to adjust treatment. The authors also noted that matching NRT flavor with a preferred e-cigarette flavor, such as cinnamon-flavored nicotine gum in this case, may influence treatment acceptance and dosing. Additional research and clearer clinical guidelines are needed to improve assessment of dependence and guide treatment strategies for individuals seeking to discontinue ENDS use, including NRT, other pharmacologic therapies, and behavioral interventions. [5]