# From “harm reduction” to real smoking cessation—evidence sorting and realistic choices for different paths

On March 12, 2021, an underground garage of an office building in Pudong, Shanghai. I put the cigarette butts into the car ashtray and counted the cigarette packs: 8 cigarettes from morning to noon, and the target for the whole day is still 18–20. It was day 11 of my 7th serious attempt to quit smoking. For the first 10 days, I relied on 21mg nicotine patches to resist the tremors in my morning hands. On the 11th day, the project review was postponed until 21:40. A colleague in the elevator offered me cigarettes, and I took them. Later that day, I smoked 6 more cigarettes. The patch is still attached to the upper arm, and the person has returned to burning cigarettes.

Many people attribute this failure to "lack of willpower." I'm more concerned about another thing: the simultaneous existence of e-cigarettes, heated tobacco, NRT in drugstores, and the slogan "no touch tomorrow across the board." They are promoted as different tools on the same road, but actually answer three different questions-

1. Can ** help you stop burning cigarettes? **(Smoking cessation ending)

2. **Does harmful exposure decrease compared to continuing to smoke cigarettes? **(Harm reduction/exposure)

3. **Can we finally get rid of nicotine? **(Dependent on endpoint)

When these three issues are mixed together, the most common self-deception will appear: dual use (smoking e-cigarettes or heated tobacco while continuing to light cigarettes), subjectively feeling that "the harm has been reduced", and objectively the combustion exposure is almost continuous. Below, the four paths are laid out according to the level of evidence, rather than according to advertising popularity. My personal ranking will be written later, but the ranking must be based on public evidence, not taste preference.

1. Set the ruler first: what does “have evidence” mean?

I only recognize the weight of three types of materials:

**Smoking cessation rates** in standardized trials usually require at least **6 months** of sustained abstinence (biochemical verification is better). **Reduced exposure** looks at harmful markers in urine/blood (such as NNAL, COHb). **Disease outcomes** (MI, COPD progression, lung cancer) require longer time periods and larger samples. Mixing the three rulers is where the harm reduction narrative is most likely to overturn.

2. NRT: The least sexy, but the clearest rule

Evidence location

Cochrane's conclusions on nicotine replacement therapies (patch, gum, lozenges, inhalers, nasal sprays, etc.) are stable over time: **High-quality evidence** shows that all types of approved NRT can improve the long-term success rate of quitting smoking, and overall increase the chance of abstinence by approximately **50%–60%** (relative effect). Converted to absolute numbers, roughly: approximately 105 long-term abstinence per 1,000 people in the control group, and approximately **162** after using NRT (the order of magnitude varies with baseline and support intensity).

The network Meta level also prompts:

• **Combined NRT** (long-acting patch + immediate release gum/lozenge) tends to be closer to the "stronger" drug route;
• The patch alone or the immediate-release dosage form alone is effective, but usually weaker than the combination strategy and some prescription drugs (such as varenicline, domestic availability will be discussed separately).

The endpoint design of NRT is very clear: **replacement first, then tapering weekly, and finally discontinuation**. It's not a lifestyle product, the instructions say the course of treatment and tapering.

My operation record (March–April 2021, Shanghai)

• **Plan**: 21mg/24h patch × 14 days → 14mg × 14 days → 7mg × 14 days; prepare additional 2mg chewing gum during the day, and plan not to exceed 10-12 pieces per day.
• **Day 1–3**: Apply to outside of arm within 20 minutes after waking up, away from scratches and direct sunlight. The withdrawal peak is between 13:00 and 15:00 after lunch. Chewing gum should be chewed 5 minutes in advance until it feels "spicy" before sticking to the gums.
• **Actual problem**: On the 6th day, the edge of the patch was red and swollen, and it was itchy at night, which was relieved after switching to the opposite thigh; the chewing gum caused me to have mild hiccups and oral mucosal tingling on the 4th day, so I lowered the daily upper limit to 8 pieces.
• **Result**: After my social relapse on the 11th day, I did not throw away the patch, but entered a chaotic state of "patches + occasional cigarettes", which was equivalent to self-invalidation of the experimental conditions. This is not because NRT is ineffective, but because regimen compliance has collapsed.

My verdict on NRT

If your goal is to **maximize the probability of "really stopping nicotine" within 6 months** and be able to accept the feeling of being "less like smoking", NRT is still one of the paths with the most solid evidence and the cleanest medical semantics. Its shortcomings are not science, but experience: hand-mouth movements, smoke smell rituals, social cigarette passing scenes, it barely covers them all. Therefore, the patch alone is not enough for many heavy smokers. The **combined dosage form + behavior plan** is the part besides the instructions that should be included in the schedule.

3. Nicotine-containing e-cigarettes: The evidence on the endpoint of smoking cessation is getting stronger, but the time on the safety endpoint is not long enough

Evidence location

The core information given in Cochrane's update on "E-cigarettes for smoking cessation" (including a concise summary in Chinese) can be condensed into three sentences:

1. **High-quality evidence**: People who are randomly assigned to nicotine-containing e-cigarettes have a higher rate of quitting smoking 6 months or more than those who are randomly assigned to NRT (approximately **RR=1.63**; in absolute terms, there are approximately **3–4** more successful quitters per 100 people, and the range fluctuates slightly with updates).

2. **Moderate quality evidence**: Nicotine-containing e-cigarettes are better than non-nicotine e-cigarettes.

3. Benefits are also shown compared with behavioral support only/no support, but bias and design issues reduce certainty.

The popular conclusion of another Cochrane network comparison of drugs and e-cigarettes is: among various interventions, **nicotine e-cigarettes, varenicline, and cytisine** are near the first echelon of "most likely to help quit smoking"; combined NRT is also very competitive; patch alone/immediate-release NRT alone/bupropion is effective but weaker.

**Safety aspects**: Serious adverse events were generally rare in the included trials, and there was insufficient evidence of short-term differences between groups; the author repeatedly emphasized that **longer and larger samples** are needed to talk about comprehensive safety; the conclusions are mainly focused on **regulated nicotine-containing e-cigarettes** and cannot be extrapolated to illegal products or liquids mixed with other active substances.

The WHO's stance is even colder: e-cigarettes are **harmful and not a safe product**; for never-smokers, especially teenagers, the risks of initiating nicotine dependence and subsequent smoking of cigarettes have been repeatedly emphasized. Under the premise of strict supervision, systems such as the United Kingdom are more willing to discuss e-cigarettes as a smoking cessation tool for adult smokers. The difference in stance is essentially a difference in the objective function: one gives priority to guarding the "entrance" on the crowd side, and the other gives priority to the "exit" on the individual side that has already smoked.

My operation record (June–September 2022, Hangzhou remote working period)

• **Starting point**: An average of 15-18 cigarettes per day; choose an open device, the e-liquid is labeled with nicotine **20mg/ml** (salt nicotine), and the flavor is tobacco rather than fruit, in order to reduce the additional reinforcement of "smoking it as a dessert".
• **Switching Rules**: You are allowed to "roll cigarettes" for the first 7 days, but keep accounts every day; starting from the 8th day, the cigarettes are locked in the iron box on the balcony, and the key is left with the wife.
• **Data for Week 2**: The number of cigarettes dropped to 2-4 cigarettes/day, the number of e-cigarette puffs was out of control, and I smoked continuously while watching dramas at night. My tongue turned white and my throat became dry the next day.
• **Week 5**: The number of days with basically 0 cigarettes increased, but there was a typical dual-use rebound-two cigarettes at dinner, and using e-cigarettes to "wash away the guilt" at home.
• **Week 12**: No cigarettes for 21 days in a row; the nicotine in e-cigarettes was tried to be reduced to 10mg/ml, and the irritability and concentration decreased significantly. After a week, it was increased back to 15–20mg/ml.
• **Problem List**: Disposable cigarette cartridges leak and stain the keyboard; flight security limits restrictions on equipment and e-liquid capacity; the most difficult thing is **not knowing when to start reducing nicotine** - there is no how many milligrams to change in weeks printed on the instructions like NRT.

My judgment on electronic cigarettes

If the question is strictly defined as: **For people who already smoke, how to improve the probability of "not smoking combustible cigarettes for at least half a year"**, the current system review supports: Under comparable conditions, **regulated nicotine-containing e-cigarettes can be stronger than traditional NRT**.

If the question is changed to: **Is it close to harmless, suitable for long-term lifestyle, and friendly to never-smokers** - the answer immediately becomes hard: no, no, no.

The biggest structural risk of e-cigarettes is not the toxicity list of a certain puff of vapor, but the **ambiguous endpoint**: NRT will be stopped by default, and e-cigarettes can easily become "indefinite replacement". Harm reduction can only be achieved if you switch completely and never go back to smoking cigarettes; dual use is almost like giving yourself a self-comfort invoice.

4. Heated tobacco: Too many exposure stories are told, but there is little evidence on the outcome of smoking cessation.

Evidence location

The key points of Cochrane's systematic review of heated tobacco (HTP) are very harsh:

• The included randomized trials** have almost no high-quality evidence that reports "successful smoking cessation" as the reported outcome**, so whether it can be used as a means of smoking cessation is still uncertain**;
• Some toxicants/exposure markers (e.g. NNAL, COHb) show reductions in the short to medium term relative to continued cigarette smoking (medium certainty, subject to bias);
• Exposure is usually still higher relative to complete tobacco abstinence;
• Insufficient evidence of differences in adverse events; multiple trials and industry funding backgrounds require readers to weight them themselves.

The US FDA has given an **exposure modification** type authorization to a specific IQOS system: it is allowed to communicate under strict conditions that "complete switching can reduce exposure to certain harmful chemicals" - this does not mean approval as a smoking cessation drug, nor does it mean that the risk of long-term disease has been proven to be proportionally reduced. The CDC puts it more bluntly: Heated tobacco** has not been scientifically proven to help quit smoking** and is not an FDA-approved method of smoking cessation.

Professional organizations such as the European Respiratory Society (ERS) emphasize that: there is a lack of effective evidence as an aid to smoking cessation; dual use is common; and "maybe less harmful than burning cigarettes" cannot be packaged as a green light for public health.

My operation record (January 2023, returned to Changsha for the New Year for 18 days)

• **Motive**: The elderly in the family are disgusted with the sweet taste of e-cigarettes. The "ceremonial feeling" of heated tobacco is closer to that of cigarettes. The one after a meal is better disguised as "not that bad".
• **Usage**: averaged 12–15 heated cigarettes per day, claimed to be a “complete switch”, but actually smoked burning cigarettes when relatives handed them cigarettes, about half of dual-use days out of 18 days.
• **Feelings**: The residual smell in the room is lighter than that of cigarettes, but it is by no means odorless; the cough in the morning is slightly reduced, but the bleeding gums have not miraculously disappeared.
• **Cost**: Equipment + cigarette expenses were about 30%–40% higher than my cigarette budget at the time.
• **Ending method**: I ran out of heated cigarettes on the return high-speed train, and only cigarettes were left in the station convenience store. I resumed an average of more than 10 cigarettes per day on that day - **After behavioral substitution breaks, there is no preset withdrawal ladder**.

My verdict on heated tobacco

On the scale of "exposure after complete switch", heated tobacco may be better than continuing to smoke only cigarettes, but still worse than complete abstinence; on the scale of "**increased quitting rates**", the public independent evidence is significantly weaker than that of NRT and nicotine-containing e-cigarettes. It is most like the continuation of the tobacco company's product logic: retaining the tobacco matrix and brand path, and using the temperature curve to tell the story of harm reduction.

If your real goal is to quit smoking, I would not put it in the first toolbox; if you just want to reduce some combustion-related exposure when you cannot quit immediately, you must also meet a demanding prerequisite-**really switch 100% and set a withdrawal date for yourself**. Harm reduction without an exit date will most likely end up being another long-term use.

5. Complete smoking cessation: the gold standard and the only endpoint that does not require "comparative toxicity"

Complete smoking cessation (both tobacco burning and nicotine intake approaches zero) has no rival in terms of health benefits. The question is never "should I", but "how to survive the first 28 days".

Changes on the timeline that I personally checked (combined three attempts in 2019, 2021, and 2024)

On May 6, 2024, I set another withdrawal day in Nanshan District, Shenzhen: combined with NRT (14mg patch, reduced due to weight and previous use) for the first two weeks, and all e-cigarettes and heated tobacco were physically removed from the drawer. By day 45, cigarettes were 0; on day 60, patches were discontinued. The highest risk of relapse occurred during a wedding in July. I asked for one in the hotel corridor, smoked two puffs and threw them away - **I didn't finish the whole one, it was still a break.** The next day I immediately returned to the count of "today is the new day 1" instead of "it's ruined so let go".

The advantage of the evidence for complete smoking cessation is that the end point is clean; the disadvantage is that it has the highest requirements for **environmental design**. Without drugs, without alternatives, the success rate is lower than with supported pathways - this is not a moral issue, it is a pharmacology of addiction and learning psychology issue.

6. Sorting of evidence for four paths (according to different goals)

For the same set of tools with different goals, the order must be changed.

Objective A: Maximize the probability of “not smoking combustible cigarettes” within 6–12 months

1. **Regulated nicotine-containing e-cigarettes** (can be better than NRT under experimental conditions) or **prescription drugs such as varenicline** (medical advice will be given priority if available)

2. **Joint NRT**

3. **Single NRT + Strict Behavioral Support**

4. **Heated Tobacco** (Insufficient evidence on the outcome of smoking cessation, not a priority)

5. **Unplanned hard quit** (feasible for some people, but the average success rate is usually lower)

Objective B: Reduce harmful exposure relative to cigarettes when immediate withdrawal is still not possible

There is only one premise: **Complete switching, dual use is prohibited**.

1. Complete withdrawal (maximum decrease in exposure)

2. Regulate e-cigarettes or NRT (NRT also points to deactivation)

3. Heated tobacco (some exposure markers may decrease, and long-term disease endpoints are not yet clear)

4. Continue to smoke/dual use (dual use often makes “harm reduction” exist in name only)

Goal C: Ultimate freedom from nicotine dependence

1. **NRT (with tapering endpoint) + complete smoking cessation**

2. E-cigarettes (you must create your own reduction schedule, otherwise it will be easily delayed)

3. Heated tobacco (tobacco base + nicotine, often weaker motivation to quit)

4. Indefinite harm-reduced use without a stop date

My current ranking is very clear:

**True quitting (zero burning tobacco) > Medical path with exit plan (NRT/prescription drugs) > Full switch to e-cigarettes with exit plan > Full switch to heated tobacco > Any form of long-term dual use > Self-soothing “I’m already using new technology.” **

This is not a moral ranking, but the result of weighting "evidence of smoking cessation outcomes" and "reliance on endpoint clarity" over "advertising quality".

7. A practical decision tree that can be used

**Q1: Are you already a daily smoker? **

• No (never smoker/teen): Should not touch any nicotine products. The evidence argument is none of your business.
• Yes: Go to Q2.

**Q2: In the next 90 days, do you accept that "nicotine can be used temporarily, but cigarettes must be stopped"? **

• No: Quit smoking completely + use NRT/prescription drugs/behavioral support as much as possible, do not introduce multiple new addiction vehicles at the same time.
• Yes: Go to Q3.

**Q3: Do you need "smoking-like" movements and smoke sensations to survive the cue trigger? **

• No: Priority **Combined NRT**, the treatment course is written on the calendar, and tapering must occur in weeks 8–12.
• Yes: Under the premise that **local regulations permit and the product source is traceable**, regulated nicotine-containing e-cigarettes can be considered as a **limited** complete switching tool; at the same time, write down:
• Switching day;
• Zero tolerance for dual use;
• Assessment of nicotine concentration decline every 2–4 weeks;
• Deactivation or transfer to NRT must be entered after a maximum replacement window (e.g. 3–6 months).

**Q4: When will heated tobacco become an option? **

Only if you are completely intolerant to e-cigarettes, cannot quit in the short term, and can commit to a complete switch and withdrawal date - it is still an **alternative among alternatives**, not the preferred method of quitting smoking based on evidence.

**Q5: How to deal with relapse? **

It will be treated as a "single incident" and not as a "personality failure". Returning to the original plan within 24 hours is much more important than "finishing the pack". My mistake that time in the garage was not that I took the cigarette, but that I mentally canceled the patch plan after taking the cigarette.

8. I would like to spread my ugly words to the first few boundaries.

1. **Harm reduction ≠ Harmless**. Relative risk reduction is not absolute safety.

2. **Exposure decreases ≠ Disease risk decreases by the same proportion**. Marker improvements are encouraging but are not a substitute for long-term outcome studies.

3. **The test works ≠ It works in your living room**. Trials have follow-up, product controls, and clearly defined “withdrawal”; you have meals, overtime, emotional breakdowns, and filter inertia.

4. **Dual use is a black hole for the harm reduction narrative**. Don’t allow yourself to mask the burning smoke with “I vaped a lot today so it’s okay.”

5. **Industry-funded research must be read with reduced authority**, and independent systematic reviews and regulatory wording must be read word for word: whether it is "reducing exposure" or "reducing disease", whether it is "marketable statement" or "approved therapy".

6. **Pregnant women, teenagers, non-smokers** are outside the scope of this article’s tool discussion - for them, the correct order is to stay away, not to choose which "cooler nicotine".

9. Write to the person who is clicking on the price comparison page

If you currently have the heating cigarette device details page, e-cigarette oil concentration table, and pharmacy NRT instructions open in your browser at the same time, it is recommended to turn off price sorting first, open the memo and write three lines:

1. Is my main goal to **stop burning cigarettes**, or to **change smoking methods in the long term**?

2. The day I set for myself to completely switch is ____ month ____, year ____.

3. My nicotine withdrawal day (or NRT wrap-up day) is ____ month ____, year ____.

People who can’t write down the date will most likely become dual users after six months, and then argue about “harm reduction” on social platforms – that’s identity consumption, not health decision-making.

I’ve experienced patch allergies, out-of-control e-cigarette puffs, performative switching of heated tobacco at relatives’ dinner tables, and a recount after two puffs at a wedding. What finally pulled me away from the one-pack-a-day state was not a certain inspirational sentence, but an admission:

• **E-cigarettes can be a probabilistic tool for quitting smoking, but they can easily turn into a lifelong nicotine subscription;**
• **NRT is boring, but boring often equals endable;**
• **Heated tobacco will tell the most beautiful technological story, but it lacks independent evidence on the outcome of smoking cessation;**
• **Quitting smoking completely is the hardest step, but it is the only end point where you no longer need to ask for leave from the toxicity form. **

Choice can be divided into stages, but self-deception cannot be divided into stages. Let’s clear out burning cigarettes first, and then talk about how to get rid of nicotine; kill dual-use ones first, and then talk about harm reduction figures. The path can be discussed, but the ruler cannot be thrown away.

Main evidence source types (for self-review)

• Cochrane: Systematic review and plain language summary of e-cigarettes for smoking cessation (nicotine-containing e-cigarettes vs NRT, etc.)
• Cochrane: Web-based meta/systematic review popular summary of the effectiveness of smoking cessation medications and e-cigarettes
• Cochrane: Systematic review of NRT vs control (relative effect in long-term abstinence approximately 50%–60%)
• Cochrane: Systematic review of heated tobacco and smoking cessation/harm reduction (insufficient evidence on smoking cessation outcomes; comparison of exposure markers)
• US FDA: Authorization context for modified exposure of certain heated tobacco products
• US CDC: Heated Tobacco Products Fact Sheet (Not Approved Cessation Law; Insufficient Evidence for Cessation)
• WHO: E-cigarette Q&A (harmful, not safe; youth and initiation risks)
• Position papers on heated tobacco from professional organizations such as the European Respiratory Society

(The specific effect size will be slightly adjusted as the review is updated; it is recommended to check the absolute number and level of evidence in the latest version of the abstract before making a decision.)