The Cochrane findings do not exist in a vacuum. Critics — most notably Stanton Glantz and colleagues, whose 2026 paper argued that e-cigarettes "increase harm and should be discouraged" — raise important population-level concerns that individual-level RCT data cannot address:
- Population-level vs individual-level effects: Even if vapes help individual smokers quit, if they also recruit new young users who would never have smoked, the net population effect could be negative
- Dual use persistence: Many RCT participants who "quit" using vapes may become long-term dual users (vaping + smoking intermittently), which may not deliver the same health benefits as complete cessation
- Youth gateway concerns: The review's RCTs focus on adult smokers; they do not address youth uptake, which the CDC's own data shows peaked at 20% in 2019 before declining to 5.9% by 2026
- Industry influence: Some cessation studies received industry funding, potentially biasing results
Our editorial assessment: Both the Cochrane review (RCT evidence, individual-level) and the Glantz critique (population modeling, ecological data) are legitimate scientific contributions. They answer different questions. The Cochrane review answers: "If I am an adult smoker trying to quit, do nicotine vapes work better than NRT?" The answer is yes, with high certainty. The Glantz critique asks: "At a population level, do e-cigarettes reduce or increase total harm?" That answer depends on how you weigh adult cessation gains against youth uptake — a policy judgment, not a purely scientific one.
