Older adults who smoke heavily have a hard time kicking the habit, even when they receive the most promising cessation treatment. “These are people who started smoking when they were very young, before we knew of all the dangers,” says Jaqueline Avila, assistant professor of gerontology at UMass Boston. “They are heavily dependent on nicotine [the addictive substance in tobacco].” Nicotine gum or patches deliver far less of the substance and at a slower rate of absorption, she says.

As the only age group in which smoking rates haven’t declined over the past decade, older smokers face a high risk of developing lung cancer. The disease is caused not by the nicotine in cigarettes but by the smoke and tar that a smoker inhales.

In a recent study of 640 older smokers at high risk for lung cancer who were offered  smoking cessation counseling and nicotine replacement therapy, just about 15 percent successfully quit the habit, Avila says. ”We’re failing these people if we’re giving them the best treatment we know and it’s only 15 percent effective.”

So Avila is studying a controversial alternative: Testing the harm reduction potential of asking these long-time smokers to switch from smoking cigarettes to using electronic cigarettes, or vaping.

“Because e-cigarettes aren’t combustive, the user inhales nicotine vapor instead of tobacco smoke. There is growing evidence that exposure to toxic substances from combustible cigarettes is significantly lower in e-cigarettes, and that completely switching to e-cigarettes results in reduced exposure to carcinogens, as well as lower levels of biomarkers of tobacco exposure and oxidative stress.” Avila says, quickly adding a disclaimer that people who don’t smoke or vape shouldn’t start.

Avila is partnering with Nancy Rigotti, MD, a professor of medicine at Harvard Medical School, associate chief of the general internal medicine division at Massachusetts General Hospital, and an internationally known expert in tobacco use, tobacco cessation, and tobacco control public policy. The researchers have been working together through the UMass Boston– Dana-Farber/Harvard Cancer Center U54 Partnership, a National Cancer Institute effort to increase cancer health equity and diversity in cancer research. The program pairs large cancer research centers with institutions serving underserved health disparity populations and underrepresented students, including UMass Boston.

In the first phase of their research, completed in the spring of 2024, Avila and Rigotti surveyed 209 heavy smokers aged 50 and older who were at risk for lung cancer and who tried to quit smoking through the smoking cessation program but weren’t successful. The survey asked the smokers what they think about e-cigarettes and what they know about nicotine. About 43% of those surveyed said they would not try e-cigarettes, and nearly 80 percent thought that vaping was somewhat or very harmful.

Yet, the majority said they were interested in learning more about e-cigarettes. The researchers realized they should add education about nicotine, smoking, and health risks into the second phase of the study. Working with 30 respondents who said they would be willing to try e-cigarettes, they will give the participants e-cigarettes to use for four weeks instead of cigarettes. The researchers will measure changes in cigarettes smoked per day, the carbon monoxide that they expire in their breath and biomarkers for cancer in their urine.

“We’ll be looking for evidence of harm reduction,” Avila says, which should be evident in just a month’s time.

Their study should add to a growing body of evidence on how e-cigarettes can serve as a harm reduction tool for heavy smokers, Avila says. Research from a large Cochrane review of randomized controlled trials has shown e-cigarette’s efficacy for smoking cessation. In the United Kingdom, it is already approved as a smoking cessation tool. Recent RCTs have also shown that completely or even partially switching from cigarettes to e-cigarettes significantly reduces exposures to carcinogens, oxidative stress, number of cigarettes smoked and carbon monoxide levels.