International best practice in the management and cessation of vaping and alternative nicotine use, and barriers, facilitators and treatment preferences: A rapid review protocol

Rory Coyne; Mengyang Zhang; Gintare Valentelyte; Paul Kavanagh; Kenneth D. Ward; Jan Sorensen; Frank Doyle

doi:10.12688/hrbopenres.14293.2

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Study Protocol

Revised

International best practice in the management and cessation of vaping and alternative nicotine use, and barriers, facilitators and treatment preferences: A rapid review protocol

[version 2; peer review: 1 approved, 1 not approved]

Previously titled: "International best practice in the management and cessation of vaping and recreational nicotine use, and barriers, facilitators and treatment preferences: A rapid review protocol"

Rory Coyne ¹, Mengyang Zhang¹, Gintare Valentelyte¹, [...] Paul Kavanagh^1,2, Kenneth D. Ward³, Jan Sorensen¹, Frank Doyle¹

Rory Coyne ¹, Mengyang Zhang¹, [...] Gintare Valentelyte¹, Paul Kavanagh^1,2, Kenneth D. Ward³, Jan Sorensen¹, Frank Doyle¹

PUBLISHED 26 May 2026

Author details Author details

¹ Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland
² Health Service Executive, County Dublin, County Dublin, Ireland
³ University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA

Rory Coyne
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Mengyang Zhang
Roles: Conceptualization, Methodology, Project Administration, Writing – Review & Editing

Gintare Valentelyte
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Paul Kavanagh
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Kenneth D. Ward
Roles: Conceptualization, Supervision, Writing – Review & Editing

Jan Sorensen
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Frank Doyle
Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

The use of electronic cigarettes, also known as ‘vapes’, has more than doubled in Ireland in recent years, and has been accompanied by the arrival of other alternative forms of alternative, non-combustible nicotine use. There is ample evidence that many vape users want to quit. However, in the absence of widely available and evidence-based cessation and management services that are tailored to these products, individuals may struggle to become nicotine-free. The development of effective services which target these behaviours must also be sensitive to the factors which influence their successful implementation.

Aim

This rapid review seeks to evaluate the extent to which interventions that address the management and cessation of vaping and alternative nicotine use align with best practice, as well as to understand the key barriers and facilitators to implementation, and the patient-reported treatment preferences that have been reported in the literature.

Methods

A rapid review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be conducted. Three electronic databases of peer-reviewed journal articles and one electronic database of grey literature will be searched for reports of interventions for the management and cessation of vaping and alternative nicotine products, published since 2003. Relevant data will be extracted and presented using a narrative synthesis. An evaluation of the extent to which included interventions align with best practice will also be conducted.

Ethics and dissemination

Ethical approval is not required for this review. The protocol for the rapid review, as well as the resulting report of its findings, will be submitted to a scientific journal for peer review. This research was commissioned by HSE Tobacco Free Ireland. A variety of knowledge users will be engaged with to disseminate the findings, in collaboration with our partners at the Health Service Executive.

Keywords

Vaping; Recreational nicotine use; Interventions; Treatment preferences; Best practice; Vaping treatment; Barriers and facilitators; Recreational treatment.

Corresponding author: Rory Coyne

Competing interests: No competing interests were disclosed.

Grant information: This work is supported by the Health Services Executive Tobacco Free Ireland Programme, under collaborative agreement TFIRCA-2024.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2026 Coyne R et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Coyne R, Zhang M, Valentelyte G et al. International best practice in the management and cessation of vaping and alternative nicotine use, and barriers, facilitators and treatment preferences: A rapid review protocol [version 2; peer review: 1 approved, 1 not approved]. HRB Open Res 2026, 8:130 (https://doi.org/10.12688/hrbopenres.14293.2) First published: 12 Dec 2025, 8:130 (https://doi.org/10.12688/hrbopenres.14293.1) Latest published: 26 May 2026, 8:130 (https://doi.org/10.12688/hrbopenres.14293.2)

Revised Amendments from Version 1

The main changes introduced in this revised version of the protocol include clarifications regarding the target population and types of services to be included in the review, additional information on what is known concerning alternative nicotine products, and refinement of the terminology used in the previous version.

See the authors' detailed response to the review by Jean-Francois ETTER
See the authors' detailed response to the review by Jo Longman

Introduction

The use of vapes, also commonly referred to as ‘e-cigarettes’, has risen considerably in recent years. A recent examination of changes between 2015 and 2023 in Ireland found that vaping and dual-use (i.e., smoking and vaping) had more than doubled, with the largest increase seen among 15–24-year-olds (Brennan et al., 2025). A recent estimate from the 2024 Irish Health Survey indicates that 13.6% young adults in Ireland aged 18 to 34 are using vapes daily, whereas a further 10% vape occasionally (Central Statistics Office, 2025). A wide variety of reasons for vaping have been reported in the literature. They include switching from cigarettes or other tobacco products, long-term nicotine dependence, or flavour/taste-related influences (Ledgerwood et al., 2024). Among adolescents, factors such as attractive packaging, peer influence, or socialising with friends may be more influential (Pbert et al., 2024; Weinstein et al., 2024). The precise health consequences of vaping, beyond forming a nicotine dependency (or perpetuating it, when used as a cigarette substitution) are currently unclear.. Whilst the health consequences of vaping are not yet certain, with some finding no evidence of an association between vaping nicotine and adverse health effects (Agrawal et al., 2024), a review by Glantz et al. (2024) found similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use. Developing approaches to help individuals quit vaping is therefore important not only in terms of becoming nicotine-free, but also in terms of limiting exposure to chemicals contained within vapes, which could result in adverse health effects for vape users, compared with those who do not smoke or vape, when consumed long-term. A distinction can be made in terms of pathways to vaping, between those who are using vaping as a smoking cessation tool, and others (largely children and young people) who have never smoked (Notley et al., 2021). These differential pathways are also reflected in the approaches to vaping taken internationally, with countries such as the United Kingdom offering vapes as a smoking cessation aid – in stark contrast from India, where vaping is illegal (Kokabisaghi et al., 2023). The market is constantly shifting; in 2017, refillable tank devices were the most popular form of vapes, prior to being overtaken by disposable vapes in 2023 (Hammond et al., 2025). The rise in vaping has also coincided with the influx of a litany of alternative nicotine products onto the market. Most notably, nicotine pouches (which involve the placement of a sachet between the gum and lip for potent nicotine delivery) are increasingly commonplace. Recent data indicated that among a large sample of 15–18-year-olds in Ireland, 8.9% had used nicotine pouches, whilst 13.1% had used moist snuff, in which finely ground smokeless tobacco is used to absorb nicotine orally (Hanafin et al., 2025). Another examination of trends among adults in England (Cox et al., 2025) found increases in the use of nicotine pouches and heated tobacco products (or ‘heat-not-burn’), in which tobacco is heated to produce an aerosol without combustion (Tattan-Birch et al., 2021) – however, overall prevalence was 0.7% (Cox et al., 2025). Current knowledge therefore suggests that use of this range of products is low, but increasing – and appears concentrated among those with a previous history of nicotine use (Brose et al., 2025).

A study by Jongenelis et al. (2024) found that 61% of young Australian vape users expressed desire to quit, with 55% have made at least one quit attempt (Jongenelis et al., 2024). Another qualitative study (Pbert et al., 2024) found that nearly all of their participants had experienced multiple failed quit attempts, with quit strategies including seeking social support and using distraction techniques. A number of important barriers to quitting vaping exist, such as fear of relapsing to smoking among those who have used vaping to quit smoking (Dyson et al., 2022), and low perceived risk of vaping to one’s health, particularly among younger vapers (Patterson et al., 2025). Ultimately, however, vape users who do want to quit will face difficulties quitting in the absence of dedicated services and supports (Struik & Yang, 2021). There is also a risk that dedicated services for the cessation of vaping, for which the precise health consequences are still unclear, may divert resources away from smoking cessation services. At the same, long-term nicotine dependence proliferated by both smoking and vaping may also place strain on healthcare services (Neczypor et al., 2022). A review by Tan et al. (2025) identified barriers and facilitators experienced by health professionals in providing vaping cessation support, with lack of knowledge and training identified as key barriers. Some early work has also been conducted to identify barriers and facilitators to quitting vaping among service users. Barriers can include normalisation or the ease of access to vapes (Rahman et al., 2024a), whereas facilitators may include factors such as health concerns about vapes (Sanchez et al., 2021). However, to date, there is no comprehensive investigation of barriers and facilitators to the implementation of vaping and alternative nicotine product cessation interventions internationally.

Interventions for quitting vaping can take many forms: they include behavioural interventions (such as those which draw on cognitive-behavioural or motivational interviewing techniques), pharmacological interventions (such as Nicotine Replacement Therapy (NRT; Buela et al., 2025)) and interventions that seek to change the characteristics of vapes, such as reducing nicotine content (Sahr et al., 2019). The types of interventions which have emerged as having the strongest supportive evidence for vaping cessation include text message based-interventions and varenicline (a medication which binds to nicotine receptors in the brain to reduce cravings; Butler et al., 2025). However, the majority of vaping cessation interventions have to date shown limited evidence of effectiveness, with many simply adapting smoking cessation approaches to vaping (Kundu et al., 2023). A review by Huerne and Eisenberg (2023) stressed the need for intervention protocols which are specific to vaping cessation. Moreover, there is currently a lack of evidence-based clinical guidelines for vaping cessation (Rahman et al., 2024b), and no approved vaping cessation aids currently exist (Heshmati et al., 2025). This could result in inconsistent approaches to vaping cessation internationally, potentially contributing to the weaker evidence for their effectiveness.

While there is a substantial evidence base to assist the design and delivery of effective stop smoking services, health systems are struggling to determine how best to respond to the needs of people who vape and want advice and support to stop smoking. As the types of nicotine products, and as patterns of product use (i.e., vaping versus dual-use) become more varied, there will be an increasing need for nicotine cessation services to adopt a nuanced and complex approach – one that is sensitive to the factors which serve as barriers or facilitators to their successful implementation. Additionally, identifying best practice in public health interventions (i.e., one that shows evidence of effectiveness in a particular setting, and is likely to be replicable in other settings; Ng & De Colombani, 2015) is crucially important in developing standardised recommendations and avoiding resource waste. This review therefore seeks to pull together findings from interventions which have targeted a range of nicotine product types, in order to establish a rich, nuanced set of recommendations to inform practice. Furthermore, synthesising the international evidence for the extent to which these interventions align with best practice will identify tangible ways in which the impact of interventions can be maximised.

Review questions

This rapid review seeks to evaluate the extent to which interventions for the management and cessation of vaping and alternative nicotine products align with best practice, and to identify the factors which influence their implementation. These findings will allow the identification of areas of opportunity as well as areas of difficulty that have been reported in previous interventions. As this is an area of research which is continuously emerging, particularly as new products continue to enter the market (e.g., nicotine lozenges, tablets, gummies, and gum), this work aims to provide timely recommendations using a streamlined approach to evidence synthesis, for which rapid reviews are particularly useful (Moons et al., 2021).

The central research question of this rapid review therefore is ‘What can be considered best practice in the management and cessation of vaping and alternative (i.e., non-combustible) nicotine use, and what barriers, facilitators and treatment preferences have been reported to these practices?’

This central question will be addressed through synthesising the results of included studies according to the following sub-questions:

RQ1: Which approaches to the management and cessation of vaping and/or alternative nicotine product use can be considered best practice?

RQ2: What are the perceived or actual barriers and facilitators to the implementation of interventions for vaping cessation and/or alternative nicotine product use?

RQ3: What treatment preferences have been reported by those who vape and/or use alternative nicotine products (excluding forms of combustible tobacco such as cigarettes)?

Methods

This protocol is reported in adherence with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines (Shamseer et al., 2015). This is recommended as the preferred method of reporting rapid review protocols, in advance of dedicated guidelines for this type of review being made available (Stevens et al., 2018; Stevens et al., 2025). The protocol for the review has also been registered on PROSPERO (ID: CRD420251141677). A PRIMSA-P checklist for this protocol has also been uploaded to the Open Science Framework: https://doi.org/10.17605/OSF.IO/5X9R6 (Coyne et al., 2025).

Patient and public involvement

This research is part of a HSE Tobacco Free Ireland funded project, titled ‘Vaping/alternate non-medicinal nicotine products and Dual-use along with regular Tobacco use: Integrated Interventions and Economic Modelling in Ireland’ (VAPE-INTERVENE). Public and patient representatives were not specifically involved in the design of this review protocol, but informed the overall conceptualisation of the project and application for funding. A Public Health Advisor for HSE Tobacco Free Ireland (PK) is also included as a co-author, providing a natural pathway for addressing relevant policy aspects and ensuring adaption of the findings into national and local policy.

Eligibility criteria

Population: We will seek to include studies which recruited human participants who identify as being either a ‘single’ user (i.e., user of either vapes or alternative nicotine products) or ‘dual user’ (i.e., user of both vapes and alternative nicotine products). Participants who use traditional cigarettes in tandem with vapes and/or alternative nicotine products will still be included, but participants who use traditional cigarettes only will be excluded. We aim to include individuals who are motivated to quit vapes and/or alternative nicotine products by virtue of signing up to participate in a cessation intervention or attending a cessation service. Studies who recruit participants who are using these products exclusively as a smoking cessation aid or on the advice of a healthcare practitioner at the time of the study will be excluded. As the focus of this review is on nicotine vaping and other forms of alternative nicotine use, we will exclude studies which focus solely on cannabis/tetrahydrocannabinol (THC) vaping or other illicit substances. No restrictions regarding gender, the presence of comorbid medical conditions, or frequency of vaping/alternative nicotine product use (e.g., frequent user versus ever used) will be applied. We will also seek to include participants from a broad range of settings, such as healthcare, community-based, and other contexts. As such, there will be no restrictions regarding the study site. Studies will not be eligible for inclusion if they recruited animal subjects or did not recruit participants who either vape or are a user of alternative nicotine products.

Intervention(s) or exposure(s) : Eligible studies will focus on an intervention which targets vaping and/or alternative nicotine product use. ‘Intervention’ in this case refers to individual-level support for the cessation of vaping and/or alternative nicotine products, to those who are motivated to quit these products. As noted previously, these may include (but are not limited to) behavioural interventions, pharmacological interventions, or interventions which seek to change the characteristics of the product(s) used.

Comparator(s) or control(s): Study selection will not be guided by the use of comparators. Therefore, the sample may include studies which have involved the use of a comparator/control group, as well as those which did not employ a comparison group, so long as the intervention targets vaping or alternative nicotine product use.

Outcome(s): The intervention must target vaping and/or alternative nicotine product use as a target behaviour. Interventions which do not target either vaping or alternative nicotine product use (e.g., those that target tobacco smoking only) will be excluded. Where available, we will also collect information regarding barriers and facilitators to implementation (both in terms of author-reported barriers and facilitators, and user-experienced barriers and facilitators), similar to previous research (Gargaritano et al., 2020; Pilch et al., 2021; Sharpe et al., 2018). Data concerning treatment preferences (i.e., qualitative data on experiences, perspectives or attitudes to the intervention, or quantitative measures of acceptability, perceived utility, or perceived efficacy) will also be examined where available.

Study: We will include peer-reviewed journal articles and grey literature on primary research published between 2003 and the date of the search in the English language. Studies not published in English and studies published before 2003 will be excluded (this cut-off roughly coincides with the introduction of commercially available e-cigarettes – as such, eligible articles are unlikely to be published before this date). Review papers (systematic reviews, scoping reviews, etc.) will be excluded. Studies that used quantitative, qualitative or mixed methods will be included.

Information sources and search strategy

A systematic search of three electronic databases of peer-reviewed journal articles (MEDLINE, PsycInfo and Scopus) as well as an electronic database of grey literature (PsycEXTRA) will be searched for records published between January 1^st, 2003 and the date of the search (estimated to be November 2025). The search strategies that will be used for each database are included in Appendix A. The search strategy was developed in consultation with previous reviews of vaping cessation (e.g., Belon et al., 2025; Butler et al., 2025; East et al., 2025), as well as a library information specialist. A combination of subject headings (where available in the respective database) and free terms will be used. In the first block, search terms related to vaping and alternative nicotine products will be entered (e.g., vaping, electronic cigarette, heat-not-burn, etc.) and combined using the OR Boolean operator. The NOT operator will also be applied in this block, to exclude articles that are indexed under ‘tobacco smoking’ using the relevant subject heading. It was decided not to exclude articles that mention tobacco smoking in the title and/or abstract, as this may inadvertently exclude articles potentially relevant to the review. The second block will include terms related to the type or aim of the intervention (e.g., cessation, stop, discontinue, etc.). The third and final block will consist of terms related to attitudes, experiences or perceptions of vaping cessation interventions. These three blocks will be combined using the AND Boolean operator, and the results of this combined search will be filtered according to English-language articles published between 2003 and the date of search.

Screening and study selection

The results of the database search will be exported to the Zotero reference management software for de-duplication, before being imported into Covidence for screening. The de-duplicated sample of extracted articles will be screened by one reviewer (RC) in two phases: Stage 1 screening will involve assessing the title and abstract of included studies in accordance with the above eligibility criteria. Articles that are deemed potentially eligible for inclusion at Stage 1 will then undergo screening at Stage 2, which will involve the full-text articles being assessed for eligibility. Articles excluded at both Stage 1 and Stage 2 will be reported in a PRISMA flow diagram, with reasons for exclusion, along with the number of articles deemed eligible at both stages. A second reviewer (MZ) will double screen a random sample of 20% of articles at Stage 1 and Stage 2 to ensure consistency. Disagreements will be resolved in consultation with a third reviewer (GV) where necessary.

Data extraction and management

Once the final sample of included studies has been determined, data will be extracted by one reviewer (RC) and entered into a data extraction form in Microsoft Excel. The types of data extraction from included studies will be: study characteristics (authors, year published, journal published); study setting (country, the setting in which the study was conducted), participant characteristics (demographic information, types of products used (i.e., vapes and/or alternative nicotine products), type of usage (i.e., daily versus weekly use), intervention characteristics (intervention content, frequency, modality and duration of the intervention), information on barriers and facilitators to implementation (author or user-reported), and treatment preferences (quantitative measures of acceptability, perceived efficacy, etc., and/or qualitative data on experiences, attitudes, etc.). We will also collect information on intervention effectiveness (e.g., reduction in product use, cessation rates), and attitudes towards financial incentives where available.

Finally, to assess the extent to which the included interventions align with best practice, a checklist developed by Ng and De Colombani (2015) will be used. This framework provides guidance on assessing whether a public health intervention aligns with best practice according to eight criteria – relevance, community participation, stakeholder collaboration, ethical soundness, replicability, effectiveness, efficiency, and sustainability. The framework provides guidance on the precise manner in which each criterion should be implemented in order to align with best practice. The included articles will therefore be evaluated in accordance with this framework based on the full-text article, with the outcome extracted into the data extraction form.

Data analysis and synthesis

The extracted data will be synthesised in accordance with the three sub-questions designed to address the overarching aim of this rapid review. A narrative synthesis will be conducted using the extracted data, in which information will be organised into themes, patterns or discrepancies that are relevant to the review questions. The findings regarding the extent to which interventions align with best practice will be presented in table format, to facilitate common areas of strength as well as areas of opportunity to be identified.

Conclusion

As the nicotine product marketplace becomes increasingly complex, an equally complex and nuanced approach to developing cessation and management services will be required. This rapid review seeks to synthesise the available evidence for the extent to which existing interventions align with best practice. Key information concerning barriers and facilitators to implementation, and user-reported treatment preferences will also be examined. The findings of the review will inform the development of vaping and alternative nicotine product cessation services in Ireland and internationally. The findings of the review will also assist in the identification of areas of strengths as well as areas of opportunity for vaping and alternative nicotine product cessation services, and identify patient-related factors which are particularly influential on the success of these vitally important services.

Ethics and dissemination

Ethical approval is not required for rapid reviews. The findings of the rapid review will inform the co-design of services for the management and cessation of vaping and alternative nicotine product use in Ireland. The authors will also ensure that the findings are disseminated amongst key knowledge users by engaging with a variety of channels.

Data availability

The search strategies that will be used for this review are available on the Open Science Framework; https://doi.org/10.17605/OSF.IO/5X9R6 (Coyne et al., 2025).

Reporting guidelines

Open Science Framework: PRISMA-P checklist for ‘International best practice in the management and cessation of vaping and alternative nicotine use, and barriers, facilitators and treatment preferences: A rapid review protocol’. https://doi.org/10.17605/OSF.IO/5X9R6 (Coyne et al., 2025).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Weinstein D, Jones E, Endrighi R, et al.:“I knew the effects the whole time.” Examination of facilitators and barriers to quit vaping among adolescents. Addict Behav. 2024; 157: 108087. Publisher Full Text

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Version 2

VERSION 2 PUBLISHED 12 Dec 2025

Author details Author details

Rory Coyne
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Mengyang Zhang
Roles: Conceptualization, Methodology, Project Administration, Writing – Review & Editing

Gintare Valentelyte
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Paul Kavanagh
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Kenneth D. Ward
Roles: Conceptualization, Supervision, Writing – Review & Editing

Jan Sorensen
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Frank Doyle
Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

This work is supported by the Health Services Executive Tobacco Free Ireland Programme, under collaborative agreement TFIRCA-2024.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (2)

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Published: 26 May 2026, 8:130

https://doi.org/10.12688/hrbopenres.14293.2

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https://doi.org/10.12688/hrbopenres.14293.1

© 2026 Coyne R et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Coyne R, Zhang M, Valentelyte G et al. International best practice in the management and cessation of vaping and alternative nicotine use, and barriers, facilitators and treatment preferences: A rapid review protocol [version 2; peer review: 1 approved, 1 not approved]. HRB Open Res 2026, 8:130 (https://doi.org/10.12688/hrbopenres.14293.2)

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Reviewer Report 10 Jun 2026

Jo Longman, The University of Sydney, Sydney, Australia

Approved

https://doi.org/10.21956/hrbopenres.15836.r55678

I am satisfied that my comments have been ... Continue reading

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Reviewer Report 30 Jan 2026

Jean-Francois ETTER, University of Geneva, Geneva, Switzerland

Not Approved

https://doi.org/10.21956/hrbopenres.15729.r52793

1.This is a study protocol for a rapid literature review on interventions aimed at the cessation of vaping and recreational nicotine use.

2.One drawback of vaping cessation interventions is that they divert already limited resources away from smoking cessation interventions, and this can be counterproductive, as the latter have a greater impact on mortality and morbidity than the former. This point should be discussed.

Are vapers interested in vaping cessation support? A brief literature search shows that most are not interested, for various reasons: they use e-cigarettes to stop smoking and fear they would relapse to smoking if they stopped vaping, they understand that vaping is less dangerous than smoking, they already used other smoking cessation aids but failed to quit with these aids, they therefore do not see why they should stop vaping, etc. This literature should be cited in the introduction.
A corollary of this lack of interest in support is that it will be very costly to recruit vapers in these interventions, and services that offer this type of support would struggle to be profitable.
Information on the cost of these interventions, their cost effectiveness (cost per quitter, cost per cancer case prevented), and their cost-benefit (medical care costs avoided) should also be collected in this review.
3A.
To support their affirmation that “vapes can introduce considerable respiratory and cardiovascular problems,” the authors cite an article published in 2024 in an obscure Polish sports journal that has been cited only once. Instead, they should cite the NASEM report or that of the Royal College of Physicians (RCP), which are serious and widely cited reviews:

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: smoking, nicotine, tobacco, vaping, tobacco harm reduction

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Author Response 26 May 2026

Rory Coyne, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Ireland

26 May 2026

Author Response
2.One drawback of vaping cessation interventions is that they divert already limited resources away from smoking cessation interventions, and this can be counterproductive, as the latter have a greater impact ... Continue reading
2.One drawback of vaping cessation interventions is that they divert already limited resources away from smoking cessation interventions, and this can be counterproductive, as the latter have a greater impact on mortality and morbidity than the former. This point should be discussed.
Response: Thank you for this helpful suggestion. It is certainly fair to say that resources for smoking cessation supports are often limited, and that the provision of resources for separate vaping cessation services may risk funding being spread too thinly. This issue is now highlighted in the introduction section – with the point also made that long-term nicotine dependence proliferated by both smoking and vaping also risks placing additional strain on cessation services (page 3, lines 31-35).
Text added: “There is also a risk that dedicated services for the cessation of vaping, for which the precise health consequences are still unclear, may divert resources away from smoking cessation services. At the same, long-term nicotine dependence proliferated by both smoking and vaping may also place strain on healthcare services (Neczypor et al., 2022).”

Are vapers interested in vaping cessation support? A brief literature search shows that most are not interested, for various reasons: they use e-cigarettes to stop smoking and fear they would relapse to smoking if they stopped vaping, they understand that vaping is less dangerous than smoking, they already used other smoking cessation aids but failed to quit with these aids, they therefore do not see why they should stop vaping, etc. This literature should be cited in the introduction.
Response: There is evidence that vapers do express a desire to quit and make quit attempts, but as you have outlined, there are also several notable barriers to quitting that must be considered, and indeed there are likely differences among age groups. We have therefore revised the introduction to include literature which highlights the barriers you have pointed out, whilst also making the point that those who do wish to quit (i.e., those motivated to quit) will face difficulties in the absence of dedicated services and supports (page 3, lines 28-30).
Text added: “A number of important barriers to quitting vaping exist, such as fear of relapsing to smoking among those who have used vaping to quit smoking (Dyson et al., 2022), and low perceived risk of vaping to one’s health, particularly among younger vapers (Patterson et al., 2025). Ultimately, however, it is likely that vape users who do want to quit will face difficulties quitting in the absence of dedicated services and supports (Struick & Yang, 2021).”

A corollary of this lack of interest in support is that it will be very costly to recruit vapers in these interventions, and services that offer this type of support would struggle to be profitable.
Information on the cost of these interventions, their cost effectiveness (cost per quitter, cost per cancer case prevented), and their cost-benefit (medical care costs avoided) should also be collected in this review.
Response: It is a fair point that services which offer vaping cessation support may struggle to be profitable. Ireland has a public health system which is managed by the Health Service Executive (HSE), which is funded by general taxation and allows residents to access many services at little or no direct cost at the point of delivery, so profit is unlikely to be important for such settings. However, the reviewer’s general point about costs is of course important, so we will also evaluate the cost-effectiveness of included interventions. This will form part of our best practice assessment (under the domain of efficiency), as included interventions may have resource requirements (such as digital proprietary platforms) to be implemented.

3A.
To support their affirmation that “vapes can introduce considerable respiratory and cardiovascular problems,” the authors cite an article published in 2024 in an obscure Polish sports journal that has been cited only once. Instead, they should cite the NASEM report or that of the Royal College of Physicians (RCP), which are serious and widely cited reviews:

https://www.nationalacademies.org/read/24952

And

https://www.rcp.ac.uk/policy-and-campaigns/policy-documents/e-cigarettes-and-harm-reduction-an-evidence-review/

Contrary to the authors, these documents conclude that “vaping nicotine is not associated with a high frequency of adverse health effects.” (RCP), that “There is no available evidence whether or not e-cigarette use is associated with clinical cardiovascular outcomes” (NASEM), and that “There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans” (NASEM).
Response: Thank you for pointing out that the evidence to support this point could be stronger. We have added the RCP article that you have provided. We decided not to include the NASEM report, as this was published 8 years ago, meaning the evidence may be out-of-date. Moreover, an umbrella review published in NEJM Evidence would contradict these reports, finding similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use. We therefore have revised this section of the Introduction to highlight that the health consequences of vaping are not yet certain, providing a more balanced overview of the evidence than was initially presented (page 2, lines 16-20).
Glantz SA, Nguyen N, Oliveira da Silva AL. Population-based disease odds for e-cigarettes and dual use versus cigarettes. NEJM evidence. 2024 Feb 27;3(3):EVIDoa2300229.
Text added: “Whilst the health consequences of vaping are not yet certain, with some finding no evidence of an association between vaping nicotine and adverse health effects (Agrawal et al., 2024, a review by Glantz et al. (2024) found similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use, albeit these were largely estimates from cross-sectional studies, so further definitive work is needed in this area”.

3B:
The authors mention “the litany of harmful substances that are also contained within vapes”, but the 2 reports above make it abundantly clear that vape aerosol contains much fewer harmful substances than tobacco smoke, the relevant comparator. Failure to mention this is misleading.
Response: We have rephrased this sentence to instead say that those who vape may face adverse health effects compared with those who do not smoke or vape (which is the relevant comparator in this case), when consumed long-term
particular sentence to make it clearer that vapes, while likely being less harmful to health than cigarettes, contain substances which could have adverse health effects when consumed long-term (page 3, lines 1-2).
Text added: “…in terms of limiting exposure to chemicals contained within vapes, which could result in adverse health effects for vape users, compared with those who do not smoke or vape, when consumed long-term.”

4. The authors need to define” recreational nicotine use”. This definition cannot be based just on the products themselves (e.g. NRT excluded, all vapes and pouches and heated tobacco included, smoking excluded). The definition needs to be based on “recreation”, i.e. on the user’s intent, motivation and behavior, and these are variables that can be measured and used as inclusion / exclusion criteria. The definition should include “recreation” only, and exclude other motives such as addiction and self-medication. Are former smokers who are long-term users of medicinal NRT products but are not dependent on NRT products included ? (they should, but users of NRT for smoking cessation and those who are dependent on NRT should not). Are users of heated tobacco who use these products mainly because they are dependent on them rather than because of pleasure or “recreation” included ? (they should not, but heated tobacco users who use it mostly for pleasure should be included). Are vapers who vape mostly because they use nicotine as self-medication (e.g. for depression), or because they are dependent on nicotine be included? (they should not, but vapers who use e-cigarettes mostly for pleasure should be). And what about those who use nicotine as a stimulant, like caffeine? Does this count as recreational use? There is growing evidence that nicotine has positive effects on the ageing brain, on enhanced cognition and Parkinson’s disease. Is nicotine use as self-medication in these cases included in recreational use (it should not, and if it is, what products count as recreational in this case? Just vapes or also NRT and cigarettes?). And the authors exclude smokers, but cigarette use is both recreational and an addiction. Why are occasional smokers who are not dependent on nicotine excluded from recreational nicotine use (e.g. those who smoke only at parties)? They should be included, but addicted smokers should not.
Response: Thank you for raising this important point and stimulating our thinking in this area. We agree that there are indeed many types of pathways to vaping and dual-use, and individuals will have a variety of reasons for using these products, which may in fact change over time as dependence increases. As clearly pointed out by the reviewer, we now think that our original terminology around ‘recreational’ use was incorrect. Whilst organising our definition around recreation could indeed serve a practical purpose, it may be difficult to distinguish this, given the range of products and patterns of use that the searches will likely identify. It also raises the question, in the case of dual-use, of how to regard differing intentions and motivations for the use of two or more products in the same individual(s). To simplify our approach for readers, and to better conceptualise the work according to our original aims, we therefore have removed the term ‘recreational’. We were instead interested in service provision for those motivated to quit, as these are the people who will engage with services. We have now elaborated under eligibility criteria that we aim to recruit individuals who are motivated to quit vapes and/or alternative nicotine products by signing up to participate in such an intervention. We also specify that studies who only recruit participants who are using these products exclusively as a smoking cessation aid at the time of the study, or on the advice of a healthcare practitioner at the time of the study, will be excluded. (page 5, lines 31-35).
Text added: “We aim to include individuals who are motivated to quit vapes and/or alternative nicotine products by virtue of signing up to participate in a cessation intervention or attending a cessation service. Studies who recruit participants who are using these products exclusively as a smoking cessation aid or on the advice of a healthcare practitioner at the time of the study will be excluded”.

To If the review does not use intent, motivation and behavior as inclusion / exclusion criteria, a definition of recreational use based on the products only is meaningless, as it confuses the different reasons for use. The key term here is “recreational”, and this should be measured.
For instance, research question 2 (barriers and facilitators) cannot be adequately answered if users are classified according to the type of product they use rather than on their intent and motivations.
Similarly, eligibility criteria on page 4 must be revised.
Response: As above, we have revised the eligibility criteria to more clearly specify the target population, and we have removed the word ‘recreational’ to avoid confusion.

5. If the authors revise the article, just changing the research question from “vaping and recreational nicotine use” to “vaping and non-combustible nicotine use” will not be an acceptable change, since this would not address the fundamental problem discussed above.
Response: This is a fair point, and we believe that clarifying that the focus of this review is on those motivated to quit nicotine products that are not being consumed for health reasons, or in accordance with advice from their general practitioner, will address this issue.

6. Excluding studies that are not written in English (page 4) is not acceptable anymore, because automatic translation tools are now available at no cost.
Response: It is possible that including studies published in all languages could yield some interesting insights. However, establishing the accuracy of AI-powered translation tools, which are often used to achieve this, is difficult without human-in-the-loop input from fluent speakers. The review team unfortunately do not have the resources to accommodate this. In addition, Cochrane recommendations for rapid review methods advise that excluding articles not published in the English language at the study selection stage is an acceptable practice for rapid reviews.

Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

7. Data extraction: the authors should also extract information on the users’ intentions and motivations for use (see above).
Response: As above, whilst this information may be useful, it will likely be difficult to parse intentions and motivations among included studies given the range of products and patterns of use that are likely to identified. We believe that organising the eligibility around cessation interventions will provide a clearer approach to examining findings from studies of those who are demonstrably motivated to quit by virtue of attending and participating in such interventions or services.

8. Stopping nicotine use can have adverse effects, and information about these adverse effects should also be extracted too. The main adverse effect of stopping vaping is relapse to smoking, and it is essential to document whether interventions aimed at stopping vaping lead to relapse to smoking. Other adverse effects include the onset of depression in people at risk or with a history of depression, this should also be documented.
Response: This would certainly be an interesting point to consider. To that end, we will record any information on adverse events that are reported in included studies, and present it alongside the findings of the review.

9. Ethical approval may not be required for a literature review, but an ethics board would most probably have identified the problems listed above. Their guidance would be useful and may be necessary if you consult users during a rewriting of this protocol.
Response: Research Ethics Committees in Ireland do not, in most circumstances, review applications for research involving literature reviews or other evidence syntheses. Therefore, it was unfortunately not possible to consult with a Research Ethics Committee during the preparation of this protocol.

10. The authors did not involve the public in drafting the protocol, but they should have done so. If they had, they would probably have identified the problems listed above. If a revised version is submitted, the authors should then include stakeholders: users of the various products, vape shop owners (who are de facto the first-line advisors on smoking cessation, whether we like it or not), representatives of vaping associations, etc.
Response: You have raised an important point. Engagement with public and patient representatives is important, and this review is part of an overall project concerning vaping cessation in Ireland that includes co-design approaches in collaboration with product users and smoking cessation providers. We also have dedicated product user representatives providing feedback on the project, and are in the process of establishing a Steering Group. The findings of this review will be presented to this Group before the paper is submitted for publication, to ensure that the recommendations are timely and relevant. We also have a co-author who is a representative from the Health Service Executive Tobacco Free Ireland programme, and assisted with the conceptualisation of this protocol.
Information on PPI that is relevant to this protocol is provided under the ‘Patient and public involvement’ section of this manuscript.
2.One drawback of vaping cessation interventions is that they divert already limited resources away from smoking cessation interventions, and this can be counterproductive, as the latter have a greater impact on mortality and morbidity than the former. This point should be discussed.
Response: Thank you for this helpful suggestion. It is certainly fair to say that resources for smoking cessation supports are often limited, and that the provision of resources for separate vaping cessation services may risk funding being spread too thinly. This issue is now highlighted in the introduction section – with the point also made that long-term nicotine dependence proliferated by both smoking and vaping also risks placing additional strain on cessation services (page 3, lines 31-35).
Text added: “There is also a risk that dedicated services for the cessation of vaping, for which the precise health consequences are still unclear, may divert resources away from smoking cessation services. At the same, long-term nicotine dependence proliferated by both smoking and vaping may also place strain on healthcare services (Neczypor et al., 2022).”

Are vapers interested in vaping cessation support? A brief literature search shows that most are not interested, for various reasons: they use e-cigarettes to stop smoking and fear they would relapse to smoking if they stopped vaping, they understand that vaping is less dangerous than smoking, they already used other smoking cessation aids but failed to quit with these aids, they therefore do not see why they should stop vaping, etc. This literature should be cited in the introduction.
Response: There is evidence that vapers do express a desire to quit and make quit attempts, but as you have outlined, there are also several notable barriers to quitting that must be considered, and indeed there are likely differences among age groups. We have therefore revised the introduction to include literature which highlights the barriers you have pointed out, whilst also making the point that those who do wish to quit (i.e., those motivated to quit) will face difficulties in the absence of dedicated services and supports (page 3, lines 28-30).
Text added: “A number of important barriers to quitting vaping exist, such as fear of relapsing to smoking among those who have used vaping to quit smoking (Dyson et al., 2022), and low perceived risk of vaping to one’s health, particularly among younger vapers (Patterson et al., 2025). Ultimately, however, it is likely that vape users who do want to quit will face difficulties quitting in the absence of dedicated services and supports (Struick & Yang, 2021).”

A corollary of this lack of interest in support is that it will be very costly to recruit vapers in these interventions, and services that offer this type of support would struggle to be profitable.
Information on the cost of these interventions, their cost effectiveness (cost per quitter, cost per cancer case prevented), and their cost-benefit (medical care costs avoided) should also be collected in this review.
Response: It is a fair point that services which offer vaping cessation support may struggle to be profitable. Ireland has a public health system which is managed by the Health Service Executive (HSE), which is funded by general taxation and allows residents to access many services at little or no direct cost at the point of delivery, so profit is unlikely to be important for such settings. However, the reviewer’s general point about costs is of course important, so we will also evaluate the cost-effectiveness of included interventions. This will form part of our best practice assessment (under the domain of efficiency), as included interventions may have resource requirements (such as digital proprietary platforms) to be implemented.

3A.
To support their affirmation that “vapes can introduce considerable respiratory and cardiovascular problems,” the authors cite an article published in 2024 in an obscure Polish sports journal that has been cited only once. Instead, they should cite the NASEM report or that of the Royal College of Physicians (RCP), which are serious and widely cited reviews:

https://www.nationalacademies.org/read/24952

And

https://www.rcp.ac.uk/policy-and-campaigns/policy-documents/e-cigarettes-and-harm-reduction-an-evidence-review/

Contrary to the authors, these documents conclude that “vaping nicotine is not associated with a high frequency of adverse health effects.” (RCP), that “There is no available evidence whether or not e-cigarette use is associated with clinical cardiovascular outcomes” (NASEM), and that “There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans” (NASEM).
Response: Thank you for pointing out that the evidence to support this point could be stronger. We have added the RCP article that you have provided. We decided not to include the NASEM report, as this was published 8 years ago, meaning the evidence may be out-of-date. Moreover, an umbrella review published in NEJM Evidence would contradict these reports, finding similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use. We therefore have revised this section of the Introduction to highlight that the health consequences of vaping are not yet certain, providing a more balanced overview of the evidence than was initially presented (page 2, lines 16-20).
Glantz SA, Nguyen N, Oliveira da Silva AL. Population-based disease odds for e-cigarettes and dual use versus cigarettes. NEJM evidence. 2024 Feb 27;3(3):EVIDoa2300229.
Text added: “Whilst the health consequences of vaping are not yet certain, with some finding no evidence of an association between vaping nicotine and adverse health effects (Agrawal et al., 2024, a review by Glantz et al. (2024) found similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use, albeit these were largely estimates from cross-sectional studies, so further definitive work is needed in this area”.

3B:
The authors mention “the litany of harmful substances that are also contained within vapes”, but the 2 reports above make it abundantly clear that vape aerosol contains much fewer harmful substances than tobacco smoke, the relevant comparator. Failure to mention this is misleading.
Response: We have rephrased this sentence to instead say that those who vape may face adverse health effects compared with those who do not smoke or vape (which is the relevant comparator in this case), when consumed long-term
particular sentence to make it clearer that vapes, while likely being less harmful to health than cigarettes, contain substances which could have adverse health effects when consumed long-term (page 3, lines 1-2).
Text added: “…in terms of limiting exposure to chemicals contained within vapes, which could result in adverse health effects for vape users, compared with those who do not smoke or vape, when consumed long-term.”

4. The authors need to define” recreational nicotine use”. This definition cannot be based just on the products themselves (e.g. NRT excluded, all vapes and pouches and heated tobacco included, smoking excluded). The definition needs to be based on “recreation”, i.e. on the user’s intent, motivation and behavior, and these are variables that can be measured and used as inclusion / exclusion criteria. The definition should include “recreation” only, and exclude other motives such as addiction and self-medication. Are former smokers who are long-term users of medicinal NRT products but are not dependent on NRT products included ? (they should, but users of NRT for smoking cessation and those who are dependent on NRT should not). Are users of heated tobacco who use these products mainly because they are dependent on them rather than because of pleasure or “recreation” included ? (they should not, but heated tobacco users who use it mostly for pleasure should be included). Are vapers who vape mostly because they use nicotine as self-medication (e.g. for depression), or because they are dependent on nicotine be included? (they should not, but vapers who use e-cigarettes mostly for pleasure should be). And what about those who use nicotine as a stimulant, like caffeine? Does this count as recreational use? There is growing evidence that nicotine has positive effects on the ageing brain, on enhanced cognition and Parkinson’s disease. Is nicotine use as self-medication in these cases included in recreational use (it should not, and if it is, what products count as recreational in this case? Just vapes or also NRT and cigarettes?). And the authors exclude smokers, but cigarette use is both recreational and an addiction. Why are occasional smokers who are not dependent on nicotine excluded from recreational nicotine use (e.g. those who smoke only at parties)? They should be included, but addicted smokers should not.
Response: Thank you for raising this important point and stimulating our thinking in this area. We agree that there are indeed many types of pathways to vaping and dual-use, and individuals will have a variety of reasons for using these products, which may in fact change over time as dependence increases. As clearly pointed out by the reviewer, we now think that our original terminology around ‘recreational’ use was incorrect. Whilst organising our definition around recreation could indeed serve a practical purpose, it may be difficult to distinguish this, given the range of products and patterns of use that the searches will likely identify. It also raises the question, in the case of dual-use, of how to regard differing intentions and motivations for the use of two or more products in the same individual(s). To simplify our approach for readers, and to better conceptualise the work according to our original aims, we therefore have removed the term ‘recreational’. We were instead interested in service provision for those motivated to quit, as these are the people who will engage with services. We have now elaborated under eligibility criteria that we aim to recruit individuals who are motivated to quit vapes and/or alternative nicotine products by signing up to participate in such an intervention. We also specify that studies who only recruit participants who are using these products exclusively as a smoking cessation aid at the time of the study, or on the advice of a healthcare practitioner at the time of the study, will be excluded. (page 5, lines 31-35).
Text added: “We aim to include individuals who are motivated to quit vapes and/or alternative nicotine products by virtue of signing up to participate in a cessation intervention or attending a cessation service. Studies who recruit participants who are using these products exclusively as a smoking cessation aid or on the advice of a healthcare practitioner at the time of the study will be excluded”.

To If the review does not use intent, motivation and behavior as inclusion / exclusion criteria, a definition of recreational use based on the products only is meaningless, as it confuses the different reasons for use. The key term here is “recreational”, and this should be measured.
For instance, research question 2 (barriers and facilitators) cannot be adequately answered if users are classified according to the type of product they use rather than on their intent and motivations.
Similarly, eligibility criteria on page 4 must be revised.
Response: As above, we have revised the eligibility criteria to more clearly specify the target population, and we have removed the word ‘recreational’ to avoid confusion.

5. If the authors revise the article, just changing the research question from “vaping and recreational nicotine use” to “vaping and non-combustible nicotine use” will not be an acceptable change, since this would not address the fundamental problem discussed above.
Response: This is a fair point, and we believe that clarifying that the focus of this review is on those motivated to quit nicotine products that are not being consumed for health reasons, or in accordance with advice from their general practitioner, will address this issue.

6. Excluding studies that are not written in English (page 4) is not acceptable anymore, because automatic translation tools are now available at no cost.
Response: It is possible that including studies published in all languages could yield some interesting insights. However, establishing the accuracy of AI-powered translation tools, which are often used to achieve this, is difficult without human-in-the-loop input from fluent speakers. The review team unfortunately do not have the resources to accommodate this. In addition, Cochrane recommendations for rapid review methods advise that excluding articles not published in the English language at the study selection stage is an acceptable practice for rapid reviews.

Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

7. Data extraction: the authors should also extract information on the users’ intentions and motivations for use (see above).
Response: As above, whilst this information may be useful, it will likely be difficult to parse intentions and motivations among included studies given the range of products and patterns of use that are likely to identified. We believe that organising the eligibility around cessation interventions will provide a clearer approach to examining findings from studies of those who are demonstrably motivated to quit by virtue of attending and participating in such interventions or services.

8. Stopping nicotine use can have adverse effects, and information about these adverse effects should also be extracted too. The main adverse effect of stopping vaping is relapse to smoking, and it is essential to document whether interventions aimed at stopping vaping lead to relapse to smoking. Other adverse effects include the onset of depression in people at risk or with a history of depression, this should also be documented.
Response: This would certainly be an interesting point to consider. To that end, we will record any information on adverse events that are reported in included studies, and present it alongside the findings of the review.

9. Ethical approval may not be required for a literature review, but an ethics board would most probably have identified the problems listed above. Their guidance would be useful and may be necessary if you consult users during a rewriting of this protocol.
Response: Research Ethics Committees in Ireland do not, in most circumstances, review applications for research involving literature reviews or other evidence syntheses. Therefore, it was unfortunately not possible to consult with a Research Ethics Committee during the preparation of this protocol.

10. The authors did not involve the public in drafting the protocol, but they should have done so. If they had, they would probably have identified the problems listed above. If a revised version is submitted, the authors should then include stakeholders: users of the various products, vape shop owners (who are de facto the first-line advisors on smoking cessation, whether we like it or not), representatives of vaping associations, etc.
Response: You have raised an important point. Engagement with public and patient representatives is important, and this review is part of an overall project concerning vaping cessation in Ireland that includes co-design approaches in collaboration with product users and smoking cessation providers. We also have dedicated product user representatives providing feedback on the project, and are in the process of establishing a Steering Group. The findings of this review will be presented to this Group before the paper is submitted for publication, to ensure that the recommendations are timely and relevant. We also have a co-author who is a representative from the Health Service Executive Tobacco Free Ireland programme, and assisted with the conceptualisation of this protocol.
Information on PPI that is relevant to this protocol is provided under the ‘Patient and public involvement’ section of this manuscript.
Competing Interests: None Close
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Respond or Comment

COMMENTS ON THIS REPORT

Author Response 26 May 2026

Rory Coyne, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Ireland

26 May 2026

Author Response
2.One drawback of vaping cessation interventions is that they divert already limited resources away from smoking cessation interventions, and this can be counterproductive, as the latter have a greater impact ... Continue reading
2.One drawback of vaping cessation interventions is that they divert already limited resources away from smoking cessation interventions, and this can be counterproductive, as the latter have a greater impact on mortality and morbidity than the former. This point should be discussed.
Response: Thank you for this helpful suggestion. It is certainly fair to say that resources for smoking cessation supports are often limited, and that the provision of resources for separate vaping cessation services may risk funding being spread too thinly. This issue is now highlighted in the introduction section – with the point also made that long-term nicotine dependence proliferated by both smoking and vaping also risks placing additional strain on cessation services (page 3, lines 31-35).
Text added: “There is also a risk that dedicated services for the cessation of vaping, for which the precise health consequences are still unclear, may divert resources away from smoking cessation services. At the same, long-term nicotine dependence proliferated by both smoking and vaping may also place strain on healthcare services (Neczypor et al., 2022).”

Are vapers interested in vaping cessation support? A brief literature search shows that most are not interested, for various reasons: they use e-cigarettes to stop smoking and fear they would relapse to smoking if they stopped vaping, they understand that vaping is less dangerous than smoking, they already used other smoking cessation aids but failed to quit with these aids, they therefore do not see why they should stop vaping, etc. This literature should be cited in the introduction.
Response: There is evidence that vapers do express a desire to quit and make quit attempts, but as you have outlined, there are also several notable barriers to quitting that must be considered, and indeed there are likely differences among age groups. We have therefore revised the introduction to include literature which highlights the barriers you have pointed out, whilst also making the point that those who do wish to quit (i.e., those motivated to quit) will face difficulties in the absence of dedicated services and supports (page 3, lines 28-30).
Text added: “A number of important barriers to quitting vaping exist, such as fear of relapsing to smoking among those who have used vaping to quit smoking (Dyson et al., 2022), and low perceived risk of vaping to one’s health, particularly among younger vapers (Patterson et al., 2025). Ultimately, however, it is likely that vape users who do want to quit will face difficulties quitting in the absence of dedicated services and supports (Struick & Yang, 2021).”

A corollary of this lack of interest in support is that it will be very costly to recruit vapers in these interventions, and services that offer this type of support would struggle to be profitable.
Information on the cost of these interventions, their cost effectiveness (cost per quitter, cost per cancer case prevented), and their cost-benefit (medical care costs avoided) should also be collected in this review.
Response: It is a fair point that services which offer vaping cessation support may struggle to be profitable. Ireland has a public health system which is managed by the Health Service Executive (HSE), which is funded by general taxation and allows residents to access many services at little or no direct cost at the point of delivery, so profit is unlikely to be important for such settings. However, the reviewer’s general point about costs is of course important, so we will also evaluate the cost-effectiveness of included interventions. This will form part of our best practice assessment (under the domain of efficiency), as included interventions may have resource requirements (such as digital proprietary platforms) to be implemented.

3A.
To support their affirmation that “vapes can introduce considerable respiratory and cardiovascular problems,” the authors cite an article published in 2024 in an obscure Polish sports journal that has been cited only once. Instead, they should cite the NASEM report or that of the Royal College of Physicians (RCP), which are serious and widely cited reviews:

https://www.nationalacademies.org/read/24952

And

https://www.rcp.ac.uk/policy-and-campaigns/policy-documents/e-cigarettes-and-harm-reduction-an-evidence-review/

Contrary to the authors, these documents conclude that “vaping nicotine is not associated with a high frequency of adverse health effects.” (RCP), that “There is no available evidence whether or not e-cigarette use is associated with clinical cardiovascular outcomes” (NASEM), and that “There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans” (NASEM).
Response: Thank you for pointing out that the evidence to support this point could be stronger. We have added the RCP article that you have provided. We decided not to include the NASEM report, as this was published 8 years ago, meaning the evidence may be out-of-date. Moreover, an umbrella review published in NEJM Evidence would contradict these reports, finding similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use. We therefore have revised this section of the Introduction to highlight that the health consequences of vaping are not yet certain, providing a more balanced overview of the evidence than was initially presented (page 2, lines 16-20).
Glantz SA, Nguyen N, Oliveira da Silva AL. Population-based disease odds for e-cigarettes and dual use versus cigarettes. NEJM evidence. 2024 Feb 27;3(3):EVIDoa2300229.
Text added: “Whilst the health consequences of vaping are not yet certain, with some finding no evidence of an association between vaping nicotine and adverse health effects (Agrawal et al., 2024, a review by Glantz et al. (2024) found similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use, albeit these were largely estimates from cross-sectional studies, so further definitive work is needed in this area”.

3B:
The authors mention “the litany of harmful substances that are also contained within vapes”, but the 2 reports above make it abundantly clear that vape aerosol contains much fewer harmful substances than tobacco smoke, the relevant comparator. Failure to mention this is misleading.
Response: We have rephrased this sentence to instead say that those who vape may face adverse health effects compared with those who do not smoke or vape (which is the relevant comparator in this case), when consumed long-term
particular sentence to make it clearer that vapes, while likely being less harmful to health than cigarettes, contain substances which could have adverse health effects when consumed long-term (page 3, lines 1-2).
Text added: “…in terms of limiting exposure to chemicals contained within vapes, which could result in adverse health effects for vape users, compared with those who do not smoke or vape, when consumed long-term.”

4. The authors need to define” recreational nicotine use”. This definition cannot be based just on the products themselves (e.g. NRT excluded, all vapes and pouches and heated tobacco included, smoking excluded). The definition needs to be based on “recreation”, i.e. on the user’s intent, motivation and behavior, and these are variables that can be measured and used as inclusion / exclusion criteria. The definition should include “recreation” only, and exclude other motives such as addiction and self-medication. Are former smokers who are long-term users of medicinal NRT products but are not dependent on NRT products included ? (they should, but users of NRT for smoking cessation and those who are dependent on NRT should not). Are users of heated tobacco who use these products mainly because they are dependent on them rather than because of pleasure or “recreation” included ? (they should not, but heated tobacco users who use it mostly for pleasure should be included). Are vapers who vape mostly because they use nicotine as self-medication (e.g. for depression), or because they are dependent on nicotine be included? (they should not, but vapers who use e-cigarettes mostly for pleasure should be). And what about those who use nicotine as a stimulant, like caffeine? Does this count as recreational use? There is growing evidence that nicotine has positive effects on the ageing brain, on enhanced cognition and Parkinson’s disease. Is nicotine use as self-medication in these cases included in recreational use (it should not, and if it is, what products count as recreational in this case? Just vapes or also NRT and cigarettes?). And the authors exclude smokers, but cigarette use is both recreational and an addiction. Why are occasional smokers who are not dependent on nicotine excluded from recreational nicotine use (e.g. those who smoke only at parties)? They should be included, but addicted smokers should not.
Response: Thank you for raising this important point and stimulating our thinking in this area. We agree that there are indeed many types of pathways to vaping and dual-use, and individuals will have a variety of reasons for using these products, which may in fact change over time as dependence increases. As clearly pointed out by the reviewer, we now think that our original terminology around ‘recreational’ use was incorrect. Whilst organising our definition around recreation could indeed serve a practical purpose, it may be difficult to distinguish this, given the range of products and patterns of use that the searches will likely identify. It also raises the question, in the case of dual-use, of how to regard differing intentions and motivations for the use of two or more products in the same individual(s). To simplify our approach for readers, and to better conceptualise the work according to our original aims, we therefore have removed the term ‘recreational’. We were instead interested in service provision for those motivated to quit, as these are the people who will engage with services. We have now elaborated under eligibility criteria that we aim to recruit individuals who are motivated to quit vapes and/or alternative nicotine products by signing up to participate in such an intervention. We also specify that studies who only recruit participants who are using these products exclusively as a smoking cessation aid at the time of the study, or on the advice of a healthcare practitioner at the time of the study, will be excluded. (page 5, lines 31-35).
Text added: “We aim to include individuals who are motivated to quit vapes and/or alternative nicotine products by virtue of signing up to participate in a cessation intervention or attending a cessation service. Studies who recruit participants who are using these products exclusively as a smoking cessation aid or on the advice of a healthcare practitioner at the time of the study will be excluded”.

To If the review does not use intent, motivation and behavior as inclusion / exclusion criteria, a definition of recreational use based on the products only is meaningless, as it confuses the different reasons for use. The key term here is “recreational”, and this should be measured.
For instance, research question 2 (barriers and facilitators) cannot be adequately answered if users are classified according to the type of product they use rather than on their intent and motivations.
Similarly, eligibility criteria on page 4 must be revised.
Response: As above, we have revised the eligibility criteria to more clearly specify the target population, and we have removed the word ‘recreational’ to avoid confusion.

5. If the authors revise the article, just changing the research question from “vaping and recreational nicotine use” to “vaping and non-combustible nicotine use” will not be an acceptable change, since this would not address the fundamental problem discussed above.
Response: This is a fair point, and we believe that clarifying that the focus of this review is on those motivated to quit nicotine products that are not being consumed for health reasons, or in accordance with advice from their general practitioner, will address this issue.

6. Excluding studies that are not written in English (page 4) is not acceptable anymore, because automatic translation tools are now available at no cost.
Response: It is possible that including studies published in all languages could yield some interesting insights. However, establishing the accuracy of AI-powered translation tools, which are often used to achieve this, is difficult without human-in-the-loop input from fluent speakers. The review team unfortunately do not have the resources to accommodate this. In addition, Cochrane recommendations for rapid review methods advise that excluding articles not published in the English language at the study selection stage is an acceptable practice for rapid reviews.

Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

7. Data extraction: the authors should also extract information on the users’ intentions and motivations for use (see above).
Response: As above, whilst this information may be useful, it will likely be difficult to parse intentions and motivations among included studies given the range of products and patterns of use that are likely to identified. We believe that organising the eligibility around cessation interventions will provide a clearer approach to examining findings from studies of those who are demonstrably motivated to quit by virtue of attending and participating in such interventions or services.

8. Stopping nicotine use can have adverse effects, and information about these adverse effects should also be extracted too. The main adverse effect of stopping vaping is relapse to smoking, and it is essential to document whether interventions aimed at stopping vaping lead to relapse to smoking. Other adverse effects include the onset of depression in people at risk or with a history of depression, this should also be documented.
Response: This would certainly be an interesting point to consider. To that end, we will record any information on adverse events that are reported in included studies, and present it alongside the findings of the review.

9. Ethical approval may not be required for a literature review, but an ethics board would most probably have identified the problems listed above. Their guidance would be useful and may be necessary if you consult users during a rewriting of this protocol.
Response: Research Ethics Committees in Ireland do not, in most circumstances, review applications for research involving literature reviews or other evidence syntheses. Therefore, it was unfortunately not possible to consult with a Research Ethics Committee during the preparation of this protocol.

10. The authors did not involve the public in drafting the protocol, but they should have done so. If they had, they would probably have identified the problems listed above. If a revised version is submitted, the authors should then include stakeholders: users of the various products, vape shop owners (who are de facto the first-line advisors on smoking cessation, whether we like it or not), representatives of vaping associations, etc.
Response: You have raised an important point. Engagement with public and patient representatives is important, and this review is part of an overall project concerning vaping cessation in Ireland that includes co-design approaches in collaboration with product users and smoking cessation providers. We also have dedicated product user representatives providing feedback on the project, and are in the process of establishing a Steering Group. The findings of this review will be presented to this Group before the paper is submitted for publication, to ensure that the recommendations are timely and relevant. We also have a co-author who is a representative from the Health Service Executive Tobacco Free Ireland programme, and assisted with the conceptualisation of this protocol.
Information on PPI that is relevant to this protocol is provided under the ‘Patient and public involvement’ section of this manuscript.
2.One drawback of vaping cessation interventions is that they divert already limited resources away from smoking cessation interventions, and this can be counterproductive, as the latter have a greater impact on mortality and morbidity than the former. This point should be discussed.
Response: Thank you for this helpful suggestion. It is certainly fair to say that resources for smoking cessation supports are often limited, and that the provision of resources for separate vaping cessation services may risk funding being spread too thinly. This issue is now highlighted in the introduction section – with the point also made that long-term nicotine dependence proliferated by both smoking and vaping also risks placing additional strain on cessation services (page 3, lines 31-35).
Text added: “There is also a risk that dedicated services for the cessation of vaping, for which the precise health consequences are still unclear, may divert resources away from smoking cessation services. At the same, long-term nicotine dependence proliferated by both smoking and vaping may also place strain on healthcare services (Neczypor et al., 2022).”

Are vapers interested in vaping cessation support? A brief literature search shows that most are not interested, for various reasons: they use e-cigarettes to stop smoking and fear they would relapse to smoking if they stopped vaping, they understand that vaping is less dangerous than smoking, they already used other smoking cessation aids but failed to quit with these aids, they therefore do not see why they should stop vaping, etc. This literature should be cited in the introduction.
Response: There is evidence that vapers do express a desire to quit and make quit attempts, but as you have outlined, there are also several notable barriers to quitting that must be considered, and indeed there are likely differences among age groups. We have therefore revised the introduction to include literature which highlights the barriers you have pointed out, whilst also making the point that those who do wish to quit (i.e., those motivated to quit) will face difficulties in the absence of dedicated services and supports (page 3, lines 28-30).
Text added: “A number of important barriers to quitting vaping exist, such as fear of relapsing to smoking among those who have used vaping to quit smoking (Dyson et al., 2022), and low perceived risk of vaping to one’s health, particularly among younger vapers (Patterson et al., 2025). Ultimately, however, it is likely that vape users who do want to quit will face difficulties quitting in the absence of dedicated services and supports (Struick & Yang, 2021).”

A corollary of this lack of interest in support is that it will be very costly to recruit vapers in these interventions, and services that offer this type of support would struggle to be profitable.
Information on the cost of these interventions, their cost effectiveness (cost per quitter, cost per cancer case prevented), and their cost-benefit (medical care costs avoided) should also be collected in this review.
Response: It is a fair point that services which offer vaping cessation support may struggle to be profitable. Ireland has a public health system which is managed by the Health Service Executive (HSE), which is funded by general taxation and allows residents to access many services at little or no direct cost at the point of delivery, so profit is unlikely to be important for such settings. However, the reviewer’s general point about costs is of course important, so we will also evaluate the cost-effectiveness of included interventions. This will form part of our best practice assessment (under the domain of efficiency), as included interventions may have resource requirements (such as digital proprietary platforms) to be implemented.

3A.
To support their affirmation that “vapes can introduce considerable respiratory and cardiovascular problems,” the authors cite an article published in 2024 in an obscure Polish sports journal that has been cited only once. Instead, they should cite the NASEM report or that of the Royal College of Physicians (RCP), which are serious and widely cited reviews:

https://www.nationalacademies.org/read/24952

And

https://www.rcp.ac.uk/policy-and-campaigns/policy-documents/e-cigarettes-and-harm-reduction-an-evidence-review/

Contrary to the authors, these documents conclude that “vaping nicotine is not associated with a high frequency of adverse health effects.” (RCP), that “There is no available evidence whether or not e-cigarette use is associated with clinical cardiovascular outcomes” (NASEM), and that “There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans” (NASEM).
Response: Thank you for pointing out that the evidence to support this point could be stronger. We have added the RCP article that you have provided. We decided not to include the NASEM report, as this was published 8 years ago, meaning the evidence may be out-of-date. Moreover, an umbrella review published in NEJM Evidence would contradict these reports, finding similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use. We therefore have revised this section of the Introduction to highlight that the health consequences of vaping are not yet certain, providing a more balanced overview of the evidence than was initially presented (page 2, lines 16-20).
Glantz SA, Nguyen N, Oliveira da Silva AL. Population-based disease odds for e-cigarettes and dual use versus cigarettes. NEJM evidence. 2024 Feb 27;3(3):EVIDoa2300229.
Text added: “Whilst the health consequences of vaping are not yet certain, with some finding no evidence of an association between vaping nicotine and adverse health effects (Agrawal et al., 2024, a review by Glantz et al. (2024) found similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use, albeit these were largely estimates from cross-sectional studies, so further definitive work is needed in this area”.

3B:
The authors mention “the litany of harmful substances that are also contained within vapes”, but the 2 reports above make it abundantly clear that vape aerosol contains much fewer harmful substances than tobacco smoke, the relevant comparator. Failure to mention this is misleading.
Response: We have rephrased this sentence to instead say that those who vape may face adverse health effects compared with those who do not smoke or vape (which is the relevant comparator in this case), when consumed long-term
particular sentence to make it clearer that vapes, while likely being less harmful to health than cigarettes, contain substances which could have adverse health effects when consumed long-term (page 3, lines 1-2).
Text added: “…in terms of limiting exposure to chemicals contained within vapes, which could result in adverse health effects for vape users, compared with those who do not smoke or vape, when consumed long-term.”

4. The authors need to define” recreational nicotine use”. This definition cannot be based just on the products themselves (e.g. NRT excluded, all vapes and pouches and heated tobacco included, smoking excluded). The definition needs to be based on “recreation”, i.e. on the user’s intent, motivation and behavior, and these are variables that can be measured and used as inclusion / exclusion criteria. The definition should include “recreation” only, and exclude other motives such as addiction and self-medication. Are former smokers who are long-term users of medicinal NRT products but are not dependent on NRT products included ? (they should, but users of NRT for smoking cessation and those who are dependent on NRT should not). Are users of heated tobacco who use these products mainly because they are dependent on them rather than because of pleasure or “recreation” included ? (they should not, but heated tobacco users who use it mostly for pleasure should be included). Are vapers who vape mostly because they use nicotine as self-medication (e.g. for depression), or because they are dependent on nicotine be included? (they should not, but vapers who use e-cigarettes mostly for pleasure should be). And what about those who use nicotine as a stimulant, like caffeine? Does this count as recreational use? There is growing evidence that nicotine has positive effects on the ageing brain, on enhanced cognition and Parkinson’s disease. Is nicotine use as self-medication in these cases included in recreational use (it should not, and if it is, what products count as recreational in this case? Just vapes or also NRT and cigarettes?). And the authors exclude smokers, but cigarette use is both recreational and an addiction. Why are occasional smokers who are not dependent on nicotine excluded from recreational nicotine use (e.g. those who smoke only at parties)? They should be included, but addicted smokers should not.
Response: Thank you for raising this important point and stimulating our thinking in this area. We agree that there are indeed many types of pathways to vaping and dual-use, and individuals will have a variety of reasons for using these products, which may in fact change over time as dependence increases. As clearly pointed out by the reviewer, we now think that our original terminology around ‘recreational’ use was incorrect. Whilst organising our definition around recreation could indeed serve a practical purpose, it may be difficult to distinguish this, given the range of products and patterns of use that the searches will likely identify. It also raises the question, in the case of dual-use, of how to regard differing intentions and motivations for the use of two or more products in the same individual(s). To simplify our approach for readers, and to better conceptualise the work according to our original aims, we therefore have removed the term ‘recreational’. We were instead interested in service provision for those motivated to quit, as these are the people who will engage with services. We have now elaborated under eligibility criteria that we aim to recruit individuals who are motivated to quit vapes and/or alternative nicotine products by signing up to participate in such an intervention. We also specify that studies who only recruit participants who are using these products exclusively as a smoking cessation aid at the time of the study, or on the advice of a healthcare practitioner at the time of the study, will be excluded. (page 5, lines 31-35).
Text added: “We aim to include individuals who are motivated to quit vapes and/or alternative nicotine products by virtue of signing up to participate in a cessation intervention or attending a cessation service. Studies who recruit participants who are using these products exclusively as a smoking cessation aid or on the advice of a healthcare practitioner at the time of the study will be excluded”.

To If the review does not use intent, motivation and behavior as inclusion / exclusion criteria, a definition of recreational use based on the products only is meaningless, as it confuses the different reasons for use. The key term here is “recreational”, and this should be measured.
For instance, research question 2 (barriers and facilitators) cannot be adequately answered if users are classified according to the type of product they use rather than on their intent and motivations.
Similarly, eligibility criteria on page 4 must be revised.
Response: As above, we have revised the eligibility criteria to more clearly specify the target population, and we have removed the word ‘recreational’ to avoid confusion.

5. If the authors revise the article, just changing the research question from “vaping and recreational nicotine use” to “vaping and non-combustible nicotine use” will not be an acceptable change, since this would not address the fundamental problem discussed above.
Response: This is a fair point, and we believe that clarifying that the focus of this review is on those motivated to quit nicotine products that are not being consumed for health reasons, or in accordance with advice from their general practitioner, will address this issue.

6. Excluding studies that are not written in English (page 4) is not acceptable anymore, because automatic translation tools are now available at no cost.
Response: It is possible that including studies published in all languages could yield some interesting insights. However, establishing the accuracy of AI-powered translation tools, which are often used to achieve this, is difficult without human-in-the-loop input from fluent speakers. The review team unfortunately do not have the resources to accommodate this. In addition, Cochrane recommendations for rapid review methods advise that excluding articles not published in the English language at the study selection stage is an acceptable practice for rapid reviews.

Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

7. Data extraction: the authors should also extract information on the users’ intentions and motivations for use (see above).
Response: As above, whilst this information may be useful, it will likely be difficult to parse intentions and motivations among included studies given the range of products and patterns of use that are likely to identified. We believe that organising the eligibility around cessation interventions will provide a clearer approach to examining findings from studies of those who are demonstrably motivated to quit by virtue of attending and participating in such interventions or services.

8. Stopping nicotine use can have adverse effects, and information about these adverse effects should also be extracted too. The main adverse effect of stopping vaping is relapse to smoking, and it is essential to document whether interventions aimed at stopping vaping lead to relapse to smoking. Other adverse effects include the onset of depression in people at risk or with a history of depression, this should also be documented.
Response: This would certainly be an interesting point to consider. To that end, we will record any information on adverse events that are reported in included studies, and present it alongside the findings of the review.

9. Ethical approval may not be required for a literature review, but an ethics board would most probably have identified the problems listed above. Their guidance would be useful and may be necessary if you consult users during a rewriting of this protocol.
Response: Research Ethics Committees in Ireland do not, in most circumstances, review applications for research involving literature reviews or other evidence syntheses. Therefore, it was unfortunately not possible to consult with a Research Ethics Committee during the preparation of this protocol.

10. The authors did not involve the public in drafting the protocol, but they should have done so. If they had, they would probably have identified the problems listed above. If a revised version is submitted, the authors should then include stakeholders: users of the various products, vape shop owners (who are de facto the first-line advisors on smoking cessation, whether we like it or not), representatives of vaping associations, etc.
Response: You have raised an important point. Engagement with public and patient representatives is important, and this review is part of an overall project concerning vaping cessation in Ireland that includes co-design approaches in collaboration with product users and smoking cessation providers. We also have dedicated product user representatives providing feedback on the project, and are in the process of establishing a Steering Group. The findings of this review will be presented to this Group before the paper is submitted for publication, to ensure that the recommendations are timely and relevant. We also have a co-author who is a representative from the Health Service Executive Tobacco Free Ireland programme, and assisted with the conceptualisation of this protocol.
Information on PPI that is relevant to this protocol is provided under the ‘Patient and public involvement’ section of this manuscript.
Competing Interests: None Close
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Reviewer Report 29 Jan 2026

Jo Longman, The University of Sydney, Sydney, Australia

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15729.r52798

Thank you for the opportunity to review this rapid review protocol which seeks to review the international published and grey literature to answer the questions: which approaches to the management and cessation of vaping and/or recreational nicotine product use can be considered best practice?; what are the barriers and facilitators of implementation, and what treatment preferences have been reported?. This is an important topic to keep abreast of as it is so rapidly changing and is therefore suitable for a rapid review.

General comments:
I had some difficulty understanding some of the objectives and rationale as there is a bit of inconsistency with language between cessation and management services, and interventions which included BOTH individual cessation interventions (cessation support/treatment) and more public health interventions that might change the characteristics of vapes (reducing accessibility, reducing the level of nicotine in vapes etc.).

The introduction lacks sufficient coverage of what is known/not known about recreational nicotine use.
In the introduction you make the important point that there are different approaches to vaping across countries. These differences in culture, policy and regulatory/legislative frameworks have implications for how you might synthesise the findings of the rapid review and how applicable to Ireland the findings could be. There are also differences in health systems which might play into this too.

I wondered if your reporting groups might be complex: vaping only; recreational nicotine only; vapes and tobacco; recreational nicotine and tobacco for interventions at the individual level and the same groups for interventions at the public health level. I suspect in many papers you won’t be able to tease apart these groups.

Search strategy
I presume the search has been trialled and:

including the NOT term “tobacco smoking” doesn’t exclude any relevant papers which might be about dual using?
you are satisfied that the terms in your second block pick up the Public Health type interventions such as policy, restricting access, regulation/legislation to reduce nicotine in these products etc?
block 3 seems to be all about RQ3 but if you AND all 3 blocks together won’t you only get records which answer RQ3? Blocks 1 and 2 ANDed together will identify which interventions (public health or individual cessation support) exist and then you are going to apply the 8 criteria to assess if they meet best practice criteria so should you do this before ANDing all 3 together?
should your block 3 include effect*
where is the search strategy for the grey literature?

Minor points
Each time you use the key barriers and facilitators phrase it would help to spell out barriers to what.
In the Introduction I think you need to describe what moist snuff is.
I did not understand the final sentence of paragraph 4 in the introduction “This risks a splintered…”
Last sentence before Information Sources: I think some papers/reports you find will be mixed methods.
Did you know you can handle data extraction within Covidence?

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Smoking and vaping cessation support in health services

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

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Author Response 26 May 2026

Rory Coyne, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Ireland

26 May 2026

Author Response

I had some difficulty understanding some of the objectives and rationale as there is a bit of inconsistency with language between cessation and management services, and interventions which included BOTH ... Continue reading I had some difficulty understanding some of the objectives and rationale as there is a bit of inconsistency with language between cessation and management services, and interventions which included BOTH individual cessation interventions (cessation support/treatment) and more public health interventions that might change the characteristics of vapes (reducing accessibility, reducing the level of nicotine in vapes etc.).
Response: Thank you for pointing this out. To clarify, we are concentrating on individual-level interventions as part of this rapid review, rather than public health initiatives (such as restricting accessibility or nicotine content). To make this clearer for the reader, we have added a definition for how we are using the term ‘intervention’ – that is, the fact that intervention studies refer to individual-level supports for the cessation and management of vaping and/or alternative nicotine products – under eligibility criteria (page 6, lines 5-7).
Text added: “‘Intervention’ in this case refers to individual-level support for the cessation of vaping and/or alternative nicotine products, to those who are motivated to quit these products” We are not concerned here with public health interventions that might change the characteristics of vapes or accessibility, etc..

The introduction lacks sufficient coverage of what is known/not known about recreational nicotine use.
Response: See response to the reviewer above regarding the term ‘recreational’. We agree that more information about current knowledge of these alternative nicotine products could be provided in the manuscript. We have taken steps to address this by providing additional data on current prevalence rates of several types of products, such as nicotine pouches and heated tobacco (also known as ‘heat-not-burn’). We have also noted that current evidence suggests that prevalence is low, but increasing, and that use tends to be concentrated among those with a previous history of using nicotine (page 3, lines 32-37).
Text added: “Another examination of trends among adults in England (Cox et al., 2025) found increases in the use of nicotine pouches and heated tobacco products (or ‘heat-not-burn’), in which tobacco is heated to produce an aerosol without combustion (Tattan-Birch et al., 2021) – however, overall prevalence was 0.7% (Cox et al., 2025). Current knowledge therefore suggests that use of this range of products is low, but increasing – and appears concentrated among those with a previous history of nicotine use (Brose et al., 2025).”

In the introduction you make the important point that there are different approaches to vaping across countries. These differences in culture, policy and regulatory/legislative frameworks have implications for how you might synthesise the findings of the rapid review and how applicable to Ireland the findings could be. There are also differences in health systems which might play into this too.
Response: This is a very timely and relevant observation. It is true that differences in health systems may play into the findings of the review – in Ireland, for example, we have a mixed public and private healthcare system, often making translation of findings challenging. As part of the best practice assessment, we will be evaluating factors such as respect for local norms and cultures, and engagement with local communities. As Ireland does not currently have any vaping cessation services, we intend to look at the international evidence, with an understanding that practices which have been successfully implemented may need to be adapted for the Irish context.

I wondered if your reporting groups might be complex: vaping only; recreational nicotine only; vapes and tobacco; recreational nicotine and tobacco for interventions at the individual level and the same groups for interventions at the public health level. I suspect in many papers you won’t be able to tease apart these groups.
Response: You have raised an important point it is indeed fair to say that the user groups are likely to vary considerably in terms of the types of products, and patterns of use (i.e., dual-use, or vaping in tandem with other products). See also response to reviewer 1 above. We have taken this into consideration in two ways: by clarifying eligibility criteria, we specify that both single-users of vapes and/or alternative nicotine products will be included, and in the data extraction form, we will collect information on types of products used and type of usage. Differences in terms of types of products and usage will be noted in the results of the review.

Search strategy
I presume the search has been trialled and:

including the NOT term “tobacco smoking” doesn’t exclude any relevant papers which might be about dual using?

Response: No, dual-use papers do not appear to be excluded when applying this NOT operator – we tested this iteratively an in collaboration with a library information specialist.

you are satisfied that the terms in your second block pick up the Public Health type interventions such as policy, restricting access, regulation/legislation to reduce nicotine in these products etc?

Response: As the focus of this rapid review is to look at interventions for vaping and alternative nicotine cessation, rather than public health initiatives such as the ones you have listed, this particular type of intervention will be outside the scope of the current review.

block 3 seems to be all about RQ3 but if you AND all 3 blocks together won’t you only get records which answer RQ3? Blocks 1 and 2 ANDed together will identify which interventions (public health or individual cessation support) exist and then you are going to apply the 8 criteria to assess if they meet best practice criteria so should you do this before ANDing all 3 together?

Response: You have raised an important point, and it would certainly be interesting to separate blocks 1 and 2 from block 3, by querying the databases for terms related to RQ2 and RQ3 independently. Because this is a rapid review, we ultimately decided not to do this in order to limit the number of interventions, in line with Cochrane recommendations for rapid review methods (Garritty et al., 2024). Restricting the searches by combining the search blocks relevant to RQ1, RQ2 and RQ3 will ensure the timeliness of the review, which is a key advantage over this type of review, in comparison to systematic review methods. It would also be interesting to consider barriers, facilitators and treatment preferences in greater detail – however, this type of work may be better suited to a qualitative evidence synthesis, perhaps as part of an analysis that is ultimately aligned to theory. In the full paper resulting from this review, we will note this as a limitation of the findings that are obtained from answering RQ2 and RQ3.
Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

should your block 3 include effect*

Response: This is a good question – however, as the primary aim of this review is not to synthesise the evidence for the effectiveness of these interventions (as this has been reported elsewhere), we ultimately decided to omit this term. We also trialled the search strategy having added this term, and it did not appear to yield any additionally relevant articles.

where is the search strategy for the grey literature?

Response: The search strategy for grey literature that we will use has been designed for PsycEXTRA, a grey literature database that is hosted by EBSCO, who also host PsycINFO. Since OpenGrey is no longer available, we feel that this is the most suitable database for our review. We will therefore be able to use the search strategy from PsycINFO to query PsycEXTRA, and have made a note of this in the supplementary material.

Minor points
Each time you use the key barriers and facilitators phrase it would help to spell out barriers to what.
Response: Thank you for pointing this out. To make this clearer for the reviewer, we have added “…to implementation” wherever barriers and facilitators are discussed in the manuscript.

In the Introduction I think you need to describe what moist snuff is.
Response: Apologies for this oversight. We now provide a definition for moist snuff in the introduction (page 3, line 11).
Text added: “…in which finely ground smokeless tobacco is used to absorb nicotine orally ( Hanafin et al., 2025).”

I did not understand the final sentence of paragraph 4 in the introduction “This risks a splintered…”
Response: Thank you for pointing this out. We have rephrased this particular sentence to be clearer for the reader: (page 3, lines 41-42), as follows:.
Text added: “This could result in inconsistent approaches to vaping cessation internationally, potentially contributing to the weaker evidence for their effectiveness”

Last sentence before Information Sources: I think some papers/reports you find will be mixed methods.
Response: Thank you for this – we have rephrased to account for the fact that included studies may be quantitative, qualitative or mixed methods (page 6, lines 6-7).
Text added: “Studies that used quantitative, qualitative or mixed methods will be included.”

Did you know you can handle data extraction within Covidence?
Response: This is a helpful suggestion, and we did consider using Covidence to perform data extraction, but given the varying ways in which barriers, facilitators and treatment preferences are likely to be reported in included studies, we ultimately felt that a more manual approach was better, so as not to miss any important information.
I had some difficulty understanding some of the objectives and rationale as there is a bit of inconsistency with language between cessation and management services, and interventions which included BOTH individual cessation interventions (cessation support/treatment) and more public health interventions that might change the characteristics of vapes (reducing accessibility, reducing the level of nicotine in vapes etc.).
Response: Thank you for pointing this out. To clarify, we are concentrating on individual-level interventions as part of this rapid review, rather than public health initiatives (such as restricting accessibility or nicotine content). To make this clearer for the reader, we have added a definition for how we are using the term ‘intervention’ – that is, the fact that intervention studies refer to individual-level supports for the cessation and management of vaping and/or alternative nicotine products – under eligibility criteria (page 6, lines 5-7).
Text added: “‘Intervention’ in this case refers to individual-level support for the cessation of vaping and/or alternative nicotine products, to those who are motivated to quit these products” We are not concerned here with public health interventions that might change the characteristics of vapes or accessibility, etc..

The introduction lacks sufficient coverage of what is known/not known about recreational nicotine use.
Response: See response to the reviewer above regarding the term ‘recreational’. We agree that more information about current knowledge of these alternative nicotine products could be provided in the manuscript. We have taken steps to address this by providing additional data on current prevalence rates of several types of products, such as nicotine pouches and heated tobacco (also known as ‘heat-not-burn’). We have also noted that current evidence suggests that prevalence is low, but increasing, and that use tends to be concentrated among those with a previous history of using nicotine (page 3, lines 32-37).
Text added: “Another examination of trends among adults in England (Cox et al., 2025) found increases in the use of nicotine pouches and heated tobacco products (or ‘heat-not-burn’), in which tobacco is heated to produce an aerosol without combustion (Tattan-Birch et al., 2021) – however, overall prevalence was 0.7% (Cox et al., 2025). Current knowledge therefore suggests that use of this range of products is low, but increasing – and appears concentrated among those with a previous history of nicotine use (Brose et al., 2025).”

In the introduction you make the important point that there are different approaches to vaping across countries. These differences in culture, policy and regulatory/legislative frameworks have implications for how you might synthesise the findings of the rapid review and how applicable to Ireland the findings could be. There are also differences in health systems which might play into this too.
Response: This is a very timely and relevant observation. It is true that differences in health systems may play into the findings of the review – in Ireland, for example, we have a mixed public and private healthcare system, often making translation of findings challenging. As part of the best practice assessment, we will be evaluating factors such as respect for local norms and cultures, and engagement with local communities. As Ireland does not currently have any vaping cessation services, we intend to look at the international evidence, with an understanding that practices which have been successfully implemented may need to be adapted for the Irish context.

I wondered if your reporting groups might be complex: vaping only; recreational nicotine only; vapes and tobacco; recreational nicotine and tobacco for interventions at the individual level and the same groups for interventions at the public health level. I suspect in many papers you won’t be able to tease apart these groups.
Response: You have raised an important point it is indeed fair to say that the user groups are likely to vary considerably in terms of the types of products, and patterns of use (i.e., dual-use, or vaping in tandem with other products). See also response to reviewer 1 above. We have taken this into consideration in two ways: by clarifying eligibility criteria, we specify that both single-users of vapes and/or alternative nicotine products will be included, and in the data extraction form, we will collect information on types of products used and type of usage. Differences in terms of types of products and usage will be noted in the results of the review.

Search strategy
I presume the search has been trialled and:

including the NOT term “tobacco smoking” doesn’t exclude any relevant papers which might be about dual using?

Response: No, dual-use papers do not appear to be excluded when applying this NOT operator – we tested this iteratively an in collaboration with a library information specialist.

you are satisfied that the terms in your second block pick up the Public Health type interventions such as policy, restricting access, regulation/legislation to reduce nicotine in these products etc?

Response: As the focus of this rapid review is to look at interventions for vaping and alternative nicotine cessation, rather than public health initiatives such as the ones you have listed, this particular type of intervention will be outside the scope of the current review.

block 3 seems to be all about RQ3 but if you AND all 3 blocks together won’t you only get records which answer RQ3? Blocks 1 and 2 ANDed together will identify which interventions (public health or individual cessation support) exist and then you are going to apply the 8 criteria to assess if they meet best practice criteria so should you do this before ANDing all 3 together?

Response: You have raised an important point, and it would certainly be interesting to separate blocks 1 and 2 from block 3, by querying the databases for terms related to RQ2 and RQ3 independently. Because this is a rapid review, we ultimately decided not to do this in order to limit the number of interventions, in line with Cochrane recommendations for rapid review methods (Garritty et al., 2024). Restricting the searches by combining the search blocks relevant to RQ1, RQ2 and RQ3 will ensure the timeliness of the review, which is a key advantage over this type of review, in comparison to systematic review methods. It would also be interesting to consider barriers, facilitators and treatment preferences in greater detail – however, this type of work may be better suited to a qualitative evidence synthesis, perhaps as part of an analysis that is ultimately aligned to theory. In the full paper resulting from this review, we will note this as a limitation of the findings that are obtained from answering RQ2 and RQ3.
Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

should your block 3 include effect*

Response: This is a good question – however, as the primary aim of this review is not to synthesise the evidence for the effectiveness of these interventions (as this has been reported elsewhere), we ultimately decided to omit this term. We also trialled the search strategy having added this term, and it did not appear to yield any additionally relevant articles.

where is the search strategy for the grey literature?

Response: The search strategy for grey literature that we will use has been designed for PsycEXTRA, a grey literature database that is hosted by EBSCO, who also host PsycINFO. Since OpenGrey is no longer available, we feel that this is the most suitable database for our review. We will therefore be able to use the search strategy from PsycINFO to query PsycEXTRA, and have made a note of this in the supplementary material.

Minor points
Each time you use the key barriers and facilitators phrase it would help to spell out barriers to what.
Response: Thank you for pointing this out. To make this clearer for the reviewer, we have added “…to implementation” wherever barriers and facilitators are discussed in the manuscript.

In the Introduction I think you need to describe what moist snuff is.
Response: Apologies for this oversight. We now provide a definition for moist snuff in the introduction (page 3, line 11).
Text added: “…in which finely ground smokeless tobacco is used to absorb nicotine orally ( Hanafin et al., 2025).”

I did not understand the final sentence of paragraph 4 in the introduction “This risks a splintered…”
Response: Thank you for pointing this out. We have rephrased this particular sentence to be clearer for the reader: (page 3, lines 41-42), as follows:.
Text added: “This could result in inconsistent approaches to vaping cessation internationally, potentially contributing to the weaker evidence for their effectiveness”

Last sentence before Information Sources: I think some papers/reports you find will be mixed methods.
Response: Thank you for this – we have rephrased to account for the fact that included studies may be quantitative, qualitative or mixed methods (page 6, lines 6-7).
Text added: “Studies that used quantitative, qualitative or mixed methods will be included.”

Did you know you can handle data extraction within Covidence?
Response: This is a helpful suggestion, and we did consider using Covidence to perform data extraction, but given the varying ways in which barriers, facilitators and treatment preferences are likely to be reported in included studies, we ultimately felt that a more manual approach was better, so as not to miss any important information.
Competing Interests: None Close
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Respond or Comment

COMMENTS ON THIS REPORT

Author Response 26 May 2026

Rory Coyne, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Ireland

26 May 2026

Author Response

I had some difficulty understanding some of the objectives and rationale as there is a bit of inconsistency with language between cessation and management services, and interventions which included BOTH ... Continue reading I had some difficulty understanding some of the objectives and rationale as there is a bit of inconsistency with language between cessation and management services, and interventions which included BOTH individual cessation interventions (cessation support/treatment) and more public health interventions that might change the characteristics of vapes (reducing accessibility, reducing the level of nicotine in vapes etc.).
Response: Thank you for pointing this out. To clarify, we are concentrating on individual-level interventions as part of this rapid review, rather than public health initiatives (such as restricting accessibility or nicotine content). To make this clearer for the reader, we have added a definition for how we are using the term ‘intervention’ – that is, the fact that intervention studies refer to individual-level supports for the cessation and management of vaping and/or alternative nicotine products – under eligibility criteria (page 6, lines 5-7).
Text added: “‘Intervention’ in this case refers to individual-level support for the cessation of vaping and/or alternative nicotine products, to those who are motivated to quit these products” We are not concerned here with public health interventions that might change the characteristics of vapes or accessibility, etc..

The introduction lacks sufficient coverage of what is known/not known about recreational nicotine use.
Response: See response to the reviewer above regarding the term ‘recreational’. We agree that more information about current knowledge of these alternative nicotine products could be provided in the manuscript. We have taken steps to address this by providing additional data on current prevalence rates of several types of products, such as nicotine pouches and heated tobacco (also known as ‘heat-not-burn’). We have also noted that current evidence suggests that prevalence is low, but increasing, and that use tends to be concentrated among those with a previous history of using nicotine (page 3, lines 32-37).
Text added: “Another examination of trends among adults in England (Cox et al., 2025) found increases in the use of nicotine pouches and heated tobacco products (or ‘heat-not-burn’), in which tobacco is heated to produce an aerosol without combustion (Tattan-Birch et al., 2021) – however, overall prevalence was 0.7% (Cox et al., 2025). Current knowledge therefore suggests that use of this range of products is low, but increasing – and appears concentrated among those with a previous history of nicotine use (Brose et al., 2025).”

In the introduction you make the important point that there are different approaches to vaping across countries. These differences in culture, policy and regulatory/legislative frameworks have implications for how you might synthesise the findings of the rapid review and how applicable to Ireland the findings could be. There are also differences in health systems which might play into this too.
Response: This is a very timely and relevant observation. It is true that differences in health systems may play into the findings of the review – in Ireland, for example, we have a mixed public and private healthcare system, often making translation of findings challenging. As part of the best practice assessment, we will be evaluating factors such as respect for local norms and cultures, and engagement with local communities. As Ireland does not currently have any vaping cessation services, we intend to look at the international evidence, with an understanding that practices which have been successfully implemented may need to be adapted for the Irish context.

I wondered if your reporting groups might be complex: vaping only; recreational nicotine only; vapes and tobacco; recreational nicotine and tobacco for interventions at the individual level and the same groups for interventions at the public health level. I suspect in many papers you won’t be able to tease apart these groups.
Response: You have raised an important point it is indeed fair to say that the user groups are likely to vary considerably in terms of the types of products, and patterns of use (i.e., dual-use, or vaping in tandem with other products). See also response to reviewer 1 above. We have taken this into consideration in two ways: by clarifying eligibility criteria, we specify that both single-users of vapes and/or alternative nicotine products will be included, and in the data extraction form, we will collect information on types of products used and type of usage. Differences in terms of types of products and usage will be noted in the results of the review.

Search strategy
I presume the search has been trialled and:

including the NOT term “tobacco smoking” doesn’t exclude any relevant papers which might be about dual using?

Response: No, dual-use papers do not appear to be excluded when applying this NOT operator – we tested this iteratively an in collaboration with a library information specialist.

you are satisfied that the terms in your second block pick up the Public Health type interventions such as policy, restricting access, regulation/legislation to reduce nicotine in these products etc?

Response: As the focus of this rapid review is to look at interventions for vaping and alternative nicotine cessation, rather than public health initiatives such as the ones you have listed, this particular type of intervention will be outside the scope of the current review.

block 3 seems to be all about RQ3 but if you AND all 3 blocks together won’t you only get records which answer RQ3? Blocks 1 and 2 ANDed together will identify which interventions (public health or individual cessation support) exist and then you are going to apply the 8 criteria to assess if they meet best practice criteria so should you do this before ANDing all 3 together?

Response: You have raised an important point, and it would certainly be interesting to separate blocks 1 and 2 from block 3, by querying the databases for terms related to RQ2 and RQ3 independently. Because this is a rapid review, we ultimately decided not to do this in order to limit the number of interventions, in line with Cochrane recommendations for rapid review methods (Garritty et al., 2024). Restricting the searches by combining the search blocks relevant to RQ1, RQ2 and RQ3 will ensure the timeliness of the review, which is a key advantage over this type of review, in comparison to systematic review methods. It would also be interesting to consider barriers, facilitators and treatment preferences in greater detail – however, this type of work may be better suited to a qualitative evidence synthesis, perhaps as part of an analysis that is ultimately aligned to theory. In the full paper resulting from this review, we will note this as a limitation of the findings that are obtained from answering RQ2 and RQ3.
Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

should your block 3 include effect*

Response: This is a good question – however, as the primary aim of this review is not to synthesise the evidence for the effectiveness of these interventions (as this has been reported elsewhere), we ultimately decided to omit this term. We also trialled the search strategy having added this term, and it did not appear to yield any additionally relevant articles.

where is the search strategy for the grey literature?

Response: The search strategy for grey literature that we will use has been designed for PsycEXTRA, a grey literature database that is hosted by EBSCO, who also host PsycINFO. Since OpenGrey is no longer available, we feel that this is the most suitable database for our review. We will therefore be able to use the search strategy from PsycINFO to query PsycEXTRA, and have made a note of this in the supplementary material.

Minor points
Each time you use the key barriers and facilitators phrase it would help to spell out barriers to what.
Response: Thank you for pointing this out. To make this clearer for the reviewer, we have added “…to implementation” wherever barriers and facilitators are discussed in the manuscript.

In the Introduction I think you need to describe what moist snuff is.
Response: Apologies for this oversight. We now provide a definition for moist snuff in the introduction (page 3, line 11).
Text added: “…in which finely ground smokeless tobacco is used to absorb nicotine orally ( Hanafin et al., 2025).”

I did not understand the final sentence of paragraph 4 in the introduction “This risks a splintered…”
Response: Thank you for pointing this out. We have rephrased this particular sentence to be clearer for the reader: (page 3, lines 41-42), as follows:.
Text added: “This could result in inconsistent approaches to vaping cessation internationally, potentially contributing to the weaker evidence for their effectiveness”

Last sentence before Information Sources: I think some papers/reports you find will be mixed methods.
Response: Thank you for this – we have rephrased to account for the fact that included studies may be quantitative, qualitative or mixed methods (page 6, lines 6-7).
Text added: “Studies that used quantitative, qualitative or mixed methods will be included.”

Did you know you can handle data extraction within Covidence?
Response: This is a helpful suggestion, and we did consider using Covidence to perform data extraction, but given the varying ways in which barriers, facilitators and treatment preferences are likely to be reported in included studies, we ultimately felt that a more manual approach was better, so as not to miss any important information.
I had some difficulty understanding some of the objectives and rationale as there is a bit of inconsistency with language between cessation and management services, and interventions which included BOTH individual cessation interventions (cessation support/treatment) and more public health interventions that might change the characteristics of vapes (reducing accessibility, reducing the level of nicotine in vapes etc.).
Response: Thank you for pointing this out. To clarify, we are concentrating on individual-level interventions as part of this rapid review, rather than public health initiatives (such as restricting accessibility or nicotine content). To make this clearer for the reader, we have added a definition for how we are using the term ‘intervention’ – that is, the fact that intervention studies refer to individual-level supports for the cessation and management of vaping and/or alternative nicotine products – under eligibility criteria (page 6, lines 5-7).
Text added: “‘Intervention’ in this case refers to individual-level support for the cessation of vaping and/or alternative nicotine products, to those who are motivated to quit these products” We are not concerned here with public health interventions that might change the characteristics of vapes or accessibility, etc..

The introduction lacks sufficient coverage of what is known/not known about recreational nicotine use.
Response: See response to the reviewer above regarding the term ‘recreational’. We agree that more information about current knowledge of these alternative nicotine products could be provided in the manuscript. We have taken steps to address this by providing additional data on current prevalence rates of several types of products, such as nicotine pouches and heated tobacco (also known as ‘heat-not-burn’). We have also noted that current evidence suggests that prevalence is low, but increasing, and that use tends to be concentrated among those with a previous history of using nicotine (page 3, lines 32-37).
Text added: “Another examination of trends among adults in England (Cox et al., 2025) found increases in the use of nicotine pouches and heated tobacco products (or ‘heat-not-burn’), in which tobacco is heated to produce an aerosol without combustion (Tattan-Birch et al., 2021) – however, overall prevalence was 0.7% (Cox et al., 2025). Current knowledge therefore suggests that use of this range of products is low, but increasing – and appears concentrated among those with a previous history of nicotine use (Brose et al., 2025).”

In the introduction you make the important point that there are different approaches to vaping across countries. These differences in culture, policy and regulatory/legislative frameworks have implications for how you might synthesise the findings of the rapid review and how applicable to Ireland the findings could be. There are also differences in health systems which might play into this too.
Response: This is a very timely and relevant observation. It is true that differences in health systems may play into the findings of the review – in Ireland, for example, we have a mixed public and private healthcare system, often making translation of findings challenging. As part of the best practice assessment, we will be evaluating factors such as respect for local norms and cultures, and engagement with local communities. As Ireland does not currently have any vaping cessation services, we intend to look at the international evidence, with an understanding that practices which have been successfully implemented may need to be adapted for the Irish context.

I wondered if your reporting groups might be complex: vaping only; recreational nicotine only; vapes and tobacco; recreational nicotine and tobacco for interventions at the individual level and the same groups for interventions at the public health level. I suspect in many papers you won’t be able to tease apart these groups.
Response: You have raised an important point it is indeed fair to say that the user groups are likely to vary considerably in terms of the types of products, and patterns of use (i.e., dual-use, or vaping in tandem with other products). See also response to reviewer 1 above. We have taken this into consideration in two ways: by clarifying eligibility criteria, we specify that both single-users of vapes and/or alternative nicotine products will be included, and in the data extraction form, we will collect information on types of products used and type of usage. Differences in terms of types of products and usage will be noted in the results of the review.

Search strategy
I presume the search has been trialled and:

including the NOT term “tobacco smoking” doesn’t exclude any relevant papers which might be about dual using?

Response: No, dual-use papers do not appear to be excluded when applying this NOT operator – we tested this iteratively an in collaboration with a library information specialist.

you are satisfied that the terms in your second block pick up the Public Health type interventions such as policy, restricting access, regulation/legislation to reduce nicotine in these products etc?

Response: As the focus of this rapid review is to look at interventions for vaping and alternative nicotine cessation, rather than public health initiatives such as the ones you have listed, this particular type of intervention will be outside the scope of the current review.

block 3 seems to be all about RQ3 but if you AND all 3 blocks together won’t you only get records which answer RQ3? Blocks 1 and 2 ANDed together will identify which interventions (public health or individual cessation support) exist and then you are going to apply the 8 criteria to assess if they meet best practice criteria so should you do this before ANDing all 3 together?

Response: You have raised an important point, and it would certainly be interesting to separate blocks 1 and 2 from block 3, by querying the databases for terms related to RQ2 and RQ3 independently. Because this is a rapid review, we ultimately decided not to do this in order to limit the number of interventions, in line with Cochrane recommendations for rapid review methods (Garritty et al., 2024). Restricting the searches by combining the search blocks relevant to RQ1, RQ2 and RQ3 will ensure the timeliness of the review, which is a key advantage over this type of review, in comparison to systematic review methods. It would also be interesting to consider barriers, facilitators and treatment preferences in greater detail – however, this type of work may be better suited to a qualitative evidence synthesis, perhaps as part of an analysis that is ultimately aligned to theory. In the full paper resulting from this review, we will note this as a limitation of the findings that are obtained from answering RQ2 and RQ3.
Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

should your block 3 include effect*

Response: This is a good question – however, as the primary aim of this review is not to synthesise the evidence for the effectiveness of these interventions (as this has been reported elsewhere), we ultimately decided to omit this term. We also trialled the search strategy having added this term, and it did not appear to yield any additionally relevant articles.

where is the search strategy for the grey literature?

Response: The search strategy for grey literature that we will use has been designed for PsycEXTRA, a grey literature database that is hosted by EBSCO, who also host PsycINFO. Since OpenGrey is no longer available, we feel that this is the most suitable database for our review. We will therefore be able to use the search strategy from PsycINFO to query PsycEXTRA, and have made a note of this in the supplementary material.

Minor points
Each time you use the key barriers and facilitators phrase it would help to spell out barriers to what.
Response: Thank you for pointing this out. To make this clearer for the reviewer, we have added “…to implementation” wherever barriers and facilitators are discussed in the manuscript.

In the Introduction I think you need to describe what moist snuff is.
Response: Apologies for this oversight. We now provide a definition for moist snuff in the introduction (page 3, line 11).
Text added: “…in which finely ground smokeless tobacco is used to absorb nicotine orally ( Hanafin et al., 2025).”

I did not understand the final sentence of paragraph 4 in the introduction “This risks a splintered…”
Response: Thank you for pointing this out. We have rephrased this particular sentence to be clearer for the reader: (page 3, lines 41-42), as follows:.
Text added: “This could result in inconsistent approaches to vaping cessation internationally, potentially contributing to the weaker evidence for their effectiveness”

Last sentence before Information Sources: I think some papers/reports you find will be mixed methods.
Response: Thank you for this – we have rephrased to account for the fact that included studies may be quantitative, qualitative or mixed methods (page 6, lines 6-7).
Text added: “Studies that used quantitative, qualitative or mixed methods will be included.”

Did you know you can handle data extraction within Covidence?
Response: This is a helpful suggestion, and we did consider using Covidence to perform data extraction, but given the varying ways in which barriers, facilitators and treatment preferences are likely to be reported in included studies, we ultimately felt that a more manual approach was better, so as not to miss any important information.
Competing Interests: None Close
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Version 2

VERSION 2 PUBLISHED 12 Dec 2025

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2
Version 2 (revision) 26 May 26	read
Version 1 12 Dec 25	read	read

Jo Longman, The University of Sydney, Sydney, Australia
Jean-Francois ETTER, University of Geneva, Geneva, Switzerland

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Reviewer Report

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10 Jun 2026 | for Version 2

Jo Longman, The University of Sydney, Sydney, Australia

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Approved

I am satisfied that my comments have been addressed in the revised version of this manuscript.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Smoking and vaping cessation support in health services

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

30 Views

30 Jan 2026 | for Version 1

Jean-Francois ETTER, University of Geneva, Geneva, Switzerland

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Not Approved

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

smoking, nicotine, tobacco, vaping, tobacco harm reduction

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Author Response

26 May 2026

Rory Coyne, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Ireland

2.One drawback of vaping cessation interventions is that they divert already limited resources away from smoking cessation interventions, and this can be counterproductive, as the latter have a greater impact on mortality and morbidity than the former. This point should be discussed.
Response: Thank you for this helpful suggestion. It is certainly fair to say that resources for smoking cessation supports are often limited, and that the provision of resources for separate vaping cessation services may risk funding being spread too thinly. This issue is now highlighted in the introduction section – with the point also made that long-term nicotine dependence proliferated by both smoking and vaping also risks placing additional strain on cessation services (page 3, lines 31-35).
Text added: “There is also a risk that dedicated services for the cessation of vaping, for which the precise health consequences are still unclear, may divert resources away from smoking cessation services. At the same, long-term nicotine dependence proliferated by both smoking and vaping may also place strain on healthcare services (Neczypor et al., 2022).”

Are vapers interested in vaping cessation support? A brief literature search shows that most are not interested, for various reasons: they use e-cigarettes to stop smoking and fear they would relapse to smoking if they stopped vaping, they understand that vaping is less dangerous than smoking, they already used other smoking cessation aids but failed to quit with these aids, they therefore do not see why they should stop vaping, etc. This literature should be cited in the introduction.
Response: There is evidence that vapers do express a desire to quit and make quit attempts, but as you have outlined, there are also several notable barriers to quitting that must be considered, and indeed there are likely differences among age groups. We have therefore revised the introduction to include literature which highlights the barriers you have pointed out, whilst also making the point that those who do wish to quit (i.e., those motivated to quit) will face difficulties in the absence of dedicated services and supports (page 3, lines 28-30).
Text added: “A number of important barriers to quitting vaping exist, such as fear of relapsing to smoking among those who have used vaping to quit smoking (Dyson et al., 2022), and low perceived risk of vaping to one’s health, particularly among younger vapers (Patterson et al., 2025). Ultimately, however, it is likely that vape users who do want to quit will face difficulties quitting in the absence of dedicated services and supports (Struick & Yang, 2021).”

A corollary of this lack of interest in support is that it will be very costly to recruit vapers in these interventions, and services that offer this type of support would struggle to be profitable.
Information on the cost of these interventions, their cost effectiveness (cost per quitter, cost per cancer case prevented), and their cost-benefit (medical care costs avoided) should also be collected in this review.
Response: It is a fair point that services which offer vaping cessation support may struggle to be profitable. Ireland has a public health system which is managed by the Health Service Executive (HSE), which is funded by general taxation and allows residents to access many services at little or no direct cost at the point of delivery, so profit is unlikely to be important for such settings. However, the reviewer’s general point about costs is of course important, so we will also evaluate the cost-effectiveness of included interventions. This will form part of our best practice assessment (under the domain of efficiency), as included interventions may have resource requirements (such as digital proprietary platforms) to be implemented.

3A.
To support their affirmation that “vapes can introduce considerable respiratory and cardiovascular problems,” the authors cite an article published in 2024 in an obscure Polish sports journal that has been cited only once. Instead, they should cite the NASEM report or that of the Royal College of Physicians (RCP), which are serious and widely cited reviews:

Contrary to the authors, these documents conclude that “vaping nicotine is not associated with a high frequency of adverse health effects.” (RCP), that “There is no available evidence whether or not e-cigarette use is associated with clinical cardiovascular outcomes” (NASEM), and that “There is no available evidence whether or not e-cigarette use is associated with intermediate cancer endpoints in humans” (NASEM).
Response: Thank you for pointing out that the evidence to support this point could be stronger. We have added the RCP article that you have provided. We decided not to include the NASEM report, as this was published 8 years ago, meaning the evidence may be out-of-date. Moreover, an umbrella review published in NEJM Evidence would contradict these reports, finding similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use. We therefore have revised this section of the Introduction to highlight that the health consequences of vaping are not yet certain, providing a more balanced overview of the evidence than was initially presented (page 2, lines 16-20).
Glantz SA, Nguyen N, Oliveira da Silva AL. Population-based disease odds for e-cigarettes and dual use versus cigarettes. NEJM evidence. 2024 Feb 27;3(3):EVIDoa2300229.
Text added: “Whilst the health consequences of vaping are not yet certain, with some finding no evidence of an association between vaping nicotine and adverse health effects (Agrawal et al., 2024, a review by Glantz et al. (2024) found similar odds of cardiovascular disease, stroke, and metabolic dysfunction between cigarette and vape use, albeit these were largely estimates from cross-sectional studies, so further definitive work is needed in this area”.

3B:
The authors mention “the litany of harmful substances that are also contained within vapes”, but the 2 reports above make it abundantly clear that vape aerosol contains much fewer harmful substances than tobacco smoke, the relevant comparator. Failure to mention this is misleading.
Response: We have rephrased this sentence to instead say that those who vape may face adverse health effects compared with those who do not smoke or vape (which is the relevant comparator in this case), when consumed long-term
particular sentence to make it clearer that vapes, while likely being less harmful to health than cigarettes, contain substances which could have adverse health effects when consumed long-term (page 3, lines 1-2).
Text added: “…in terms of limiting exposure to chemicals contained within vapes, which could result in adverse health effects for vape users, compared with those who do not smoke or vape, when consumed long-term.”

4. The authors need to define” recreational nicotine use”. This definition cannot be based just on the products themselves (e.g. NRT excluded, all vapes and pouches and heated tobacco included, smoking excluded). The definition needs to be based on “recreation”, i.e. on the user’s intent, motivation and behavior, and these are variables that can be measured and used as inclusion / exclusion criteria. The definition should include “recreation” only, and exclude other motives such as addiction and self-medication. Are former smokers who are long-term users of medicinal NRT products but are not dependent on NRT products included ? (they should, but users of NRT for smoking cessation and those who are dependent on NRT should not). Are users of heated tobacco who use these products mainly because they are dependent on them rather than because of pleasure or “recreation” included ? (they should not, but heated tobacco users who use it mostly for pleasure should be included). Are vapers who vape mostly because they use nicotine as self-medication (e.g. for depression), or because they are dependent on nicotine be included? (they should not, but vapers who use e-cigarettes mostly for pleasure should be). And what about those who use nicotine as a stimulant, like caffeine? Does this count as recreational use? There is growing evidence that nicotine has positive effects on the ageing brain, on enhanced cognition and Parkinson’s disease. Is nicotine use as self-medication in these cases included in recreational use (it should not, and if it is, what products count as recreational in this case? Just vapes or also NRT and cigarettes?). And the authors exclude smokers, but cigarette use is both recreational and an addiction. Why are occasional smokers who are not dependent on nicotine excluded from recreational nicotine use (e.g. those who smoke only at parties)? They should be included, but addicted smokers should not.
Response: Thank you for raising this important point and stimulating our thinking in this area. We agree that there are indeed many types of pathways to vaping and dual-use, and individuals will have a variety of reasons for using these products, which may in fact change over time as dependence increases. As clearly pointed out by the reviewer, we now think that our original terminology around ‘recreational’ use was incorrect. Whilst organising our definition around recreation could indeed serve a practical purpose, it may be difficult to distinguish this, given the range of products and patterns of use that the searches will likely identify. It also raises the question, in the case of dual-use, of how to regard differing intentions and motivations for the use of two or more products in the same individual(s). To simplify our approach for readers, and to better conceptualise the work according to our original aims, we therefore have removed the term ‘recreational’. We were instead interested in service provision for those motivated to quit, as these are the people who will engage with services. We have now elaborated under eligibility criteria that we aim to recruit individuals who are motivated to quit vapes and/or alternative nicotine products by signing up to participate in such an intervention. We also specify that studies who only recruit participants who are using these products exclusively as a smoking cessation aid at the time of the study, or on the advice of a healthcare practitioner at the time of the study, will be excluded. (page 5, lines 31-35).
Text added: “We aim to include individuals who are motivated to quit vapes and/or alternative nicotine products by virtue of signing up to participate in a cessation intervention or attending a cessation service. Studies who recruit participants who are using these products exclusively as a smoking cessation aid or on the advice of a healthcare practitioner at the time of the study will be excluded”.

To If the review does not use intent, motivation and behavior as inclusion / exclusion criteria, a definition of recreational use based on the products only is meaningless, as it confuses the different reasons for use. The key term here is “recreational”, and this should be measured.
For instance, research question 2 (barriers and facilitators) cannot be adequately answered if users are classified according to the type of product they use rather than on their intent and motivations.
Similarly, eligibility criteria on page 4 must be revised.
Response: As above, we have revised the eligibility criteria to more clearly specify the target population, and we have removed the word ‘recreational’ to avoid confusion.

5. If the authors revise the article, just changing the research question from “vaping and recreational nicotine use” to “vaping and non-combustible nicotine use” will not be an acceptable change, since this would not address the fundamental problem discussed above.
Response: This is a fair point, and we believe that clarifying that the focus of this review is on those motivated to quit nicotine products that are not being consumed for health reasons, or in accordance with advice from their general practitioner, will address this issue.

6. Excluding studies that are not written in English (page 4) is not acceptable anymore, because automatic translation tools are now available at no cost.
Response: It is possible that including studies published in all languages could yield some interesting insights. However, establishing the accuracy of AI-powered translation tools, which are often used to achieve this, is difficult without human-in-the-loop input from fluent speakers. The review team unfortunately do not have the resources to accommodate this. In addition, Cochrane recommendations for rapid review methods advise that excluding articles not published in the English language at the study selection stage is an acceptable practice for rapid reviews.

Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

7. Data extraction: the authors should also extract information on the users’ intentions and motivations for use (see above).
Response: As above, whilst this information may be useful, it will likely be difficult to parse intentions and motivations among included studies given the range of products and patterns of use that are likely to identified. We believe that organising the eligibility around cessation interventions will provide a clearer approach to examining findings from studies of those who are demonstrably motivated to quit by virtue of attending and participating in such interventions or services.

8. Stopping nicotine use can have adverse effects, and information about these adverse effects should also be extracted too. The main adverse effect of stopping vaping is relapse to smoking, and it is essential to document whether interventions aimed at stopping vaping lead to relapse to smoking. Other adverse effects include the onset of depression in people at risk or with a history of depression, this should also be documented.
Response: This would certainly be an interesting point to consider. To that end, we will record any information on adverse events that are reported in included studies, and present it alongside the findings of the review.

9. Ethical approval may not be required for a literature review, but an ethics board would most probably have identified the problems listed above. Their guidance would be useful and may be necessary if you consult users during a rewriting of this protocol.
Response: Research Ethics Committees in Ireland do not, in most circumstances, review applications for research involving literature reviews or other evidence syntheses. Therefore, it was unfortunately not possible to consult with a Research Ethics Committee during the preparation of this protocol.

10. The authors did not involve the public in drafting the protocol, but they should have done so. If they had, they would probably have identified the problems listed above. If a revised version is submitted, the authors should then include stakeholders: users of the various products, vape shop owners (who are de facto the first-line advisors on smoking cessation, whether we like it or not), representatives of vaping associations, etc.
Response: You have raised an important point. Engagement with public and patient representatives is important, and this review is part of an overall project concerning vaping cessation in Ireland that includes co-design approaches in collaboration with product users and smoking cessation providers. We also have dedicated product user representatives providing feedback on the project, and are in the process of establishing a Steering Group. The findings of this review will be presented to this Group before the paper is submitted for publication, to ensure that the recommendations are timely and relevant. We also have a co-author who is a representative from the Health Service Executive Tobacco Free Ireland programme, and assisted with the conceptualisation of this protocol.
Information on PPI that is relevant to this protocol is provided under the ‘Patient and public involvement’ section of this manuscript.

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Reviewer Report

25 Views

29 Jan 2026 | for Version 1

Jo Longman, The University of Sydney, Sydney, Australia

25 Views Cite this report Responses(1)

Approved With Reservations

including the NOT term “tobacco smoking” doesn’t exclude any relevant papers which might be about dual using?
you are satisfied that the terms in your second block pick up the Public Health type interventions such as policy, restricting access, regulation/legislation to reduce nicotine in these products etc?
block 3 seems to be all about RQ3 but if you AND all 3 blocks together won’t you only get records which answer RQ3? Blocks 1 and 2 ANDed together will identify which interventions (public health or individual cessation support) exist and then you are going to apply the 8 criteria to assess if they meet best practice criteria so should you do this before ANDing all 3 together?
should your block 3 include effect*
where is the search strategy for the grey literature?

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Smoking and vaping cessation support in health services

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Author Response

26 May 2026

Rory Coyne, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Ireland

I had some difficulty understanding some of the objectives and rationale as there is a bit of inconsistency with language between cessation and management services, and interventions which included BOTH individual cessation interventions (cessation support/treatment) and more public health interventions that might change the characteristics of vapes (reducing accessibility, reducing the level of nicotine in vapes etc.).
Response: Thank you for pointing this out. To clarify, we are concentrating on individual-level interventions as part of this rapid review, rather than public health initiatives (such as restricting accessibility or nicotine content). To make this clearer for the reader, we have added a definition for how we are using the term ‘intervention’ – that is, the fact that intervention studies refer to individual-level supports for the cessation and management of vaping and/or alternative nicotine products – under eligibility criteria (page 6, lines 5-7).
Text added: “‘Intervention’ in this case refers to individual-level support for the cessation of vaping and/or alternative nicotine products, to those who are motivated to quit these products” We are not concerned here with public health interventions that might change the characteristics of vapes or accessibility, etc..

The introduction lacks sufficient coverage of what is known/not known about recreational nicotine use.
Response: See response to the reviewer above regarding the term ‘recreational’. We agree that more information about current knowledge of these alternative nicotine products could be provided in the manuscript. We have taken steps to address this by providing additional data on current prevalence rates of several types of products, such as nicotine pouches and heated tobacco (also known as ‘heat-not-burn’). We have also noted that current evidence suggests that prevalence is low, but increasing, and that use tends to be concentrated among those with a previous history of using nicotine (page 3, lines 32-37).
Text added: “Another examination of trends among adults in England (Cox et al., 2025) found increases in the use of nicotine pouches and heated tobacco products (or ‘heat-not-burn’), in which tobacco is heated to produce an aerosol without combustion (Tattan-Birch et al., 2021) – however, overall prevalence was 0.7% (Cox et al., 2025). Current knowledge therefore suggests that use of this range of products is low, but increasing – and appears concentrated among those with a previous history of nicotine use (Brose et al., 2025).”

In the introduction you make the important point that there are different approaches to vaping across countries. These differences in culture, policy and regulatory/legislative frameworks have implications for how you might synthesise the findings of the rapid review and how applicable to Ireland the findings could be. There are also differences in health systems which might play into this too.
Response: This is a very timely and relevant observation. It is true that differences in health systems may play into the findings of the review – in Ireland, for example, we have a mixed public and private healthcare system, often making translation of findings challenging. As part of the best practice assessment, we will be evaluating factors such as respect for local norms and cultures, and engagement with local communities. As Ireland does not currently have any vaping cessation services, we intend to look at the international evidence, with an understanding that practices which have been successfully implemented may need to be adapted for the Irish context.

I wondered if your reporting groups might be complex: vaping only; recreational nicotine only; vapes and tobacco; recreational nicotine and tobacco for interventions at the individual level and the same groups for interventions at the public health level. I suspect in many papers you won’t be able to tease apart these groups.
Response: You have raised an important point it is indeed fair to say that the user groups are likely to vary considerably in terms of the types of products, and patterns of use (i.e., dual-use, or vaping in tandem with other products). See also response to reviewer 1 above. We have taken this into consideration in two ways: by clarifying eligibility criteria, we specify that both single-users of vapes and/or alternative nicotine products will be included, and in the data extraction form, we will collect information on types of products used and type of usage. Differences in terms of types of products and usage will be noted in the results of the review.

Search strategy
I presume the search has been trialled and:

including the NOT term “tobacco smoking” doesn’t exclude any relevant papers which might be about dual using?

Response: No, dual-use papers do not appear to be excluded when applying this NOT operator – we tested this iteratively an in collaboration with a library information specialist.

you are satisfied that the terms in your second block pick up the Public Health type interventions such as policy, restricting access, regulation/legislation to reduce nicotine in these products etc?

Response: As the focus of this rapid review is to look at interventions for vaping and alternative nicotine cessation, rather than public health initiatives such as the ones you have listed, this particular type of intervention will be outside the scope of the current review.

block 3 seems to be all about RQ3 but if you AND all 3 blocks together won’t you only get records which answer RQ3? Blocks 1 and 2 ANDed together will identify which interventions (public health or individual cessation support) exist and then you are going to apply the 8 criteria to assess if they meet best practice criteria so should you do this before ANDing all 3 together?

Response: You have raised an important point, and it would certainly be interesting to separate blocks 1 and 2 from block 3, by querying the databases for terms related to RQ2 and RQ3 independently. Because this is a rapid review, we ultimately decided not to do this in order to limit the number of interventions, in line with Cochrane recommendations for rapid review methods (Garritty et al., 2024). Restricting the searches by combining the search blocks relevant to RQ1, RQ2 and RQ3 will ensure the timeliness of the review, which is a key advantage over this type of review, in comparison to systematic review methods. It would also be interesting to consider barriers, facilitators and treatment preferences in greater detail – however, this type of work may be better suited to a qualitative evidence synthesis, perhaps as part of an analysis that is ultimately aligned to theory. In the full paper resulting from this review, we will note this as a limitation of the findings that are obtained from answering RQ2 and RQ3.
Garritty, C., Hamel, C., Trivella, M., Gartlehner, G., Nussbaumer-Streit, B., Devane, D., ... & King, V. J. (2024). Updated recommendations for the Cochrane rapid review methods guidance for rapid reviews of effectiveness. Bmj, 384.

should your block 3 include effect*

Response: This is a good question – however, as the primary aim of this review is not to synthesise the evidence for the effectiveness of these interventions (as this has been reported elsewhere), we ultimately decided to omit this term. We also trialled the search strategy having added this term, and it did not appear to yield any additionally relevant articles.

where is the search strategy for the grey literature?

Response: The search strategy for grey literature that we will use has been designed for PsycEXTRA, a grey literature database that is hosted by EBSCO, who also host PsycINFO. Since OpenGrey is no longer available, we feel that this is the most suitable database for our review. We will therefore be able to use the search strategy from PsycINFO to query PsycEXTRA, and have made a note of this in the supplementary material.

Minor points
Each time you use the key barriers and facilitators phrase it would help to spell out barriers to what.
Response: Thank you for pointing this out. To make this clearer for the reviewer, we have added “…to implementation” wherever barriers and facilitators are discussed in the manuscript.

In the Introduction I think you need to describe what moist snuff is.
Response: Apologies for this oversight. We now provide a definition for moist snuff in the introduction (page 3, line 11).
Text added: “…in which finely ground smokeless tobacco is used to absorb nicotine orally ( Hanafin et al., 2025).”

I did not understand the final sentence of paragraph 4 in the introduction “This risks a splintered…”
Response: Thank you for pointing this out. We have rephrased this particular sentence to be clearer for the reader: (page 3, lines 41-42), as follows:.
Text added: “This could result in inconsistent approaches to vaping cessation internationally, potentially contributing to the weaker evidence for their effectiveness”

Last sentence before Information Sources: I think some papers/reports you find will be mixed methods.
Response: Thank you for this – we have rephrased to account for the fact that included studies may be quantitative, qualitative or mixed methods (page 6, lines 6-7).
Text added: “Studies that used quantitative, qualitative or mixed methods will be included.”

Did you know you can handle data extraction within Covidence?
Response: This is a helpful suggestion, and we did consider using Covidence to perform data extraction, but given the varying ways in which barriers, facilitators and treatment preferences are likely to be reported in included studies, we ultimately felt that a more manual approach was better, so as not to miss any important information.

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Competing Interests

None

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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International best practice in the management and cessation of vaping and alternative nicotine use, and barriers, facilitators and treatment preferences: A rapid review protocol

Abstract

Background

Aim

Methods

Ethics and dissemination

Keywords

Revised Amendments from Version 1

Introduction

Review questions

Methods

Patient and public involvement

Eligibility criteria

Information sources and search strategy

Screening and study selection

Data extraction and management

Data analysis and synthesis

Conclusion

Ethics and dissemination

Data availability

Reporting guidelines

References

Comments on this article Comments (0)

Open Peer Review

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Open Peer Review

Reviewer Status

Reviewer Reports

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International best practice in the management and cessation of vaping and alternative nicotine use, and barriers, facilitators and treatment preferences: A rapid review protocol

Abstract

Background

Aim

Methods

Ethics and dissemination

Keywords

Revised Amendments from Version 1

Introduction

Review questions

Methods

Patient and public involvement

Eligibility criteria

Information sources and search strategy

Screening and study selection

Data extraction and management

Data analysis and synthesis

Conclusion

Ethics and dissemination

Data availability

Reporting guidelines

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Competing Interests Policy

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Are you a HRB-funded researcher?

Thank you!