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Vaping may help some people quit cigarettes, but what about the nicotine?

E-cigarettes helped more people quit smoking than traditional nicotine replacement therapy did, a new study says — but vapes aren’t a miracle cure for nicotine addiction. Most of the smokers who tried vaping were still smoking cigarettes by the end of the trial, and most of the vapers who did manage to quit smoking continued to vape a year later.

The new study, published Wednesday in the New England Journal of Medicine, reports that 18 percent of smokers who switched to e-cigarettes had given up cigarettes after a year. That’s more than the 9.9 percent of people who stopped smoking using conventional quitting aids like the patch, gum, lozenges, or inhalers. The results add weight to the claims that e-cigarettes could help some people quit cigarettes, but there’s still a lot we don’t know about the long term health effects of e-cigarettes, or how to keep millions of teens from using them.

E-cigarette companies market themselves as a less risky alternative for people looking to stop smoking cigarettes. But being less risky than cigarettes is a low bar, according to the CDC: “Burned cigarettes are extraordinarily dangerous, killing half of all people who smoke long-term.” And the jury’s been out about whether e-cigarettes can help people quit, Vox reports: few rigorous trials have compared vaping to other quitting aids, like the patch, or gum.

“This sort of study, a systematic, well-done randomized controlled trial, was what was severely lacking in the decade-long debate of the potential benefits and harms of e-cigarettes,” Gideon St. Helen, a tobacco researcher at the University of California, San Francisco who was not involved in the research, says in an email to The Verge. There are still major caveats: for example, the study participants knew whether they were using e-cigarettes or, say, patches — and that knowledge could have skewed the results if they thought one strategy was better than the other. Plus, the study doesn’t assess more popular types of e-cigarettes, like Juul. Still, St. Helen says, “The findings are really important and perhaps game-changing.”

Researchers led by Peter Hajek, a professor of clinical psychology at the Wolfson Institute Of Preventive Medicine, found 866 people who wanted to quit smoking, and didn’t care how. For the first month, all of them received weekly one-on-one meetings with a clinician. Half also received their favorite nicotine replacement therapies, and half were given a starter kit for a refillable vape, including a bottle of Tobacco Royale flavored vape juice. Participants could swap out the device or the liquid if they wanted to.

The researchers checked in with the study participants periodically, assessing things like their sleep, whether they felt nauseated, if their throat or mouth hurt, and how much phlegm they coughed up. The big question was whether the participants could stay off cigarettes a year out. The researchers checked by measuring the carbon monoxide that the study participants exhaled – a marker for cigarette smoking. After a year, 18 percent of the e-cigarette users had quit smoking cigarettes, as had 10 percent of the nicotine replacement group. The e-cigarette users liked their vapes more than the other group liked their nicotine replacement therapies, and they had less severe withdrawal symptoms.

Here’s the catch: Of the people who kicked combustible cigarettes, 80 percent of the people in the vaping group were still using e-cigarettes after a year. That’s a huge fraction compared to the only 9 percent of people who were still using traditional nicotine replacement therapies at that point. So while vaping made it somewhat easier to quit cigarettes, it didn’t help much with quitting nicotine altogether. Plus, the study didn’t use the types of pod-based e-cigarettes like Juuls that are dominating the market. The science is still out, but given the convenience, the high nicotine dose, and the nicotine salts formulation, it’s possible pod-based vapes could be even harder to quit than the refillable kind used in the study.

The long-term health effects of vaping will be especially important to figure out out if switching to e-cigarettes signals the start of a long-term habit. We do know that nasty chemicals can form in the e-liquids while they sit on the shelf, for example, and vapers’ pee shows signs of exposure to carcinogens and irritants. Plus, the science around the health effects of nicotine itself is still murky: some studies suggests it might be risky for people with heart problems. And it’s addictive — which can lead people to feel controlled by their cravings, or to unpleasant withdrawal symptoms.

The question, St. Helen says, is what now? Yes, the study adds weight to something vapers have been saying for awhile: that e-cigarettes might be useful tools to help a fraction of smokers quit. But it’s impossible to look at the findings in a vacuum: there are 3.6 million high school and middle school students using e-cigarettes in what the US Surgeon General has declared an epidemic. “That risk remains, but will it be prioritized even as this well-done study shows e-cigarettes can help adult smokers quit smoking?” St. Helen says. The answer likely rests with regulators and the e-cigarette industry: if they can stop young people from vaping in record numbers, then maybe.

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