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Electronic cigarette use after smoking cessation and lung cancer risk

Nature Medicine (2026) Cite this article

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Abstract

Electronic cigarettes (e-cigarettes) have gained popularity as a less harmful alternative to conventional cigarettes, yet their associations with lung cancer risk after smoking cessation remain uncertain. Here we evaluated 4,524,895 adults with a conventional smoking history who participated in the Korean National Health Screening Program in 2018 (baseline), with prior records from 2012–2014. Participants were classified as current smokers, short-term quitters or long-term quitters, and followed up to December 2023. Daily e-cigarette use at baseline was used to define post-cessation e-cigarette use. Lung cancer incidence and lung cancer-specific death (LCSD) were assessed using multivariable Cox models. Over 24,182,543 person-years, 35,887 lung cancers and 12,807 LCSD events occurred. Compared with complete quitters, e-cigarette use after smoking cessation was associated with higher risks of lung cancer incidence (adjusted hazard ratio (aHR) 1.56, 95% confidence interval (CI) 1.24–1.97) and LCSD (aHR 2.00, 95% CI 1.28–3.15). Associations were directionally consistent in short-term and long-term quitters and were prominent in the high-risk subgroup (incidence: aHR 1.91, 95% CI 1.44–2.53; LCSD: aHR 1.92, 95% CI 1.13–3.24). Although causality cannot be established, these findings suggest that e-cigarette use after smoking cessation may attenuate the benefits of complete cessation for lung cancer prevention.

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Fig. 1: Study flowchart.
The alternative text for this image may have been generated using AI.
Fig. 2: Risk of lung cancer outcomes and mortality according to smoking and e-cigarette use status.
The alternative text for this image may have been generated using AI.
Fig. 3: Risk of lung cancer outcomes and mortality according to smoking and e-cigarette use status among the high-risk subgroup.
The alternative text for this image may have been generated using AI.

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Data availability

The data supporting the findings of this study are derived from the Korean NHIS health screening and claims databases. Individual-level data are not publicly available because they contain sensitive personal health information and are protected under NHIS data governance and privacy regulations. For research purposes, de-identified data are accessible upon application through the NHIS Big Data Platform (https://nhiss.nhis.or.kr/). Applicants are required to submit a research proposal (including study aims, cohort definition and a data specification), documentation of institutional review board approval, and other materials requested by NHIS. Applications undergo administrative and data-provision review, and access is granted only for approved variables and time periods. Approved users can analyze the data through NHIS-designated secure analysis environments. The review and approval timeline is determined by NHIS and may vary by the complexity of the requested dataset and operational demand. Decisions are typically issued after completion of the review process (often within several weeks, but potentially longer for customized datasets). Further information on eligibility, required documents, fees and access procedures is available at https://nhiss.nhis.or.kr/.

Code availability

The statistical analyses in this Article were conducted using SAS v.9.4 with the built-in SAS/STAT procedure proc phreg. Figures were generated using R (v.4.3.3) with the open-source packages ggplot2 (v.3.5.1) and patchwork (v.1.2.0). No customized or nonpublic packages were used. The analytic SAS and R code used in this study is available via GitHub at https://github.com/SNUBH-bigdata/ECig_SmokingQuitters. De-identified NHIS analytic datasets are accessible upon application through the NHIS Big Data Platform, subject to NHIS approval and data extraction procedures, and can be analyzed within NHIS-designated secure analysis environments.

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Acknowledgements

The nationwide population-based data used in this study were provided by the South Korean NHIS (NHIS-2025-06-1-05).

Funding

Y.W.K. discloses support for the research of this work from the National R&D Program for Cancer Control through the National Cancer Center (NCC) funded by the Ministry of Health and Welfare, Republic of Korea (grant number HA23C0252). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Author information

Authors and Affiliations

  1. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea

    Yeon Wook Kim, Yeon Joo Lee, Jong Sun Park & Jae Ho Lee

  2. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea

    Yeon Wook Kim, Dong-Hyun Joo, Yeon Joo Lee, Jong Sun Park, Jae Ho Lee & Choon-Taek Lee

  3. Big Data Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea

    Eung Joo Park, Kyeong Im Kwak & Tae Ho Yoon

  4. Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea

    Hye-Rin Kang

  5. Seoul National University College of Medicine, Seoul, Republic of Korea

    Choon-Taek Lee

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Contributions

Y.W.K. and E.J.P. had full access to all of the study data and take responsibility for the integrity of the data and the accuracy of the data analysis. Y.W.K., E.J.P., K.I.K. and T.H.Y. contributed to the concept and design of the study, data collection, data analysis, data interpretation, paper preparation, revision and final approval of the paper. H.-R.K., D.-H.J., Y.J.L., J.S.P., J.H.L. and C.-T.L. contributed to the data analysis, revision and final approval of the paper. Y.W.K. is the overall study guarantor. The corresponding author (Y.W.K.) attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

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Correspondence to Yeon Wook Kim.

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Competing interests

Y.W.K. has received honorarium from AstraZeneca, and research grants not related to this study from AstraZeneca. The other authors declare no competing interests.

Peer review

Peer review information

Nature Medicine thanks Esther Omaiye, Guillermo Paraje, Mahdi Sheikh and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Peer reviewer reports are available. Primary Handling Editor: Ming Yang, in collaboration with the Nature Medicine team.

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Extended data

Extended Data Table 1 Association of e-cigarette use after smoking cessation with the risk of lung cancer incidence and lung cancer-specific death according to different adjustment models
Full size table
Extended Data Table 2 Demographic characteristics of individuals aged 50–80 years with a cigarette smoking intensity of ≥20 pack-years
Full size table
Extended Data Table 3 Association of e-cigarette use after smoking cessation with the risk of lung cancer incidence and lung cancer-specific death among individuals aged 50–80 years with a cigarette smoking intensity of ≥20 pack-years
Full size table

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Kim, Y.W., Park, E.J., Kwak, K.I. et al. Electronic cigarette use after smoking cessation and lung cancer risk. Nat Med (2026). https://doi.org/10.1038/s41591-026-04469-5

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