If you would have asked me two years ago, I’d have said, “probably not.” But a new study published in the New England Journal of Medicine suggests I was wrong. And the implications go way beyond cigarettes. I’ll give you the upshot.

The study was done in the UK as part of their National Health Service. Subjects got either the nicotine replacement (NRT) of their choice or an e-cig starter pack and told to buy more if they wanted. Everyone got 4 weeks of “behavioral support.” The study’s endpoint was abstinence from cigarettes at one year. Here’s how they did.

Of the NRT group, 9.9% were not smoking at one year. In the e-cig group, 18% weren’t smoking at one year. So e-cig group had nearly twice the abstinence as NRT. And there’s one more difference. The e-cig group were still using the assigned product at a rate of 80% while only 9% of the NRT group were still using ant-smoking product. If we stop and think about this, it’s really earthshaking.

What this study is showing is if you allow a group to use a substitute “as desired” they’ll get twice the abstinence rate than if you assign a dose of a medication. Not only that, the abstinence is probably greatly mediated by their continuing use of the substitute. While this study on nicotine is a small side show in the whole addiction space, the implications are huge. What if the same rules applied to the opioid crisis?

This would imply that the Swiss experience with heroin maintenance may not be the fluke that American medicine thought it was. The Swiss allowed people with addiction involving opioids to come get as much heroin as they needed in safe spaces, but there were two rules. They couldn’t bring in any drugs, and they couldn’t come back that day if they left. So, people went in and stayed all day, shooting as much as they wanted. Here’s the kicker. They stayed in the place, with addiction counselors, talking to those counselors, all day. Essentially, they were willing to stay in a treatment space because they were able to use heroin as they needed it. The Swiss had abstinence rates in their studies that American programs only dream of.

Maybe it’s time to let go of our “drugs bad” view and think about the goals of treatment. This study, and the Swiss studies, don’t give us the whole picture, but I don’t think American medicine has the whole picture either. Let’s step back and take a broader view.