E-Cigarette Use Among Adults With CVD Increased During COVID-19 After Years of Decline

Among American adults with cardiovascular disease (CVD), use of e-cigarettes dropped between 2015 and 2019 but starkly increased again in 2019 and 2020, according to a research letter published in JAMA Network Open.

According to the authors, the decrease in e-cigarette usage is believed to stem from a greater awareness of the risks associated with these devices. Conversely, the rise in usage could be attributed, at least in part, to an exacerbated psychological burden resulting from the COVID-19 pandemic.

Tobacco use has long been associated with an increased risk of cardiovascular disease, contributing to a significant reduction in life expectancy by about 10 years. Since their introduction to the US market in 2006, e-cigarettes have emerged as a popular alternative to traditional tobacco products, drawing attention as a potential tool for smoking cessation. However, e-cigarette use has already been found to be associated with an increased risk of adverse cardiovascular events, drawing attention to usage trends among adults with CVD.

The study, which follows the STROBE reporting guideline, utilized data from the National Health Interview Survey and included more than 30,000 US adults aged 18 years and older who responded to the survey between 2014 and 2020. The mean (SD) age was 65 (15) years, and the cohort was 47.8% female and 84.7% White.

The findings revealed a nuanced trajectory of e-cigarette use among this group of adults with CVD. The weighted prevalence of current e-cigarette use among the participants demonstrated a decline from 2014 to 2019, dropping from 5.2% to 3.1%. However, the data showed a subsequent rebound in 2020, with usage rates returning to 5.2%.

When the cohort was stratified by smoking status, there was a slight increase in e-cigarette use between 2014 and 2015 for people who were otherwise smoking cigarettes, cigars, or other tobacco products and likely trying to quit or find an alternative, with a subsequent drop in 2016. Meanwhile, e-cigarette use among people who never smoked remained relatively low.

Importantly, though, the prevalence of e-cigarette use among individuals who had quit smoking clearly increased from 2015 to 2020, jumping from 3.2% to 10.1%.

Despite the intention for e-cigarettes to help people quit smoking combustible tobacco, individuals who had already quit smoking (OR, 1.8; 95% CI, 1.2-2.7) and who attempted to quit but did not within the past year (OR, 2.0; 95% CI, 1.5-2.6) were more likely to use e-cigarettes than current smokers.

“e-Cigarettes may help control tobacco consumption, but whether the replacement of traditional cigarettes with e-cigarettes helps smokers improve cardiovascular health needs further verification,” the authors said. “Given the reported cardiovascular hazards of e-cigarettes, smoking cessation, rather than e-cigarette substitution, may be more beneficial for cardiovascular secondary prevention.”

Age and gender disparities were also observed in the study's results. E-cigarette use among patients aged 60 years and older saw a decline from 2.9% in 2014 to 0.9% in 2020. In contrast, among individuals younger than 60 years, e-cigarette usage remained consistently high, ranging from 6.2% in 2014 to 7.2% in 2020. Additionally, while men were initially more likely to use e-cigarettes than women, this trend reversed in 2019 and 2020, with 8.3% of women and 2.9% of men reporting e-cigarette use in 2020.

The study’s limitations are primarily due to relying on self-reported data. As e-cigarette use continues to evolve and new research emerges, further studies are warranted to gain a comprehensive understanding of the cardiovascular effects of e-cigarettes compared with traditional tobacco products.

“Further studies are needed to understand the cardiovascular effects of e-cigarettes compared with combustible tobacco to inform future legislation for cardiovascular health,” the authors concluded.

Reference

Wen X, Xia T, Li R, et al. Trends in electronic cigarette use among US adults with a history of cardiovascular disease. JAMA Netw Open. 2023;6(8):e2328962. doi:10.1001/jamanetworkopen.2023.28962