Population-Based Disease Odds for E-Cigarettes and Dual Use versus Cigarettes

Desires and Needs for Quitting Both e-Cigarettes and Cigarettes Among Young Adults: Formative Qualitative Study Informing the Development of a Smartphone Intervention for Dual Tobacco Cessation

BACKGROUND

Dual use of both e-cigarettes and cigarettes is popular among young adults and may lead to greater nicotine dependence and additive adverse health effects than single-product use. However, existing cessation programs target quitting either e-cigarettes or cigarettes, highlighting a need for interventions to help young adults quit both products (ie, dual tobacco cessation).

OBJECTIVE

This formative study is part of a larger project to develop a smartphone intervention for dual tobacco cessation among young adults. This study aimed to (1) explore desires for and experiences with quitting both e-cigarettes and cigarettes and (2) identify needs and preferences for dual tobacco cessation intervention programming.

METHODS

Semistructured interviews were conducted to elicit the need for and experience with dual tobacco cessation among 14 young adults (18-29 years old) recruited through Instagram (Meta) advertisements in 2023. We conducted a thematic analysis to identify common themes related to quitting experiences and cessation needs.

RESULTS

Participants expressed a strong desire for dual tobacco cessation and had attempted to quit both tobacco products, mostly "cold turkey." The priority product for quitting first varied by the individual's perceived harm or level of consumption. Targets for dual tobacco cessation interventions included (1) highlighting the health effects of dual tobacco use compared with single product use, (2) providing cessation support to quit one prioritized product while cutting down the other product with the explicit goal to quit both, (3) emphasizing unique facilitators and barriers to quitting each product (eg, unpleasant smell of cigarettes facilitating smoking cessation and accessibility and flavors of e-cigarettes hindering vaping cessation), and (4) addressing co-use of tobacco with alcohol or cannabis. Participants wanted personalized interventions through smartphone apps that would tailor support to their tobacco use patterns and unique quitting goals and needs. They also suggested presenting intervention content in multimedia (eg, videos, graphic pictures, quizzes, and games) to increase engagement.

CONCLUSIONS

This study provides important insights into young adults' experiences, needs, and preferences for dual tobacco product cessation. We highlight important targets for future smartphone apps to deliver personalized and tailored support to meet the heterogeneous needs and preferences of young people who want to quit using both e-cigarettes and cigarettes.

Single-cell RNA sequencing reveals heterogeneity of ALI model and epithelial cell alterations after exposure to electronic cigarette aerosol

Electronic cigarettes (e-cigarettes) have been advertised as a healthier alternative to traditional cigarettes; however, their exact effects on the bronchial epithelium are poorly understood. Air-liquid interface culture human bronchial epithelium (ALI-HBE) contains various cell types, including basal cell, ciliated cell and secretory cell, providing an in vitro model that simulates the biological characteristics of normal bronchial epithelium. Multiplex single-cell RNA sequencing of ALI-HBE was used to reveal previously unrecognized transcriptional heterogeneity within the human bronchial epithelium and cell type-specific responses to acute exposure to e-cigarette aerosol (e-aerosol) containing distinct components (nicotine and/or flavoring). The findings of our study show that nicotine-containing e-aerosol affected gene expression related to transformed basal cells into secretory cells after acute exposure; inhibition of secretory cell function by down-regulating genes related to epithelial cell differentiation, calcium ion binding, extracellular exosomes, and secreted proteins; and enhanced interaction between secretory cells and other cells. On the other hand, flavoring may alter the growth pattern of epithelial cells and make basal cells more susceptible to SARS-CoV infection. Besides, the data also indicate factors that may promote SARS-CoV-2 infection and suggest therapeutic targets for restoring normal bronchial epithelium function after e-cigarette use. In summary, the current study offered fresh perspectives on alterations in the cellular landscape and cell type-specific responses in human bronchial epithelium that are brought about by e-cigarette use.

Stopping use of E-cigarettes and smoking combustible cigarettes: findings from a large longitudinal digital smoking cessation intervention study in the United States

OBJECTIVE

Digital interventions have been widely implemented to promote tobacco cessation. However, implementations of these interventions have not yet considered how participants' e-cigarette use may influence their quitting outcomes. We explored the association of e-cigarette use and quitting smoking within the context of a study testing a digital tobacco cessation intervention among individuals in the United States who were 18 years and older, smoked combustible cigarettes, and enrolled in the intervention between August 2017 and March 2019.

RESULTS

We identified four e-cigarette user groups (n = 990) based on the participants' baseline and six-month e-cigarette use (non-users, n = 621; recently started users, n = 60; sustained users, n = 187; recently stopped users, n = 122). A multiple logistic regression was used to estimate the adjusted odds ratios (AOR) of six-month quit outcome and the e-cigarette user groups. Compared to e-cigarette non-users, the odds of quitting smoking were significantly higher among recently stopped users (AOR = 1.68, 95% CI [1.06, 2.67], p = 0.03). Participants who were most successful at quitting combustible cigarettes also stopped using e-cigarettes at follow-up, although many sustained using both products. Findings suggest that digital tobacco cessation interventions may carefully consider how to promote e-cigarette use cessation among participants who successfully quit smoking.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03224520 (July 21, 2017).

["Smoke-free in May 2024": concept and description of the participants]

BACKGROUND

Far too many people smoke in Germany, and the number of serious attempts to stop smoking has been falling for years.

METHODS

Smoke-free in May 2024 is a low-threshold measure to encourage people to stop smoking. Adults who "regularly" consume nicotine products as well as support persons were eligible to take part. As part of the measure, participants and supporters were offered daily support via app notifications, emails and/or WhatsApp. They were also made aware of existing stop-smoking programmes. Finally, prizes were raffled off among the successful participants.

RESULTS

A total of 6,386 individuals registered to take part. Of these, 550 individuals registered with a person of their choice to support them. Smokers were predominantly female (56.5%) and on average 42.9 (SD=13.2) years old. They came from all federal states in Germany, with a disproportionately high number from the federal states of Bremen, Schleswig-Holstein, Berlin, North Rhine-Westphalia, Hamburg and Bavaria in relation to the population distribution. Compared to a representative sample from a study by the Robert Koch Institute (2012), they reported a significantly higher subjective socio-economic status. Of the participants, 79.3% categorised their addiction as high. Regular use of more than one nicotine products occurred in 35.3% of the sample; 39.8% of the participants stated that they had not tried to stop smoking during the last 12 months.

CONCLUSIONS

The number of smokers participating in the program is encouraging. In addition to an efficacy study, it should be examined in subsequent years how more males and individuals with a low subjective social status can be encouraged to initiate smoking cessation.

Vaping in Youth

This JAMA Insights reviews the health effects of vaping among youth in the US and current recommendations for screening and treatment.

E-cigarette exposure disrupts antitumor immunity and promotes metastasis

Electronic cigarettes (e-cigarettes) are thought to pose low risk of cancer because the components of e-cigarette liquid are not carcinogens. We analyzed the effects of the two major components, PG/VG and nicotine, on tumor development in preclinical models. We found that PG/VG promoted tumor cell migration in migration assays and contributed to more aggressive, metastatic, and immunosuppressive tumors in vivo, aggravated by the presence of nicotine. Whole body exposure of mice to PG/VG and nicotine rendered animals more susceptible to developing tumors with high frequencies of infiltrating proinflammatory macrophages expressing IL-6 and TNFα. Moreover, tumor-infiltrating and circulating T cells in e-cigarette exposed mice showed increased levels of immune checkpoints including CTLA4 and PD-1. Treatment with anti-CTLA4 antibody was able to abrogate metastasis with no detrimental effects on its ability to induce tumor regression in exposed mice. These findings suggest that the major components used in e-cigarette fluid can impact tumor development through induced immunosuppression.

The Untapped Biomarker Potential of MicroRNAs for Health Risk-Benefit Analysis of Vaping vs. Smoking

Despite the popularity of electronic cigarettes (e-cigs) among adolescent never-smokers and adult smokers seeking a less pernicious substitute for tobacco cigarettes, the long-term health impact of vaping is largely unknown. Like cigarette smoke, e-cig vapor contains harmful and potentially harmful compounds, although in fewer numbers and at substantially lower concentrations. Many of the same constituents of e-cig vapor and cigarette smoke induce epigenetic changes that can lead to the dysregulation of disease-related genes. MicroRNAs (MiRNAs) are key regulators of gene expression in health and disease states. Extensive research has shown that miRNAs play a prominent role in the regulation of genes involved in the pathogenesis of smoking-related diseases. However, the use of miRNAs for investigating the disease-causing potential of vaping has not been fully explored. This review article provides an overview of e-cigs as a highly consequential electronic nicotine delivery system, describes trends in e-cig use among adolescents and adults, and discusses the ongoing debate on the public health impact of vaping. Highlighting the significance of miRNAs in cell biology and disease, it summarizes the published and ongoing research on miRNAs in relation to gene regulation and disease pathogenesis in e-cig users and in vitro experimental settings. It identifies gaps in knowledge and priorities for future research while underscoring the need for empirical evidence that can inform the regulation of tobacco products to protect youth and promote public health.

Longitudinal associations between exclusive, dual and polytobacco use and respiratory illness among youth

BACKGROUND

The health consequences of polytobacco use are not well understood. We evaluated prospective associations between exclusive, dual, and polytobacco use and diagnosed bronchitis, pneumonia, or chronic cough among US youth.

METHODS

Data came from Waves 1-5 of the Population Assessment of Tobacco and Health Study. We categorized time-varying past 30-day tobacco use into seven categories: (1) non-current use; exclusive use of 2) cigarettes, 3) e-cigarettes, and 4) other combustible products (OC; pipes, hookah, and cigars); dual use of 5) e-cigarettes + cigarettes or e-cigarettes + OC, and 6) cigarettes + OC; and 7) polyuse of all three products. The outcome was parent-reported diagnosis of bronchitis, pneumonia, or chronic cough among youth. We conducted weighted multilevel Poisson models (person n = 17,517, 43,290 observations) to examine the longitudinal exposure-outcome relationship, adjusting for covariates: sex, age, race and ethnicity, parental education, body mass index, secondhand smoke exposure, and household use of combustible products.

RESULTS

Compared to nonuse, exclusive cigarette use (Risk Ratio (RR) = 1.83, 95% CI 1.25-2.68), exclusive e-cigarette use (RR = 1.53, 95% CI 1.08-2.15), combustible product + e-cigarette dual use (RR = 1.90, 95% CI 1.18-3.04), cigarettes + OC dual use (RR = 1.96, 95% CI 1.11-3.48), and polytobacco use (RR = 3.06 95% CI 1.67-5.63) were associated with a higher risk of bronchitis, pneumonia, or chronic cough. In additional analyses, we found that the risk ratio for polytobacco use was higher compared to exclusive e-cigarette use (RR 2.01 CI 95% 1.02-3.95), but not higher compared to exclusive cigarette use (RR 1.67 CI 95% 0.85-3.28).

CONCLUSION

We found that exclusive, dual, and poly tobacco use were all associated with higher risk of bronchitis, pneumonia, or chronic cough compared to non-current use.

Exploring the Utility of Long Non-Coding RNAs for Assessing the Health Consequences of Vaping

Electronic cigarette (e-cig) use, otherwise known as "vaping", is widespread among adolescent never-smokers and adult smokers seeking a less-harmful alternative to combustible tobacco products. To date, however, the long-term health consequences of vaping are largely unknown. Many toxicants and carcinogens present in e-cig vapor and tobacco smoke exert their biological effects through epigenetic changes that can cause dysregulation of disease-related genes. Long non-coding RNAs (lncRNAs) have emerged as prime regulators of gene expression in health and disease states. A large body of research has shown that lncRNAs regulate genes involved in the pathogenesis of smoking-associated diseases; however, the utility of lncRNAs for assessing the disease-causing potential of vaping remains to be fully determined. A limited but growing number of studies has shown that lncRNAs mediate dysregulation of disease-related genes in cells and tissues of vapers as well as cells treated in vitro with e-cig aerosol extract. This review article provides an overview of the evolution of e-cig technology, trends in use, and controversies on the safety, efficacy, and health risks or potential benefits of vaping relative to smoking. While highlighting the importance of lncRNAs in cell biology and disease, it summarizes the current and ongoing research on the modulatory effects of lncRNAs on gene regulation and disease pathogenesis in e-cig users and in vitro experimental settings. The gaps in knowledge are identified, priorities for future research are highlighted, and the importance of empirical data for tobacco products regulation and public health is underscored.

E-Cigarette-Associated Acute Severe Asthma in a Smoking-Naïve Adolescent: A Case Report

Electronic cigarettes (e-cigarettes) have become a prevalent phenomenon among adolescents and young adults, particularly as a perceived less harmful alternative to traditional tobacco cigarettes. A number of potential health risks associated with e-cigarettes have been identified, including links to cardiovascular diseases, asthma, and cancer. Given that adolescents have not yet completed their physical development, they are particularly susceptible to adverse health effects associated with e-cigarettes. This case report details the presentation of a healthy 16-year-old female patient who developed her first episode of acute severe asthma and a concomitant lower respiratory tract infection in a primary care practice setting. Prior to the onset of her symptoms, the smoking-naïve patient intermittently shared a nicotine-containing e-cigarette with a friend over a three-day period. Following outpatient treatment with inhaled corticosteroids, beta-2 agonists, and antibiotics, the asthma and lower respiratory tract infection were found to be reversible within the first week of treatment initiation. It is imperative that preventive measures at the political level be implemented to counteract the appeal and use of e-cigarettes among adolescents.

Current perspective on e-cigarette use and respiratory outcomes: mechanisms and messaging

INTRODUCTION

There has been an increasing amount of research on the consequences of e-cigarette use for respiratory outcomes, which is significant for public health and respiratory medicine. We discuss recent findings and lay out implications for prevention and treatment.

AREAS COVERED

Based on literature searches using several databases (PubMed, Web of Science, Google Scholar) for keywords, including synonyms, 'e-cigarettes,' with 'pulmonary function,' 'oxidative stress,' and 'inflammation,' we review studies on acute effects of e-cigarette use for measures of pulmonary function and discuss selected laboratory studies on mechanisms of effect, focusing on processes with known relation to respiratory disease; oxidative stress and inflammation. We discuss available studies that have tested the effectiveness of communication strategies for prevention of e-cigarette use oriented to different audiences, including nonsmoking adolescents and adult smokers.

EXPERT OPINION

We conclude that the evidence presents a mixed picture. Evidence is found for adverse consequences of e-cigarette use on measures of lung function and two disease-related biological processes, sometimes but not always less than for cigarette smoking. How to best communicate these results to a complex audience of users, from younger susceptible adolescents to long-term adult smokers interested in quitting, is a question of significant interest and empirically validated communication strategies are greatly needed.

The Tobacco Industry Has No Business Funding Continuing Medical Education

This Viewpoint explores tobacco industry–funded continuing medical education and concerns regarding the precedents this funding sets in relation to commercial bias and influence and conflicts of interest.

Birthdate-based commercial tobacco sales restrictions: will 'tobacco-free generation' policies advance or delay the endgame?

Endgame thinking means transitioning from merely trying to 'control' the tobacco epidemic to developing plans and measures to bring it to an end within a specific time, by changing the underlying dynamics that have created and perpetuated it for more than a century. Among the innovative policies characterised as 'endgame' policies are so-called 'tobacco-free generation' or 'smoke-free generation' policies, which prohibit sales of some or all tobacco products to individuals born on or after a particular date. Such birthdate-based sales restrictions (BSR) have intuitive appeal, largely because they do not appreciably disrupt the status quo of retail sales, which continue unchanged for all those born before the designated cut-off date. They also hold the potential for further denormalising tobacco use and sales by anticipating the long-term end of tobacco sales. In this Special Communication, we analyse BSR policies through an endgame lens and propose questions that should be discussed in jurisdictions considering them. We suggest that this policy has potential underexamined pitfalls, particularly related to equity, and that if enacted, it should include policy guardrails and be part of a package of endgame measures.

Understanding the Cardiovascular Fallout of E-cigarettes: A Comprehensive Review of the Literature

E-cigarettes (ECs) deliver chemicals, including nicotine. They can cause respiratory distress, addiction, cardiovascular effects, and death. More research is needed, especially regarding their impact on the cardiovascular system (CVS) and during pregnancy. Our article aims to fill this gap by summarizing studies elaborating upon the current impact of ECs and the components thereof on the CVS. Acute respiratory distress outbreaks, nicotine addiction, CVS effects, and deaths have been occasionally reported within this cohort, although these events are not uncommon with neighboring age groups. Randomized control trials implying ECs have some contribution toward quitting smoking have been studied. To regulate EC distribution, the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) have created key checkpoints. Additionally, taxation, pricing, age restriction, and media campaigns could be modulated to significantly reduce illicit sales. Education to the users, distributors, and regulators about this product can also play an aiding role in promoting responsible EC use. Another strategy about licensing could be employed, which could incentivize genuine resellers. The effects on CVS and child-bearing by ECs are grim, which calls for strict regulation, awareness, and avoidance by the teetotaler public. They may help individuals stop smoking but not without harming themselves. Strict regulations are necessary to prevent non-judicious use of these devices.

[Medical societies in Germany call for a ban on flavors in e-cigarettes - A Position Paper of the German Respiratory Society (DGP) in cooperation with other professional associations and organizations]

E-cigarettes are primarily used by teenagers and young adults. Flavors in e-cigarettes increase their attractiveness and encourage young people and adults to start using them. This exposes young people in particular to the risk of nicotine addiction and various toxic substances from the aerosol of e-cigarettes. There are indications that various flavors in e-cigarettes are harmful to health, although toxicological studies are still lacking for the majority of flavors. There is a need for independent scientific investigations in this area. The scientific societies involved are calling for a ban on flavors in e-cigarettes, a ban on disposable e-cigarettes, effective regulation of the sale of e-cigarettes and effective control and implementation of the provisions for the protection of minors.

Through the Looking Glass: Revisiting Smoking and Health

January 11, 2024, marked the 60th anniversary of the initial U.S. Surgeon General report "Smoking and Health," which definitively linked cigarette smoking and lung cancer.1 Similar to the old Virginia Slims slogan "you've come a long way, baby," smoking rates have diminished greatly since the release of that report.2 However, smoking still represents the leading cause of preventable deaths.3 Numerous countries have enacted policies aimed at decreasing conventional cigarette use, such as including warning labels on tobacco products, limiting advertising, and imposing bans on particular products. Such measures have contributed to significant reductions in cigarette use.