Cardiologists Take Note: Troubling e-Cigarette Trends Warrant New Tack

Two new studies providing a snapshot of e-cigarette use among teens and young adults should serve as a wake-up call to physicians unaware of just how widely and how often these products are being used. Also, this is a fast-moving space, which—unlike national patterns for other cardiovascular risk factors—requires regular fresh takes.

“I think that people from the cardiovascular community should follow this story more carefully,” senior author Michael Blaha, MD (Johns Hopkins School of Medicine, Baltimore, MD), told TCTMD. “When you give most physicians these data, they're shocked. Most of the time they don't even know that [e-cigarette use] is this common, so that's my point number one: we should be asking our patients about it, even if we can’t say exactly how harmful they are.”

Number two, Blaha continued, “there’s definitely a trend more towards daily use suggesting that these could be addictive in much the same way that cigarettes are.”

Current and Frequent Use

One study, published in JAMA Network Open, looked at 2017, 2018, and 2020 data from the Behavioral Risk Factor Surveillance System, a nationally representative state-based survey capturing nearly a million US adults 18 years and older. Over this period, the prevalence of current e-cigarette use (past 30 days) increased from 4.4% in 2017 to 5.5% in 2018, then dipped to 5.1% in 2020. But worryingly, daily e-cigarette use increased from 1.5% in 2017 to 2.3% in 2020. Among adults ages 21 to 24, daily use was 6.6%, with heterogeneous use across US states.

In the second study looking at high-school students, drawing on Youth Risk Behavior Surveillance System data from 2015 to 2019 and published in Preventive Medicine Reports, the numbers are more shocking. Among the more than 41,000 students surveyed, current use rose from 24.0% in 2015 to 32.7% in 2019. More troubling still, frequent use (10 or more uses in the last 30 days) among current users rose from 22.6% in 2015 to 45.4% in 2019.

There are important reasons for considering usage patterns in young adults separately from those in teens, Blaha stressed. Social pressures are different, as are reasons for picking up a vape in the first place. But what’s worrisome, he said, is that some patterns are consistent between both the high-school students and young adults.

“What we're seeing over time, as electronic cigarette products have been out for longer and longer, both in adults and in kids, is that the proportion of users that are daily or frequent users is going up. And I think this is important because it's suggesting nicotine addiction. It's suggesting more people are using this as a daily part of their lives rather than just the occasional use.”

So much is unknown, still, about the effects of vaping and e-cigarette nicotine on the cardiopulmonary system. While advocates argue that electronic devices are likely a safer alternative to smoking, recent observational research suggests that people who swap out their combustible smokes for e-cigarettes are not likely gaining anything in terms of a reduction in cardiovascular risks. There are also data suggesting that e-cigarette use in adolescents is strongly associated with future cigarette smoking. 

Ellen Boakye, MD, MPH (Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD), and Mohammadhassan Mirbolouk, MD (Yale School of Medicine, New Haven, CT), were co-first authors on the Preventive Medicine Reports paper. Boakye was the lead author on the study in JAMA Network Open.

Safer, Not Safe?

Blaha predicts these latest papers will draw out the usual rebukes on social media from people who say they’ve managed to wean themselves off cigarettes by having e-cigarettes as an alternative, while others will decry the risks the devices pose.

Both, he says, can be true at the same time. “I think there are a lot of concerning trends in the use of e-cigarettes, particularly this one about daily use and nicotine addiction, yet it is also true that the data largely bears out that these devices are less harmful than smoking, although more research is needed.”

But what’s also true is that using e-cigarettes is more harmful than not using. “The FDA has used the phrase in their public health messaging—safer, not safe—to try to make that point,” said Blaha. “So it can be true that e-cigarettes are less harmful than smoking yet they can still be very harmful.”

He points to several other observations from the two surveys. Youth cigarette smoking is at an “all-time low,” for example. Whether that will remain true if nicotine addiction is on the rise remains to be seen. There is a growing body of evidence, said Blaha, showing that vaping is a gateway to cigarette smoking among youth who didn’t smoke prior to trying the electronic alternative.

Use of e-cigarettes was heterogeneous across US states in both surveys, but tended to follow a similar geographic pattern, Blaha noted. “One key point is that the correlates of e-cigarette use are much the same correlates as those of smoking.” This includes things like alcohol or illicit drug use, depression, and other cardiovascular risk factors.

Among teens, a growing proportion of those surveyed said they “borrowed” or purchased vapes through older youth, suggesting an increase in efforts to evade age-related restrictions. There also was an uptick in the proportion of young people who said they’ve tried to quit.

Watch this Space

It’s important to redo these types of surveys, both of which drew on prepandemic data, Blaha said. Not only did COVID-19 lockdowns and their mental health fallouts have a profound impact on people’s behaviors, but also many national surveys were altered or paused during major surges. The regulatory world is also changing, with the FDA recently announcing plans to slash nicotine levels in e-cigarette products.

As a result, these two papers, while provocative, are already out of date, Blaha said. And when it comes to e-cigarettes, physicians, researchers, and policy makers are dealing with something very different from traditional risk factors for which the demographics are well known.

“We have to update these papers a lot because the frequency of, let's say, hypertension or high cholesterol doesn't change that much from year to year, but [e-cigarette patterns] are changing so rapidly. That's why physicians need to be sort of updated on this field.”

If they are not already doing so, he added, doctors need to stop asking their patients about “smoking” and instead ask specifically about vaping in addition to traditional smoking habits.

“Just a simple ‘do you smoke or not’ is not capturing the array of tobacco-use habits that are out there, that your patients are doing. And you just don't know if you don't ask.”