Cardiologists take note: Troubling e-cigarette trends warrant a new approach

“When you give this data to most doctors, they are shocked,” said Michael Blaha.

Two new studies providing insight into e-cigarette use among teens and young adults should serve as a reminder for doctors unaware of how much and how often these products are used. Additionally, this is a rapidly changing space that, unlike national patterns for other cardiovascular risk factors, requires regular re-intake.

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

Second, Blaha continued, “there is definitely a trend towards daily use, which suggests that these could be addictive in the same way as cigarettes.”

Current and frequent use

A study, published in Open JAMA Network, examined data from 2017, 2018, and 2020 from the Behavioral Risk Factor Surveillance System, a nationally representative survey of nearly one million American adults ages 18 and older. During this period, the prevalence of current e-cigarette use (past 30 days) increased from 4.4% in 2017 to 5.5% in 2018, and then dropped to 5.1% in 2020. But, worryingly, daily e-cigarette use increased from 1.5% in 2017 to 2.3% in 2020. Among adults aged 21-24, daily use was 6.6% , with heterogeneous use in US states.

In the second study of high school students, using data from the Youth Risk Behavior Surveillance System from 2015 to 2019 and published in Preventive Medicine Reports, the numbers are more shocking. Among the more than 41,000 students surveyed, current usage increased from 24.0% in 2015 to 32.7% in 2019. Even more troubling, frequent usage (10 or more uses in the past 30 days) among current users increased from 22.6% in 2015 to 45.4% in 2019.

There are important reasons to consider usage patterns in young adults separately from those in adolescents, Blaha pointed out. The social pressures are different, as are the reasons for choosing a vape in the first place. But what’s worrying, he says, is that some trends are consistent between high school students and young adults.

“What we’re seeing over time, as e-cigarette products have come out longer and longer, both in adults and in children, is that the proportion of users who are daily or frequent users is increasing. And I think that’s important because it suggests nicotine addiction. It suggests that more people are using it on a daily basis in their lives rather than occasionally.

Much is still unknown 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 their combustible smokes for e-cigarettes probably gain nothing in terms of reduced cardiovascular risk. There is also data to suggest that e-cigarette use among adolescents is strongly associated with future 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 of the Preventive Medicine Reports paper. Boakye was the lead author of the study in Open JAMA Network.

Safer, not sure?

Blaha predicts that these latest articles will draw the usual reprimands on social media from people who say they’ve successfully quit smoking by having e-cigarettes as an alternative, while others will speak out against the risks the devices pose.

Both, he says, can be true at the same time. “I think there are a lot of worrying trends in e-cigarette use, particularly the one around daily use and nicotine addiction, but it’s also true that the data largely confirms that these devices are less harmful than smoking, although more research is needed.

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

He mentions several other observations from the two surveys. Smoking among young people is at an “all-time low”, for example. Whether this will hold true if nicotine addiction is on the rise remains to be seen. There is a growing body of evidence, Blaha said, showing that vaping is a gateway to smoking among young people who did not smoke before trying the electronic alternative.

E-cigarette use was heterogeneous across US states in both surveys, but tended to follow a similar geographic pattern, Blaha noted. “A key point is that the correlates of e-cigarette use are roughly 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 respondents said they had “borrowed” or purchased vapes through older youth, suggesting an increase in efforts to circumvent age restrictions. There was also a slight increase in the proportion of young people who said they had tried to quit smoking.

Watch this place

It’s important to redo these types of surveys, both of which rely on pre-pandemic data, Blaha said. Not only have COVID-19 lockdowns and their mental health fallout had a profound impact on people’s behaviors, but many national surveys have also been changed or halted during strong surges. The regulatory world is also changing, with the FDA recently announcing plans to reduce nicotine levels in e-cigarette products.

As a result, these two articles, while provocative, are already outdated, Blaha said. And when it comes to e-cigarettes, doctors, researchers, and policymakers are faced with something very different from the traditional risk factors for which demographics are well known.

“We need to update these documents a lot because the frequency of, say, hypertension or hypercholesterolemia doesn’t change much from year to year, but [e-cigarette patterns] change so quickly. That is why doctors need to be somehow updated in this area.

If they’re not already doing so, he added, physicians need to stop asking their patients about “smoking” and instead ask specific questions about vaping in addition to traditional smoking habits.

“A simple ‘do you smoke or not’ doesn’t reflect the range of smoking habits that your patients have. And you just don’t know if you don’t ask.

About Margaret Shaw

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