By Sulamunn R. M. Coleman, PhD | The University of Vermont

In the United States, e-cigarettes and other electronic nicotine products have surged in popularity since they entered the marketplace in 2007. Although research demonstrates that e-cigarette vapor contains fewer harmful chemicals than cigarette smoke, little is known about the long-term cardiopulmonary effects of e-cigarette use (i.e., “vaping”).¹ In contrast, the dangers of cigarette smoking are indisputable, and smoking cessation is critical for anyone with (or at risk for developing) cardiovascular or pulmonary disease.

E-cigarettes are not FDA-approved smoking-cessation aids; however, many people who vape report doing so to help quit smoking. Unfortunately, vaping (particularly infrequent, non-daily vaping) may actually hinder smoking cessation efforts,^1,2 and there is growing concern that concurrent use of e-cigarettes and cigarettes – often referred to as “dual use” – could worsen tobacco-related health disparities.¹ These concerns have promoted interest in understanding patterns of dual-use behavior and developing new interventions to help address the phenomenon.

What the Research Says

In the United States, rates of dual use are still relatively low compared to rates of smoking cigarettes exclusively. However, dual-use rates vary across populations at greater risk for poor health outcomes (e.g., minoritized groups, patients with chronic medical conditions). As discussed in a recent literature review, dual use may be lower among the non-Hispanic Black population (4%) compared to other racial and ethnic groups (>8%), but higher among LGBTQ+ (4%) vs. non-LGBTQ+ adults (2%) and also higher among individuals with (5%) vs. without (1%) psychiatric symptoms.¹ These overall prevalence rates may seem low, but at least 1/4 people who are currently smoking also report using e-cigarettes.³ Because vaping continues to grow in popularity, regular monitoring of dual use in patient populations will be important for addressing related health disparities.

Research examining how e-cigarettes impact smoking cessation shows mixed results. In general, population-based studies do not endorse vaping to promote smoking cessation.^1,2 However, studies also indicate that most people who “dual use” prefer smoking to vaping,⁴ and greater preference for (i.e., dependence on) cigarettes vs. e-cigarettes may impede efforts to vape exclusively or quit tobacco altogether. Interestingly, randomized clinical trials show that when vaping is structured within the context of a conventional intervention like smoking cessation counseling, it may help people quit smoking.² Therefore, it’s possible that e-cigarettes could exacerbate tobacco-related health disparities in their current form (i.e., as consumer products), but they could also potentially help lessen disparities if eventually approved for use as a prescription therapy.

So, what can providers do in the meantime to help mitigate the potential impact of e-cigarettes on health disparities?

Practical Recommendations

• Ask about tobacco use, correct misperceptions. Regularly ask all patients about their tobacco use, particularly e-cigarettes. Misperceptions about e-cigarettes may come in different forms. Although e-cigarettes contain fewer toxicants than cigarettes, some users may wrongfully believe that e-cigarettes are more harmful than cigarettes.¹ It’s not uncommon to hear patients make statements like “I smoke about a pack a day, but at least I don’t use e-cigarettes.” For adults who already smoke cigarettes, the greatest risk of vaping may be its potential to prolong smoking. That said, it’s important to also clarify that that the long-term health effects of vaping are largely unknown, and e-cigarettes are not approved as smoking-cessation aids in the United States¹ The safest way to taper off nicotine is to use FDA-approved nicotine replacement therapy (NRT), such as patches or gum.
• Recommend abstinence, prescribe pharmacotherapy. Strongly urge patients who smoke to quit using tobacco in all forms and prescribe smoking-cessation pharmacotherapy to patients who are ready to quit. Varenicline, bupropion and NRT are safe and effective for patients with cardiovascular⁵ and pulmonary disease,⁶ and can be tailored to alleviate nicotine withdrawal symptoms (e.g., craving, irritability) and minimize side effects (e.g., skin irritation, unusual dreams).
• Enroll in counseling services. For patients with cardiopulmonary disease, smoking-cessation pharmacotherapy is most effective when coupled with counseling.^5,6 Patients ready to quit using tobacco can be automatically enrolled in State Quitline Services, most of which offer long-term counseling support, free NRT and other medications. Providers should try to follow up with patients regularly to encourage their use of Quitline Services.
• Educate patients who insist on using an e-cigarette. If someone is set on using an e-cigarette, they should be advised to quit smoking cigarettes entirely. To benefit an attempt to quit smoking, e-cigarettes should be used only to reduce nicotine craving/withdrawal (e.g., when one might ordinarily smoke cigarettes, such as during long car rides), and nicotine levels in e-cigarettes should be gradually tapered down to eventually stop using them entirely.⁷ After presenting patients with such information, there’s a good opportunity to point out that FDA-approved pharmacotherapy is a safer, simpler option.

Takeaway

E-cigarettes are becoming increasingly popular, especially among people who are trying to quit smoking cigarettes. E-cigarette use may prolong smoking, and the prevalence of dual use varies across vulnerable populations. To help reduce the potential for e-cigarettes to exacerbate tobacco-related health disparities, it will be critical to routinely ask all patients who are current or recent former smokers about their use of e-cigarettes and to extend effective tobacco cessation treatments whenever appropriate. Additionally, providers should stay current on what the research says about patterns of dual use across various populations, the health effects of e-cigarettes and the status of e-cigarette use for smoking-cessation in the United States.

REFERENCES

1. Coleman, S. R., Piper, M. E., Byron, M. J., & Bold, K. W. (2022). Dual use of combustible cigarettes and e-cigarettes: a narrative review of current evidence. Current Addiction Reports, 9(4), 353-362. https://link.springer.com/article/10.1007/s40429-022-00448-1

2. Wang, R. J., Bhadriraju, S., & Glantz, S. A. (2021). E-cigarette use and adult cigarette smoking cessation: a meta-analysis. American journal of public health, 111(2), 230-246. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2020.305999

3. Owusu, D., Huang, J., Weaver, S. R., Pechacek, T. F., Ashley, D. L., Nayak, P., & Eriksen, M. P. (2019). Patterns and trends of dual use of e-cigarettes and cigarettes among US adults, 2015–2018. Preventive medicine reports, 16, 101009.

4. Borland, R., Murray, K., Gravely, S., Fong, G. T., Thompson, M. E., McNeill, A., ... & Cummings, K. M. (2019). A new classification system for describing concurrent use of nicotine vaping products alongside cigarettes (so‐called ‘dual use’): findings from the ITC‐4 Country Smoking and Vaping wave 1 Survey. Addiction, 114, 24-34.

5. Barth, J., Jacob, T., Daha, I., & Critchley, J. A. (2015). Psychosocial interventions for smoking cessation in patients with coronary heart disease. Cochrane Database of Systematic Reviews, (7).

6. Coleman, S. R., Menson, K. E., Kaminsky, D. A., & Gaalema, D. E. (2023). Smoking Cessation Interventions for Patients With Chronic Obstructive Pulmonary Disease: A NARRATIVE REVIEW WITH IMPLICATIONS FOR PULMONARY REHABILITATION. Journal of Cardiopulmonary Rehabilitation and Prevention, 43(4), 259-269.

7. Martinez, U., Simmons, V. N., Sutton, S. K., Drobes, D. J., Meltzer, L. R., Brandon, K. O., ... & Brandon, T. H. (2021). Targeted smoking cessation for dual users of combustible and electronic cigarettes: a randomised controlled trial. The Lancet Public Health, 6(7), e500-e509.

Sulamunn (Sully) Coleman is a Research Assistant Professor with the Vermont Center on Behavior and Health at the University of Vermont. His research focuses on understanding tobacco use in medically vulnerable populations and developing interventions to help promote smoking cessation and improve tobacco-related health outcomes.