Questionable Effects of Electronic Cigarette Use on Cardiovascular Diseases From the National Health Interview Survey (NHIS, 2014-2021).

BACKGROUND: Electronic cigarettes (e-cigarettes) and cardiovascular health risks have gained attention among tobacco researchers. While the cardiovascular risks from e-cigarettes are still unclear, a recent paper by Alzahrani in Cureus claimed that current usage of e-cigarettes increases the risks of cardiovascular diseases, such as myocardial infarction and stroke, in subjects who were never cigarette smokers. METHODS: The National Health Interview Survey (NHIS) data from 2014 to 2021 and logistic regression models were used to replicate and extend Alzahrani's analysis. RESULTS: Only 12 never smokers who were current e-cigarette users had a myocardial infarction in all eight years. The crude odds ratio (OR) for e-cigarette use was 0.42 (95%CI: 0.24, 0.75). After adjusting for age and other confounding factors and health conditions, the OR of e-cigarette use increased to 2.48 (95%CI: 1.35, 4.55). The omission of age while adjusting for all other risk factors resulted in an OR of 0.80 (95%CI: 0.45, 1.43). In addition, the adjusted ORs for coronary heart disease and stroke were 1.12 (95%CI: 0.58, 2.17) and 1.13 (95%CI: 0.55, 2.29), respectively. CONCLUSIONS: The findings indicate that Alzahrani's study is scientifically unreliable. The association between e-cigarette use and heart attack reported by Alzahrani was substantially driven by age, and the very small number of exposed cases makes the association very unstable. Given the nature of cross-sectional NHIS data, it is impossible to establish a robust association or causal claim that e-cigarette use "increases" the risks of any disease.

Why can't smokers quit? Longitudinal study of smokers in the US using the Population Assessment of Tobacco and Health (PATH) waves 1 to 5.

Introduction: Most adult cigarette smokers have tried unsuccessfully to quit. We followed participants in the Population Assessment of Tobacco and Health (PATH) study through five waves (2013-2019), comparing smoking, quit behaviors and other characteristics between persistent smokers and those who became and stayed former smokers. Methods: The main analysis employed treatment effects to estimate mean differences in smoking and quitting behaviors among smoker groups. Logistic models were used to estimate predicted means based on continuing smokers' demographic characteristics to ensure that any differences in outcomes did not come from differences in demographic characteristics. Results: Among smokers enrolled in PATH Wave 1, 68 % persisted in all subsequent waves. Compared with smokers who quit after Wave 1, persistent smokers had remarkably stable smoking behaviors, including significantly higher proportions of everyday smokers, consuming 10+ cigarettes per day, and smoking within 30 min of waking up. Persistent smokers were also less likely to try to quit completely, and experienced more negative symptoms from nicotine withdrawal. They also showed less interest in quitting and were less confident of being successful than smokers who quit by the next wave. Neither electronic nicotine delivery systems nor menthol played a role in continued smoking or quitting. Conclusions: The characteristics and behaviors of persistent smokers in this study were stable over five waves of data collection during a six-year period, suggesting that these smokers need new cessation options.

Mortality among male cigar and cigarette smokers in the USA.

BACKGROUND: Cigars and cigarettes are both smoked, but much less is known about the former's long-term health effects, due to its low prevalence and infrequent collection of cigar information in national surveys. PURPOSE: We conducted a follow-up mortality study of cigar-smoking men age 40-79 years in National Health Interview Surveys (NHIS). METHODS: We used pooled NHIS files linked to the National Death Index to obtain follow-up from year of interview to year of death or December 31, 2015. We developed categories of cigarette and cigar smoking that accommodate dual and former use of both products. We used Cox proportional hazards models, adjusted for age, race/ethnicity, marital status, education, income and region to estimate hazard ratios (HRs, 95% confidence intervals, CI) for mortality from all causes, heart diseases, malignant neoplasms, cerebrovascular disease, chronic lower respiratory diseases and two mutually exclusive categories: smoking-related and other diseases. RESULTS: There were 14,657 deaths from all causes, including 3426 never tobacco users, 3276 exclusive cigarette smokers and 176 exclusive cigar users. The latter had no statistically significant evidence of increased mortality from all causes, heart diseases, malignant neoplasms, cerebrovascular disease, smoking-related diseases or other causes. In contrast, the mortality experience of dual users of cigars and cigarettes and cigar smokers who formerly used cigarettes is similar to exclusive cigarette smokers. CONCLUSIONS: This study provides evidence that male cigar smokers age 40 + years had elevated mortality risks. However, after accounting for cigarette smoking and other confounding variables, we found significantly increased mortality only among dual and former users of cigarettes.

Heterogeneity and other problems in a pooled analysis of snus use and mortality.

A recent analysis of Swedish snus use and mortality combined eight Swedish datasets and found that exclusive Swedish male snus users have statistically significant increased mortality from all causes, cardiovascular diseases and other causes. These findings, from the Swedish Collaboration on Health Effects of Snus Use, are in sharp contrast with previous pooled results from the same group. The discrepant results may be indicative of unresolved statistical problems that haven't been addressed by the collaboration authors in any of their studies. The most important problem is unresolved heterogeneity among the eight cohorts, which we describe in detail, and we show how the use of the random effects method by the authors was not sufficient. We explain why the tables in the article are uninformative, and we demonstrate why the exclusion of smokers in the analysis was not validated and eliminated important information. Finally, we strongly recommend some straightforward and easily implemented corrective measures.

Initial Information on a Novel Nicotine Product.

BACKGROUND AND OBJECTIVES: This is the first study to assess the appeal and interest among adults in a new consumer tobacco product, ZYN. We also describe ZYN users, patterns of use, and reasons for use. METHODS: Two data sets, consisting of a ZYN-naive consumer panel (n = 5179) and ZYN users (n = 1266), were provided by Swedish Match North America. Descriptive, cross-sectional analyses and logistic regression assessed the perceptions of and likelihood of buying ZYN in the consumer panel and the characteristics of ZYN users. RESULTS: The majority of current smokeless tobacco (ST) users in the consumer panel found that ZYN was moderately-extremely appealing, while never and former tobacco users indicated much less interest; the former were more likely to buy ZYN than other groups. The highest percentage of ZYN users were former tobacco users (43%); very few were never users (4%). The most popular reason for using ZYN was "Less harmful to my health than other tobacco products," followed by "ease of use." DISCUSSION AND CONCLUSIONS: Nonusers of tobacco had very little interest in ZYN. ST users are not only more interested and likely to buy ZYN than other tobacco users, they were the largest group of regular users. SCIENTIFIC SIGNIFICANCE: The first assessment of a new nicotine product, ZYN, suggests that current and former tobacco users may perceive ZYN as a reduced-risk product. ZYN potentially could be used as a smoking/tobacco-cessation aid based on reasons of current users. (Am J Addict 2020;00:00-00).

The composition of contemporary American and Swedish smokeless tobacco products.

The major components of 70 brands of smokeless tobacco products (STPs) from Sweden and the US were determined to provide greater understanding of the general chemical composition of these products. Various styles of STPs were examined: loose and portion snus from Sweden, and chewing tobacco, dry snuff, moist snuff, hard pellet, soft pellet and plug from the US. The components analysed were major STP components such as water, nicotine, sugars, humectants, sodium ions, chloride ions and ash. The relative quantities of the components varied significantly between different styles of STP. The major component of moist snuff and Swedish loose snus is water. With Swedish portion snus water and pouch material comprise more than half of the product mass; with chewing tobaccos water and sugars comprise around 60% of the products. With these STPs, tobacco was a minor component (30-35%) of the product mass. By way of contrast, tobacco comprised the majority (around 70-90%) of the product mass with dry snuff, hard pellet and soft pellet products. Additives such as sugars, propylene glycol, glycerol, and sodium chloride comprised up to around 12% of the STPs, except for plug and chewing tobaccos where sugars comprised 15-30% by mass of the STP on average. Significant disagreements were found amongst alternative methods of determining water/moisture content for STPs. In particular the oven method, commonly used to determine moisture in tobacco, gave significantly higher values than the Karl Fischer water method when propylene glycol was present. Smaller but similar differences were found using the Near-Infrared method. Choice of measurement technique has important consequences for accuracy of toxicant levels when reporting on a dry-weight basis, a commonly used parameter in smokeless tobacco research and emerging regulatory standards. Conversion to a DWB was also found to produce a preferential bias between and within different STP categories in favour of drier products. These data provide greater understanding of differences in the compositions of contemporary smokeless tobacco products, and demonstrate challenges associated with conversion of actual product contents to dry weight basis values.

Mortality among male smokers and smokeless tobacco users in the USA.

BACKGROUND: One published study simultaneously reported the mortality associated with cigarette smoking and smokeless tobacco (ST) use in the USA. In this study, we focus only on men ages 40-79 years old and extend the follow-up by 4 years. METHODS: We used selected years (1987-2010) of National Health Interview Survey (NHIS) Linked Mortality Files to classify 46,104 men age 40-79 years with respect to 7 categories of smoking and/or ST use. We used Cox proportional hazards models adjusted for age, race/ethnicity, marital status, education, income, health status, body mass index, and region to estimate hazard ratios (HRs; 95% confidence intervals, CI) for mortality from all causes, heart diseases, malignant neoplasms, and two mutually exclusive categories: smoking-related and other diseases. RESULTS: There were 15,540 deaths from all causes, including 3476 never tobacco users, 4782 exclusive smokers, and 210 exclusive ST users. The latter had significant excess mortality from all causes (HR = 1.25, CI = 1.08-1.46), but not from heart diseases (HR = 1.16, CI = 0.85-1.59), malignant neoplasms (HR = 1.17, CI = 0.83-1.67), and all smoking-related diseases (HR = 1.19, CI = 0.97-1.46). However, they had higher mortality for all other causes (1.39, CI = 1.10-1.74), which was largely seen in age 40-59 years (HR = 1.68, CI = 1.11-2.54). Current smokers, with or without ST use, also had significantly elevated HRs for other causes (1.70 and 1.57, respectively), in addition to significant increases in mortality from heart diseases (1.98 and 2.00), malignant neoplasms (2.60 and 2.84), and all smoking-related diseases (2.32 and 2.47). CONCLUSIONS: This is the first simultaneous mortality follow-up study of older American male smokers and ST users. ST users did not have excess mortality from any smoking-related diseases, but younger users had an elevation in deaths from other causes.

Analysis of coumarin and angelica lactones in smokeless tobacco products.

Differences in health risks between different styles of smokeless tobacco products (STPs) have prompted interest in their relative levels of toxic chemicals. We report here the development of methods for the analysis of STPs for coumarin and for α-angelica lactone (α-AL), both of which have been included in various published lists of tobacco toxicants. We have also determined the concentrations of these lactones in commercial STPs from the US and Sweden, representing 80-90% of the 2010 market share for all the major STP categories in these two countries: 65 products (plus two reference products) for coumarin and 66 commercial products for α-AL. For coumarin, methanol extracts of the STPs were analysed by HPLC/MS/MS. The lower limit of quantification (LOQ) and limit of detection (LOD) were, respectively, 100 and 30 ng coumarin/g of STP on a wet weight basis (WWB). Alpha-AL was determined via direct headspace GC/MS. The LOQ and LOD were 65 and 30 ng/g WWB respectively. Coumarin was detected In 3/33 Swedish snus, 5/13 US chewing tobaccos, 16/16 moist snuffs and 5/6 dry snuffs. Concentrations in those samples with quantifiable coumarin contents ranged from 186 to 1656 ng/g WWB. Concentrations of coumarin measured in this study were consistent with levels naturally found in tobacco. None of the STPs analysed would significantly contribute to coumarin exposure in consumers compared with dietary sources, and estimated exposure levels were 1000× lower than the European Food Safety Authority Tolerable Daily Intake. Hence the relevance of coumarin to the toxicity of STPs and its inclusion in the FDA's list of harmful and potentially harmful compounds list is questionable. Measurements of α-AL in these STPs found that the majority did not have quantifiable contents, however, for three STPs concentrations of α-AL were above the LOQ (116-140 ng/g WWB) and for four other STPs concentrations of α-AL could be estimated between the LOD and LOQ. Beta-angelica lactone was tentatively identified in three of the STPs but the levels could not be reliably quantified. The levels of α-AL in tobacco products are reported here for the first time, but the relevance of α-AL to the toxicity of STPs is also highly questionable given that it has GRAS status as a permitted food additive.

Metal emissions from e-cigarettes: a risk assessment analysis of a recently-published study.

Introduction: A recent study reported levels of metal emissions in e-cigarette (EC) aerosol. Herein we present a risk assessment analysis of the published findings using total daily exposure limits. Methods: Median and 75th percentile metal concentrations in EC aerosols were used to determine the level of daily liquid consumption (g/d) that would exceed the permissible daily exposures (PDEs) defined for inhalation medications (cadmium, chromium, copper, nickel, lead, antimony and tin). For metals not having PDEs, minimal risk levels (manganese) or risk exposure levels (aluminum, iron and zinc) were converted into total daily exposure using an inhalation volume of 20 m3 (for 24 h) and 6.7 m3 (for 8 h) respectively. Results: The lowest amount of liquid consumption exceeding safety limits was found for nickel (73 g/day for median and 17 g/day for 75th percentile levels). The consumption corresponding to the 75th percentile could be associated with realistic use, although this would represent an extreme rather than average consumption. For chromium, the respective levels were 358 and 68 g/day and for lead 338 and 135 g/day. For all other metals, liquid consumption would need to be orders of magnitude higher, reaching to 1.5 million grams for aluminum. Conclusion: EC emissions contain trace levels of metals. For almost all metals, unrealistically high levels of liquid need to be consumed in order for total daily exposure to exceed established limits.

E-cigarette Use Among US Adults: Population Assessment of Tobacco and Health (PATH) Study.

Introduction: In 2011 the US Food and Drug Administration launched the Population Assessment of Tobacco and Health (PATH) Study to gather information for regulatory activities authorized by the Family Smoking Prevention and Tobacco Control Act (TCA). Methods: Data were drawn from the first wave of the PATH survey, involving interviews of 32 320 civilian and non-institutionalized adults. In addition to conventional classifications for current, former and never smoking and e-cigarette use, we used PATH questions to classify former and current triers of these products. Descriptive statistics were used to describe the prevalence, patterns of, and reasons for e-cigarette use, and the perceptions of nicotine and e-cigarettes among user groups, according to smoking status. Results: The prevalence of current smoking was 18%; an additional 3.1% of participants were current triers. The prevalence of current e-cigarette use was 2.4% (1.0% every day, 1.4% some days), with another 3.2% as current triers. The majority of nonsmokers who were current e-cigarette users were already current (56%) or former (34%) cigarette triers. Reasons for e-cigarette use were similar across subgroups, but patterns of use were different. Majorities of participants believed that nicotine is the main substance driving tobacco use, that nicotine causes most cancers, and that e-cigarettes were less harmful than cigarettes. Conclusions: E-cigarettes were used primarily by current smokers and recent former smokers. The main reasons for use center around perceptions that e-cigarettes are less harmful than cigarettes to users and others. Implications: This study reports detailed information about the prevalence, patterns of, and reasons for e-cigarette use in the first (baseline) wave of the PATH Study in 2014. In addition to conventional categories for current, former and never smoking and e-cigarette use, the PATH questionnaire facilitated classification of new usage groups consisting of current and former triers of these products, which may impact prevalence estimates.

Quit Methods Used by American Smokers, 2013-2014.

This report describes the quit methods used in the past 12 months by current and former smokers in the baseline Population Assessment of Tobacco and Health (PATH) Study during 2013-2014. Descriptive statistics were used to report the use of single and two or more quit methods; survey weights were used to compute population estimates. Logistic regression was used to estimate the association between past year former smokers and single quit method, including individual characteristics. RESULTS: Of 11,402 current smokers and 4919 former smokers, 4541 had tried and 839 had quit in the past 12 months. Unaided quit attempts were the most common; the number was almost as high as all single methods combined (n = 1797 and n = 1831 respectively). The most frequently used single method was help from friends and family (n = 676) followed by e-cigarettes (n = 587). Use of e-cigarettes was the only method with higher odds of users being a former smoker than unaided attempts (OR = 1.42, 95% CI 1.12-1.81). Current use of e-cigarettes among current (34%) and former (54%) smokers was significantly higher than current use of nicotine replacement therapy (NRT). CONCLUSIONS: In 2013-2014 e-cigarettes were used by American adult smokers as quit-smoking aids more frequently than NRT products or prescription drugs.

The Effect of Smoking on Mental Health.

OBJECTIVES: The disproportionately high smoking prevalence among persons with mental health problems has raised a concern that this population is at increased risk for smoking-related illness. We investigated the effect of smoking on mental health among US adults aged 18 and older using the 2000-2010 Behavioral Risk Factor Surveillance System (BRFSS). METHODS: Whereas previous literature has reported a significant association between smoking and mental health, identifying the causal pathway is difficult. To address the plausible reverse causality from mental health to smoking and omitted unobserved factors, we employ the method of instrumental variables (IV) by using state cigarette excise tax as an instrument for smoking. RESULTS: Our findings show that smoking increases the number of days with poor mental health especially among individuals with more severe illness (more than 14 days in the past month). CONCLUSIONS: Our estimates suggest that smoking causes poor mental health and its effects are concentrated for measures that indicate more severe problems. Public health policies that aim to reduce smoking also may reduce poor mental health.