Association of Electronic Nicotine Delivery System Use With Cigarette Smoking Relapse Among Former Smokers in the United States

Abstract

IMPORTANCE Relapse to smoking among former smokers is a serious clinical concern, and use of electronic nicotine delivery systems (ENDS) has been proposed as a new risk factor for relapse. Understanding the specificity of this risk can help guide clinical practice and lead to improved health outcomes. OBJECTIVE To assess the associations of ENDS use with cigarette smoking relapse among adult former cigarette smokers. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined data from the Population Assessment of Tobacco and Health Study, waves 1 to 4 (2013-2018). Cox proportional hazards models were developed. This is an ongoing, nationally representative, longitudinal cohort study in the US. Participants included adult (Ն18 years) former cigarette smokers who reported no tobacco product use at wave 1 (unweighted n = 2273), separated into recent former cigarette smokers (last smoked Յ12 months previously) and long-term former smokers (last smoked >12 months previously). Data analysis was conducted from July to August 2019. EXPOSURES Self-reported use of cigarettes, ENDS, and other tobacco products (ie, cigars, pipe tobacco, hookah, snus tobacco, other smokeless tobacco, and dissolvable tobacco) was assessed. MAIN OUTCOMES AND MEASURES Self-reported current (every day or some days) use of cigarettes at follow-up interviews. RESULTS Of 2273 adult former cigarette smokers, 51.8% (95% CI, 49.7%-53.8%) were women, 65.0% (95% CI, 62.6%-67.4%) were older than 50 years, and 79.5% (95% CI, 77.8%-81.2%) were non-Hispanic white participants. Use of ENDS was associated with significant risk of cigarette smoking relapse among recent former smokers (adjusted hazard ratio [AHR], 1.63; 95% CI, 1.04-2.53; unweighted n = 304) and among long-term former smokers (AHR, 3.79; 95% CI, 1.75-8.20; unweighted n = 1554). Use of other tobacco products was also associated with significant risk for cigarette smoking relapse among recent former smokers (AHR, 1.97; 95% CI, 1.27-3.05) and among long-term former smokers (AHR, 3.82; 95% CI, 1.91-7.66). CONCLUSIONS AND RELEVANCE In this study, use of ENDS and other tobacco products was associated with increased risk of cigarette smoking relapse among former cigarette smokers who did not use any tobacco product at wave 1 of the PATH Study. For clinicians treating former smokers who have successfully quit all nicotine products, the implications are that use of ENDS products should be discouraged, just as use of all other tobacco products is discouraged.

Risk of smoking relapse with the use of electronic cigarettes: A systematic review with meta-analysis of longitudinal studies

“…All studies estimated the risk of relapse adjusted for covariates, including age, gender, income, and educational level. Brose et al 22 included further information on nicotine replacement therapy and cessation duration among former smokers, while Everard et al 18 and Gomajee et al 16 included the greatest number of covariables in the model.…”

“…According to the risk of bias assessment, two studies were classified as low risk 16 , 19 , two moderate 18 , 22 and two high risk 20 , 21 . The risk of bias was mainly affected in domains related to the adjustment of confounding variables, and the loss of follow-up or failure to consider it in the analysis.…”

“…Regarding population, studies that have used data from the PATH study defined former smokers as individuals who reported consuming ≥100 combustible cigarettes in their lifetime, and no use at baseline 19 , 21 or at least five years before the baseline 20 . Everard et al 18 further excluded individuals who consumed other tobacco products at baseline, including cessation therapy with e-cigarettes. Dai et al 19 and Everard et al 18 classified the participants as ‘recent former smokers’ (smoking cessation in the last 12 months) or ‘long-term former smokers’ (smoking cessation for more than 12 months).…”

“…Everard et al 18 further excluded individuals who consumed other tobacco products at baseline, including cessation therapy with e-cigarettes. Dai et al 19 and Everard et al 18 classified the participants as ‘recent former smokers’ (smoking cessation in the last 12 months) or ‘long-term former smokers’ (smoking cessation for more than 12 months). Brose et al 22 defined former smokers as individuals who stopped smoking for at least two months at baseline, while Gomajee et al 16 as those who reported smoking cessation since 2010 (within five years from the study baseline).…”

The Effect of Graphic Health Warning Labels Placed on the ENDS Device on Young Adult Users’ Experience, Exposure and Intention to Use: A Pilot Study

“…Moreover, there is limited evidence about ENDS effectiveness as a cessation or harm reduction tool for adults (e.g., Hajek et al, 2019), especially in real-world settings. Real-world perspective studies with nationwide samples in the US (e.g., the Population Assessment of Tobacco and Health, PATH) have shown that dual-use remains the most common trajectory of ENDS use in the society (Watkins et al, 2018) and that former cigarette smokers using ENDS are more likely to relapse to cigarette smoking compared to those who did not use ENDS (Dai & Leventhal, 2019b;Everard et al, 2020). Therefore, until additional policies that can tailor ENDS products for smoking cessation are available, the combination of a highly addictive ENDS that is marketed and popular among youth is not in the best interest of public health.…”