Vaping does not lower CV risk for those who also smoke


Electronic cigarette use had a neutral effect on cardiovascular events when used alone, but dual use with traditional tobacco cigarettes was no less risky than just smoking, a study showed.

Exclusive use of e-cigarettes was equal to no use and a risk less than for the overall risk of developing cardiovascular disease (adjusted HR 1.00, 95% CI 0.69-1.45). pure smoking (aHR 0.66, 95% CI 0.46–0.94). Andrew C. Stokes, PhD, of the Boston University School of Public Health, and colleagues reported Traffic.

For major events, exclusive use of e-cigarettes showed a nonsignificant trend for a 35% greater risk than not smoking or vaping (aHR 1.35, 95% CI 0.75-2.42). And the combined risk of heart attack, heart failure, or stroke from using e-cigarettes alone was not significantly lower than from smoking alone.

Dual users had a significantly higher risk than non-users for both outcome groups: a 54% greater incidence of cardiovascular disease and a 2.08-fold greater risk of the serious events.

This risk from combined vaping and smoking was not different from exclusive smokers for either endpoint (aHR 1.01, 95% CI 0.81-1.26 and aHR 0.94, 95% CI 0.65-1.36, respectively) .

“Our results suggest that the combination of smoking and e-cigarette use does not lead to a reduction [cardiovascular disease] events and that discontinuation of both products is necessary to ensure risk mitigation,” concluded the Stokes group.

Less harm than combustible tobacco was a key reason for the FDA permit of certain electronic nicotine delivery systems (ENDs) beginning last year.

“The manufacturer’s data show that its tobacco-flavored products could benefit addicted adult smokers who switch to these products — either completely or with a significant reduction in cigarette consumption — by reducing their exposure to harmful chemicals,” said Mitch Zeller, JD, director of the FDA’s Center for Tobacco Products, in the FDA’s announcement of the first such ENDs to clarify the long-delayed regulatory process.

However, switching exclusively to e-cigarettes has proven unusual, noted David Balis, MD, who directs smoking cessation clinics at Parkland Hospital and UT Southwestern Simmons Cancer Center, both in Dallas.

“We need to know both the risks and the benefits of e-cigarettes. Do they help people quit smoking or not? I can’t say they do,” he said MedPage today. “Typically they do dual use… They just smoke e-cigarettes at work and continue their cigarettes at home.”

In fact, Stokes and colleagues’ study of data from the nationally representative PATH (Population Assessment of Tobacco and Health) cohort study found that only 822 were exclusive users of e-cigarettes compared to 6,515 who smoked only, and 1,858 dual users out of the 24,027 eligible adult respondents.

In the five annual waves of self-reporting from 2013 to 2019, 50% of respondents were under 35 and 51% were women. The study oversampled tobacco users, young adults, and African Americans.

While it was reassuring that dual use was no worse than smoking alone for cardiovascular outcomes in the study, the perception that e-cigarettes are safer has led to greater use, Balis said.

“Most people think they’re safer than traditional cigarettes, but they still have risks,” he added. “It’s going to take us a while to figure that out. It’s hard to find out. We will never have a large randomized, double-blind, placebo-controlled study to show risk and efficacy.”

The study did not include people under the age of 18, but the uptake of e-cigarettes by this group is an important area being addressed by the FDA and anti-smoking advocates.

“We fear that a generation of children will become addicted to nicotine and it will be a gateway drug,” Balis said. “It has to be in the equation somewhere.”

Other limitations of the study were the use of self-reported unassessed outcomes, a short follow-up period for the occurrence of cardiovascular events in the last 12 months in waves two through five, and the inclusion of former cigarette users in the non-user control group. In addition, there were a small number of events in the exclusive e-cigarette users group (n=41).

Balis noted that the number of participants lost and excluded from follow-up from the first to the second wave (n=5,873) was also a concern.

“Larger studies with more cardiovascular outcome events and longer follow-up are warranted,” Stokes’ group noted.


The research was supported by the National Heart, Lung, and Blood Institute and the FDA’s Center for Tobacco Products. This work was also supported by an award from the American Lung Association.

Stokes reported receiving grants from Johnson & Johnson.

Balis disclosed no relevant industry ties.


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