Abstract
Generating robust and timely evidence about the respiratory health risks of electronic cigarettes (e-cigarettes) is critical for informing state and federal regulatory standards for product safety. To examine the association of e-cigarette use with incident respiratory conditions, including chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, and asthma. This prospective cohort study used data from the nationally representative cohort of US adults from the Population Assessment of Tobacco and Health (PATH) study, including wave 1 from 2013 to 2014, wave 2 from 2014 to 2015, wave 3 from 2015 to 2016, and wave 4 from 2016 to 2018. Individuals aged 18 years and older at baseline with no prevalent respiratory conditions were included in the analyses. Analyses were conducted from February to July 2020. e-Cigarette use was assessed by self-reported current use status (never, former, or current) at baseline. Incident respiratory conditions, including COPD, emphysema, chronic bronchitis, and asthma, as well as a composite respiratory disease encompassing all 4 conditions. Among 21 618 respondents included in the analyses, 11 017 (491%) were men and 12 969 (65.2%) were non-Hispanic White. A total of 14 213 respondents were never e-cigarette users, 5076 respondents (11.6%) were former e-cigarette users, and 2329 respondents (5.2%) were current e-cigarette users. Adjusted for cigarette and other combustible tobacco product use, demographic characteristics, and chronic health conditions, there was an increased risk of respiratory disease among former e-cigarette uses (incidence rate ratio [IRR], 1.28; 95% CI, 1.09-1.50) and current e-cigarette users (IRR, 1.31; 95% CI, 1.08-1.59). Among respondents with good self-rated health, the IRR for former e-cigarette users was 1.21 (95%CI, 1.00-1.46) and the IRR for current e-cigarette users was 1.43 (95% CI, 1.14-1.79). For specific respiratory diseases among current e-cigarette users, the IRR was 1.33 (95% CI, 1.06-1.67) for chronic bronchitis, 1.69 (95% CI, 1.15-2.49) for emphysema, 1.57 (95% CI, 1.15-2.13) for COPD, and 1.31 (95% CI, 1.01-1.71) for asthma. This cohort study found that e-cigarette use was associated with an increased risk of developing respiratory disease independent of cigarette smoking. These findings add important evidence on the risk profile of novel tobacco products.
Highlights
Adjusted for cigarette and other combustible tobacco product use, demographic characteristics, and chronic health conditions, there was an increased risk of respiratory disease among former e-cigarette uses and current e-cigarette users (IRR, 1.31; 95% CI, 1.08-1.59)
For specific respiratory diseases among current e-cigarette users, the incident rate ratios (IRRs) was 1.33 for chronic bronchitis, 1.69 for emphysema, 1.57 for chronic obstructive pulmonary disease (COPD), and 1.31 for asthma
This cohort study found that e-cigarette use was associated with an increased risk of developing respiratory disease independent of cigarette smoking
Summary
The use of electronic cigarettes (e-cigarettes) has increased dramatically since their introduction to the US market in 2007.1-3 While a 2018 National Academies of Sciences, Engineering, and Medicine report[4] found substantial evidence that exposure to toxic substances from e-cigarettes is significantly lower compared with combustible cigarettes, recent studies and case reports suggest that e-cigarettes may present their own unique health risks, including to the respiratory system.[5,6,7,8] e-Cigarettes are known to contain harmful or potentially harmful constituents, including volatile organic compounds, heavy metals, and ultrafine particles.[9,10,11,12] e-Cigarette use has been associated with increased airway resistance, impairment of the immune system, and increased cytotoxic effects in the lungs.[13,14,15]Small short-term studies conducted in vitro, in vivo, and in clinical settings have documented acute adverse pulmonary effects on organ and cellular health with e-cigarette use[13,16,17,18,19,20,21,22,23,24,25,26]; e-cigarette use has been associated with the outbreak of e-cigarette or vaping product use–associated lung injury in the US.[8,27,28] Despite existing evidence, the long-term effects of e-cigarette use on clinical respiratory end points remain unclear. A handful of cross-sectional studies have reported that e-cigarette use was associated with respiratory symptoms (eg, wheezing and related respiratory symptoms) and clinical outcomes. Including asthma and chronic obstructive pulmonary disease (COPD),[29,30,31,32,33] the causality of the association could not be established given the cross-sectional design. A 2019 longitudinal study by Bhatta and Glantz[34] using Population Assessment of Tobacco and Health (PATH) study waves 1 through 3 found an association of e-cigarette use with a composite respiratory disease outcome. The study included only crude adjustment for cigarette smoking history and did not examine the sensitivity of findings to potential reverse causal biases associated with preclinical disease
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