Abstract
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. To assess the associations of ENDS use with cigarette smoking relapse among adult former cigarette smokers. 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 (≥18 years) former cigarette smokers who reported no tobacco product use at wave 1 (unweighted n = 2273), separated into recent former cigarette smokers (last smoked ≤12 months previously) and long-term former smokers (last smoked >12 months previously). Data analysis was conducted from July to August 2019. 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. Self-reported current (every day or some days) use of cigarettes at follow-up interviews. 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). 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.
Highlights
Quitting cigarettes is a difficult process for most smokers, and relapse is common
Use of electronic nicotine delivery systems (ENDS) was associated with significant risk of cigarette smoking relapse among recent former smokers and among long-term former smokers (AHR, 3.79; 95% CI, 1.75-8.20; unweighted n = 1554)
Use of other tobacco products was 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)
Summary
Quitting cigarettes is a difficult process for most smokers, and relapse is common. Causes of relapse are multiple, and recent work suggests that use of e-cigarettes may be a risk factor for relapse to combustible cigarettes.[1,2,3] Whether relapse is caused by the effects of a nicotine priming dose or a larger process involving nicotine triggering of a greater response to environmental cues has not been fully established.[4]. That study reported that after quitting, the risk of relapse after more than 1 year decreased “hyperbolically as a function of time.”[5] It found that a younger age of cessation was associated with an increase in risk of relapse. Other characteristics that have been associated with relapse include having poor health, having lower socioeconomic status, having higher body mass index, being unmarried, having higher nicotine dependence, starting daily smoking at a younger age, having previous quit attempts, and having psychiatric symptoms present.[5] Herd et al[6] reported higher levels of relapse with lower abstinence self-efficacy (ie, belief in one’s own ability to abstain), higher frequency of smoking urges, and having a higher number of smokers among 5 closest friends
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