Abstract
Heated tobacco products (HTPs) are promoted as less harmful than combustible cigarettes but epidemiological evidence is scarce, especially in youth. To investigate the associations of persistent respiratory symptoms with HTP use, cigarette use, and dual use among Hong Kong youth. This was a territorywide cross-sectional school-based survey conducted from October 2018 to July 2019 using an anonymous questionnaire. Schools were randomly invited from a proportionate stratified sample in all 18 districts of Hong Kong. Poisson regression models using generalized estimating equations yielded adjusted prevalence ratios (APRs) of respiratory symptoms in (1) former and current HTP (vs never) users in the whole sample and stratified by cigarette use status and (2) exclusive HTP and dual users vs exclusive cigarette users. Statistical analysis was performed from October 2020 to March 2021. Former and current use of cigarettes, HTPs, e-cigarettes, and other tobacco products. Respiratory symptoms for 3 consecutive months in the past 12 months. The study included 33 627 students with a mean (SD) age of 14.8 (1.9) years; 51.3% (18 171) were boys. Respiratory symptoms were reported by 16.3% (n = 5549) of all students, 29.3% (n = 226) of current users of e-cigarettes, 31.2% (n = 314) of current users of cigarettes, and 33.5% (n = 179) of current users of HTPs. Respiratory symptoms were associated with former (APR, 1.30; 95% CI, 1.06-1.59) and current (APR, 1.59; 95% CI, 1.23-2.06) vs never HTP use and current vs never cigarette use (APR, 1.50; 95% CI, 1.30-1.74) after adjusting for various tobacco use. Associations between respiratory symptoms and current vs never HTP use were observed in never (APR, 1.88; 95% CI, 1.36-2.59) and former (APR, 2.15; 95% CI, 1.12-4.12) cigarette users, but not in current cigarette users (APR, 1.24; 95% CI, 0.97-1.59). Respiratory symptoms were associated with exclusive ever HTP use (APR, 1.46, 95% CI, 1.15-1.86) and ever dual use (APR, 1.29; 95% CI, 1.08-1.54) vs exclusive ever cigarette use. There was no association between exclusive current HTP (vs cigarette) use and respiratory symptoms (1.40; 95% CI, 0.93-2.11). This cross-sectional study found that former and current HTP use were associated with persistent respiratory symptoms among youth, especially among never and former cigarette users. Respiratory symptoms were more prevalent in ever exclusive HTP users and ever dual users than ever exclusive cigarette users. These findings suggest that using HTPs instead of cigarettes may not reduce health risks.
Highlights
Heated tobacco products (HTPs) heat processed tobacco to generate an aerosol for inhalation and have been marketed as less harmful than combustible cigarettes
Respiratory symptoms were associated with former (APR, 1.30; 95% CI, 1.06-1.59) and current (APR, 1.59; 95% CI, 1.23-2.06) vs never HTP use and current vs never cigarette use (APR, 1.50; 95% CI, 1.30-1.74) after adjusting for various tobacco use
This cross-sectional study found that former and current HTP use were associated with persistent respiratory symptoms among youth, especially among never and former cigarette users
Summary
Heated tobacco products (HTPs) heat processed tobacco to generate an aerosol for inhalation and have been marketed as less harmful than combustible cigarettes. Studies have shown that exposure to harmful and potentially harmful chemicals can be significantly reduced if smokers switch completely from combustible cigarettes to HTPs.[1] whether reduced exposure would result in reduced harms to human health has not been confirmed. The potential for harm reduction by instead using HTPs is controversial. Rats exposed to HTP aerosol had similar impairments of vascular endothelial function, and their serum nicotine levels (immediately after exposure) were 3.5-fold higher than those exposed to cigarette smoke (70.3 [SD, 26.3] ng/mL in the HTP group and 15.0 [SD, 7.7] ng/mL in the cigarette group).[7]
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