A More Balanced Public Health Approach Is Needed for E-Cigarette Use

Rutgers researchers are calling for a balanced approach to examining recent trends in adult e-cigarette use.

Julia Chen-Sankey, an assistant professor in the Department of Health Behavior, Society and Policy at the Rutgers School of Public Health, and Michelle T. Bover-Manderski, an instructor in the Department of Biostatistics and Epidemiology at Rutgers, said that while there are clear health concerns with e-cigarette use, particularly the adoption by those who previously hadn’t used tobacco products, there also are potential benefits that can’t be ignored.

The Rutgers researchers published an invited commentary in the Journal of the American Medical Association (JAMA) Network Open, reviewing new data on the trend of e-cigarette use among U.S. adults. Chen-Sankey and Bover-Manderski, who are also researchers at the Rutgers Center for Tobacco Studies, discussed the need for a public health approach that balances the risks with the potential of e-cigarettes to facilitate cessation of combustible cigarette smoking by adults. 

You reviewed a study that raised important questions about e-cigarette use among U.S. adults. What did that study find, and what questions has it raised about public health policy?

Chen-Sankey: The paper was on recent trends in adult e-cigarette use in the United States in 2017, 2018 and 2020. Among the findings was the observation that while current e-cigarette use – defined as vaping in the previous 30 days – by young adults ages 18 to 20 years declined between 2018 and 2020, it increased in other age groups. Daily e-cigarette use among current users also increased.

But perhaps most alarming, e-cigarette use increased significantly for people who never smoked combustible cigarettes. It also decreased among combustible cigarette smokers attempting to quit – despite the potential that e-cigarettes have in helping people to stop smoking.

Bover-Manderski: In terms of how these conflicting findings should be applied to health policy, there is a need to balance concerns about the dangers of e-cigarette use among young people new to tobacco products with the potential benefits that e-cigarettes may have for people who want to stop smoking combustible cigarettes.

How can we strike that balance?

Chen-Sankey: There are several policy advances and strategies that may be helpful in ensuring that the net public health benefit of e-cigarette use is not eclipsed by its harm. For instance, the recent authorization of e-cigarette products by the U.S. Food and Drug Administration (FDA) through its Premarket Tobacco Product Applications pathway may help to establish public trust in authorized e-cigarette products.

The FDA is also likely to authorize certain e-cigarettes as modified-risk tobacco products, which may help encourage smokers to see e-cigarettes as a tool to stop smoking combustible cigarettes.

Bover-Manderski: Additionally, to boost combustible cigarette smokers’ acceptance of using e-cigarettes for smoking cessation, public health education and mass media communication strategies should focus on evidence-based results pertaining to the reduced harm associated with switching to e-cigarettes.

Why do you think some adults who smoke combustible cigarettes have turned away from vaping as a means of quitting?

Chen-Sankey: Over the past five years or so, e-cigarette products have become less appealing to combustible smokers interested in quitting but more appealing to people who have never smoked. A few factors can help explain this discouraging pattern.

For one, local and national policies intended to reduce the use of e-cigarettes among youths may simultaneously reduce adult smokers’ interest in and use of e-cigarettes when attempting to quit. Additionally, the media may have altered smokers’ understanding of vaping because of the substantially higher volume of media coverage of vaping risks for youths compared with the potential benefits of vaping for adult combustible cigarette smokers.

Bover-Manderski: It’s also likely that public health groups and health care professionals may have emphasized the risks of vaping for youths over the potential benefits for adults who use combustible tobacco.

A bright spot in the research is a substantial decline in e-cigarette use by young adults ages 18 to 20. What accounts for this dip?

Chen-Sankey: The discrepancy may be associated with the Tobacco to 21 Act that restricted the sale of tobacco and nicotine delivery products, including e-cigarettes, to this age group nationwide starting in January 2020. Another potential explanation for the disproportional reduction is national restrictions on certain flavored cartridge-based e-cigarettes implemented in February 2020, a policy that may have considerably reduced the appeal of e-cigarettes among young people.

Bover-Manderski: And of course, we can’t overlook COVID-19 pandemic-related lockdowns and social-distancing requirements, which may have limited this group’s opportunities to use e-cigarettes in social or group settings.