Tobacco Research

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Study Links E-Cigarette Use with Higher Risk of Heart Failure

According to the findings of a large study presented at the American College of Cardiology’s Annual Scientific Session1, people who use e-cigarettes are 19% more likely to develop heart failure compared with those who have never used them. Breaking the data down by type of heart failure, risk increase was significant for heart muscle becoming stiff and failing to properly fill with blood between contractions.

For the study, the researchers used data from a large national study of US adults to analyze associations between e-cigarette use and new diagnoses of heart failure in 175,667 study participants (an average age of 52 years and 60.5% female). Of this sample, 3,242 participants developed heart failure within a median follow-up time of 45 months. While calculating the heart failure risk increase, researchers accounted for a variety of demographic factors (age, sex), socioeconomic factors, other heart disease risk factors and participants’ substance use history (alcohol and tobacco products).

The findings are claimed to be in line with previous studies conducted in animals (i.e. e-cigarette use affecting the heart in ways that are relevant to the heart changes involved in heart failure). Other human studies to date have also shown links between e-cigarette use and some risk factors associated with developing heart failure – however, coming short of establishing a direct connection between e-cigarette use and heart failure (allegedly, due to the study design and sample size limitations).

Trends in Harm Perceptions of E-Cigarettes

University College London researchers examined how the harm perceptions of e-cigarettes (compared with cigarettes) have evolved since 2014 among the adult smokers in England2. They found that harm perceptions of e-cigarettes have worsened substantially over the last decade: the proportion of adult smokers, who believed e-cigarettes were less harmful than cigarettes, declined from 44.4% in Q4 2014 to 26.7% in Q2 2023. In the same period, the proportion, who thought e-cigarettes were more harmful, doubled to 23.3% (- the weight of “equally harmful” also increased slightly to 33.7%). Thereby, majority of the adult smokers (57%) in England now believe that e-cigarettes are equally or more harmful than cigarettes.

The evolution of perception over time was nonlinear. The timing of the two most notable changes in harm perceptions coincided with the EVALI outbreak in 2019 (short-lived, returning to pre-2019 levels by the end of 2020) and the recent increase in youth vaping in England since 2021.

Researchers observe that public health statements and media reports have often overstated the potential risks of e-cigarettes – resulting in substantial misperceptions about the harms of vaping (compared with smoking). They underscore the need to clearly communicate the risks so that adult smokers can make informed choices about the nicotine products.

In the UK, National Health Service (NHS) lists e-cigarettes as a “Stop Smoking Treatment”. To read more: Smoking Cessation Products

Online shopping for tobacco products following the flavored tobacco ban in California

UC San Diego researchers examined whether the exclusion of e-commerce in the definition of “tobacco retailer” might have resulted in a shift in consumer behavior towards e-commerce following California’s implementation of a statewide flavor restriction3. They identified that shopping queries were 194% and 162% higher than expected for cigarettes and vapes, respectively, on the week of implementation. Queries remained significantly elevated for 6 and 11 weeks for vapes and cigarettes, receptively. All search results contained links to websites that offered flavored vaping products and/or menthol cigarettes to Californian consumers.

Researchers note that

– California’s flavor restriction is enforced through its tobacco retailer licensing programs which can be an effective method of enforcing tobacco control laws (but, most programs do not require e-commerce retailers to obtain licenses)

– their findings raise concerns about potential loopholes in policy enforcement created by the absence of explicit regulations on e-commerce sales in retailer licensing programs

– strengthening regulations to include e-commerce and monitoring e-commerce compliance may enhance the impact of laws enforced through retailer licensing programs.

New “Non-menthol” cigarettes

Following California’s December 2022 menthol ban, RJ Reynolds (BAT) and ITG (Imperial Brands) introduced non-menthol cigarettes offering “a new fresh twist” and “a taste that satisfies the senses”. The records of ingredients show that the Camel Crisp and the Newport EXP contain a synthetic cooling agent called WS-3. In a recent study4, Duke University researchers found that the added amounts of synthetic cooling agent robustly activate the cold/menthol receptor and are sufficient to produce robust cooling sensations (- in some cases, even more than the menthol cigarettes).

WS-3, or N-ethyl-p-menthane-3-carboxamide, is one of the most used cooling agents in the food and beverage industry. Unlike menthol, WS-3 is virtually nonvolatile, odorless and tasteless – thereby, providing a cooling sensation without affecting the taste or aroma of the final product. It’s known for its clean, immediate cooling impact and has been found to cool primarily the roof of the mouth, the back of the mouth and the back of the tongue.

WS-3 is commonly used in gums/candies/mints, carbonated & alcoholic beverages, toothpastes and mouthwashes. WS-3 is considered safe for consumption by the US Food and Drug Administration (FDA) and the European Food Safety Authority (EFSA). However, its safety for inhalation is unknown.

In an earlier study5, Yale University researchers found that the European version of JUUL Mint pods contained WS-3 (- presumably, to keep the cooling effect and lose the distinct minty odor of menthol). The substance was absent in the US/Canadian JUUL Mint pods.


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  2. Trends in Harm Perceptions of E-Cigarettes vs Cigarettes Among Adults Who Smoke in England, 2014-2023 | Public Health | JAMA Network Open | JAMA Network ↩︎
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