A danger underestimated: Nicotine products consumption and the lungs

An increasing variety of nicotine-containing products is available. The consumption of e-cigarettes, traditional cigarettes, and also cannabis, could be more harmful than smoking alone.

A steep rise in consumer spending observed

An increasing variety of nicotine-containing products is available. The consumption of e-cigarettes, traditional cigarettes, and also cannabis, could be more harmful than smoking alone.1

Prof. Charlotta Pisinger (University of Copenhagen & Danish Heart Foundation) pointed out that a new generation of products, including e-cigarettes, smokeless tobacco, nasal snuff, snus, and oral nicotine products or nicotine pouches, are all non-flammable but highly addictive due to their nicotine content. With these products, the tobacco industry is trying to rehabilitate its reputation by claiming that they are products with a reduced health risk factor. The tobacco industry had to adapt to marketing restrictions and health warnings for conventional tobacco products. "With these novel products, they were mostly able to circumvent means of tobacco legislation such as a tobacco ban", said Prof. Pisinger. Moreover, the tax rates are considerably lower than for ordinary cigarettes, which means higher profits for the companies. The large increase in the number of consumers of new generation products is mainly driven by young non-smokers, Prof. Pisinger said.

Multiple types of consumption, especially by young men

Another trend indicates that there is a rapidly growing number of consumers who use more than one device. "This increase in multiple-use is a dream scenario for the tobacco industry," said Prof. Pisinger. This increasing rate of dual, triple, and multiple-use could be observed among young people all over the world. A large Canadian cohort study with about 40,000 high school students showed a steep increase in multiple-use (i.e. smoking, vaping, marijuana/cannabis) between 2013/14 and 2017/18, especially among young men.

Respiratory symptoms from e-cigarettes 

A number of studies have looked at the dual use of e-cigarettes and regular cigarettes. Cross-sectional studies in the population showed that the prevalence of respiratory symptoms was highest among current smokers who also consumed e-cigarettes2. Dual-use was also associated with poorer breathing. Longitudinal cohort studies documented that the toxicity burden was highest among dual users. In addition, according to a Korean study, dual users had an almost threefold higher relative risk of developing metabolic syndrome compared to non-smokers. They also had higher urinary cotinine levels and a higher nicotine dependence than cigarette smokers alone3. "In addition, studies have shown that poly-tobacco consumers have almost certainly also consumed marijuana," said Prof. Pisinger. Although it is methodologically difficult to assess the effects of cannabis smoking compared to tobacco smoking, there is evidence that cannabis smoking may be even more harmful to the lungs than smoking. "Taken together, we have a very good reason to be concerned about this new type of multiple-use," concluded Prof. Pisinger.

1. Pisinger C. Oral presentation "Now it is not only about cigarettes: dual, triple, poly use of nicotine and cannabis products. What to expect (focus on lung health)". ERS International Virtual Congress 2020, 7-9 Sept.
2. Hedmann L, et al JAMA Netw Open 2018:1:e180789.
3. Kim CY, et al. Sci Rep 2020;10:5612.

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