The National Center on Addiction and Substance Abuse released a comprehensive report on March 8 examining the prevalence and patterns of non-cigarette nicotine product use, including risk factors, consequences of use, and the current regulatory landscape. The report contains strategies for limiting non-cigarette nicotine product use and recommendations to health care professionals and policymakers for protecting public health.
The study is the first to analyze the use of all non-cigarette nicotine products, including e-cigarettes, vaping instruments, hookah, pipes, smokeless tobacco and cigars. It also explored the risk of addiction associated with each product.
“We wanted to offer a more objective and balanced examination of the issues and clarify some of the long-standing misconceptions about e-cigarettes, other vaping devices, cigars, hookah, pipes and smokeless tobacco products,” lead author Dr. Linda Richter told DrugRehab.com.
Richter, director of policy research and analysis at the National Center on Addiction and Substance Abuse, says the media conveys mixed messages about the effects of non-cigarette nicotine products on the public.
To help the public better understand these effects, Richter and her team evaluated all established research findings related to the topic, including statistics from the Centers for Disease Control and Prevention for nicotine product use among teens and adults.
The CASA report identified the most popular nicotine products among adults and teens.
Cigarettes remain the most commonly used nicotine products among adults, followed by cigars and e-cigarettes. Conversely, e-cigarettes were the most popular nicotine products among adolescents, followed by hookahs and then cigarettes.
The study also indicated that more adults than teens currently use non-cigarette nicotine products. National data from 2013 and 2014 show that about 16.3 percent of adults and 14.7 percent of middle and high school students reported using one of these products in the past month.
More than 5 percent of middle school students and 16 percent of high school students reported using e-cigarettes in the past 30 days in 2015, according to the report. However, the combined percentage of 8th-, 10th- and 12th-graders who reported past-month use of these products fell almost 3 percent from 2015 to 2016.
The study also referred to 2014 data showing that 22 percent of people aged 18 to 24 reported having tried an e-cigarette during their lifetime, and 13.6 percent of these individuals reported current use of these products.
Other key findings from the CASA study include:
The CASA study comes three months after the U.S. Surgeon General Dr. Vivek Murthy released a report describing the patterns of e-cigarette use among adolescents and young adults.
Non-cigarette nicotine use has become more popular in recent years among middle and high school students. But these products still carry risks.
“Many of the other ingredients in vaping devices, hookah, cigars, pipes, and smokeless tobacco are carcinogenic, increase the risk of cardiovascular problems and have other toxic components that can compromise health,” said Richter.
Cigars contain nicotine, tar and other toxic chemicals, according to the study. Smoking this product can increase the risk of lung problems, aortic aneurysm, coronary heart disease, cerebrovascular disease and various types of cancers.
Hookahs are devices used to smoke tobacco, nicotine and tobacco-free products. While many believe hookah use is harmless, the activity can lead to lung and gastric cancer, emphysema, respiratory disease and pregnancy problems.
Researchers also suggested that smokeless tobacco, such as snuff or dip, has been linked to several types of cancers, though evidence supporting this theory is limited.
The health consequences of e-cigarette use include respiratory distress, increased heart rate and cell damage that can result in oral disease. The study also referred to a report that found that teens who used these products over a 12-month period were more likely than their peers who did not use e-cigarettes to experience symptoms of depression.
No current national studies show that non-cigarette nicotine product use causes people to use drugs or alcohol. However, Richter says, past research suggests nicotine users are at an increased risk of using or becoming addicted to these substances.
“In other words, they generally are more likely than those who do not use nicotine to report using alcohol or other drugs and [to experience] symptoms consistent with alcohol or other drug addictions,” said Richter.
CDC data used in the study showed that an estimated 15 percent of adults who reported past-month use of a nicotine product from 2013 to 2014 met the criteria for nicotine addiction. During that time, more than 13 percent of adults who reported current use of a non-cigarette nicotine product met this standard.
CASA researchers defined nicotine addiction as reporting daily use of any nicotine product, typically using the product within 30 minutes of waking, and enduring an unsuccessful cessation attempt in the past year.
The addiction potential of non-cigarette nicotine products is difficult to ascertain. Richter noted that the nicotine content in these products varies and the absorption rate of nicotine is contingent on numerous factors.
For example, the amount of nicotine absorbed by cigar smokers depends on whether the smoke is inhaled, how deeply it is inhaled and how many puffs are taken during use. Richter said the risk of addiction also depends on frequency of use.
Meanwhile, nicotine exposure through hookah use varies by the device’s design, the type of tobacco used, the temperature of the burn, the means of inhalation, the number of puffs taken and the session’s duration.
“Some studies show that the nicotine absorbed by daily water pipe or hookah use can be equivalent to that of smoking about 10 cigarettes,” said Richter.
She said nicotine exposure from smokeless tobacco products is based on nicotine concentration, packaging, pouch size, moisture content, pH levels and the amount of unprotonated nicotine, which is more absorbable.
Still, some studies find that the risk of addiction associated with smokeless tobacco is similar to that of cigarettes, according to Richter.
E-cigarettes also may contain high levels of nicotine.
“Because e-cigarette manufacturing had not been regulated until very recently, the nicotine content in those products varies tremendously,” said Richter. “But, generally, these products may contain the same amount or more nicotine than cigarettes.”
CASA researchers found that 38 percent of adults from 2013 to 2014 and half of middle and high school students in 2014 who reported past-month use of nicotine products reported using more than one product.
Among current nicotine product users, 8 percent of adults and 20 percent of teens reported using more than one non-cigarette product during those years.
Richter called this trend a disturbing realization.
“I don’t think I would have guessed when I first became involved in this research that so many people who use non-cigarette nicotine products use more than one type or use them alongside cigarettes, and that use of multiple products poses a greater risk of addiction and other health consequences,” she explained.
The tobacco industry, she said, plays an integral role in shaping the public’s perception of non-cigarette nicotine products. Many tobacco companies promote these products as safe alternatives to cigarettes, which Richter calls astounding and depressing.
“Cigarettes are one of the most harmful substances around,” explained Richter. “It’s a pretty low threshold to claim that something is less harmful than cigarettes.”
To combat these perceptions, Richter says schools and community-based prevention programs must incorporate non-cigarette nicotine products into their prevention curricula. These entities also should offer interventions and cessation services to students who use these products.
Richter also says health care professionals should stay abreast of new developments associated with the risks of these products. However, past studies indicate that some physicians still recommend to their clients e-cigarettes as smoking cessation devices.
She encourages the Food and Drug Administration to set standards for the manufacturing, labeling and marketing of all nicotine products to ensure the public knows their risks.
“[FDA strategies] also should restrict the advertising and marketing of these products to youth — the way it does for cigarettes — by banning child-friendly flavorings, advertisements, and promotions,” said Richter.
These actions altered public perceptions against cigarettes. Richter believes similar approaches must be applied to non-cigarette nicotine products to ensure the public recognizes their consequences.
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