Different Smokes for Different Folks? E-Cigarettes and Tobacco Disparities

The burden of tobacco use and its resultant health harms is now concentrated among socially and economically disadvantaged populations in the United States. The current adult smoking rate of 14%,¹ often touted as a historic low, masks the severe disparities that exist and persist. Cigarette use is substantially higher among individuals who have less than a high-school education (23.1%), report an annual household income below $35 000 (21.4%), receive Medicaid (24.5%), have serious psychological distress (35.2%), and identify as lesbian, gay, or bisexual (20.3%).¹ These differences are even more pronounced when we consider the use of any combusted tobacco product (e.g., cigarettes, cigars, cigarillos, filtered little cigars, hookah).¹ Eliminating smoking, which remains the leading cause of preventable death in the United States, would reduce the unequal and unjust burden of morbidity and mortality more than any single public health action.

TOBACCO HARM REDUCTION

Nicotine, while highly addictive, is not the primary cause of illness and death from smoking. Rather, the inhalation of toxic smoke from combusted tobacco products exposes the user to carbon monoxide, tar, and more than 7000 chemicals, the combination of which is highly lethal.² Decoupling nicotine from its deadliest delivery mechanism could offer risk reductions for smokers who face considerable barriers to quitting. In a comprehensive review of the health effects of electronic nicotine delivery systems (ENDS), the National Academies of Sciences, Engineering, and Medicine determined that ENDS are not risk-free, but “there is conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens.”^{3(Conclusion 18-1)} Given the persistently high smoking rates and subsequent adverse health outcomes among vulnerable populations in the United States, ENDS could play a role in minimizing disparities, but this is largely dependent on patterns of use at the population level.

In this issue of AJPH, Spears et al. (p. 1224) make a novel contribution to the literature by examining sociodemographic correlates of ENDS use among cigarette smokers and smokers of noncigarette products, a group often overlooked in research on ENDS use behaviors. To my knowledge, this is the first study to assess such associations in the context of the diverse smoking product landscape. This editorial offers a commentary on the authors’ findings and the implications for smoking-related inequalities and discusses the potential for ENDS to close the enduring disparities gap more expeditiously than traditional tobacco control approaches have been able to achieve.

IMPLICATIONS FOR DISPARITIES

Health disparities related to ENDS use have not yet been examined in the way that they have for other tobacco products. Furthermore, the field’s traditional conceptualization of “disparities” may need to be reevaluated for a reduced-risk product such as ENDS. Whereas, historically, a higher prevalence of tobacco use among a vulnerable subgroup signaled a health inequity, disproportionately low rates of tobacco harm reduction may also be a problematic scenario if certain groups remain less likely to quit smoking over time. Perhaps the most notable finding in the Spears et al. study was an association that is generally consistent in the ENDS literature: cigarette smokers who have greater resources and more social “privilege” (e.g., higher income and educational attainment, White race) adopt ENDS at higher rates.⁴ Emerging longitudinal evidence suggests that these groups are also more likely to switch to exclusive ENDS use, thereby reducing harm.⁵ Several factors may explain this pattern, including ENDS accessibility, cost, social norms, and risk perceptions. If this divergence persists, differential rates of quitting cigarettes by using ENDS may exacerbate smoking-related disparities. This would not be the first example of a disruptive technology or medical innovation that shifts the socioeconomic health gradient in favor of higher-resourced individuals.⁶

Conversely, among smokers of noncigarette products in the Spears et al. study, individuals with lower income and educational attainment were more likely to be current ENDS users. Characterizing the public health impact of this relationship, however, is challenging because of the variable nature of cigar, cigarillo, and hookah use compared with cigarettes. For example, more than 80% of noncigarette smokers in the study reported using these products “rarely.” For ENDS to have any public health benefit, they must be used as a complete substitute for riskier combusted tobacco among those who cannot quit. Whereas adult cigarette smokers commonly report using ENDS to cut back on or quit smoking, ENDS use intentions among infrequent users of other tobacco products may differ, limiting their harm reduction potential. Identifying reasons for and patterns of ENDS use among users of diverse tobacco products is an emergent and important area of tobacco control research.

CLOSING THE GAP

Combusted tobacco is “Public Enemy Number One,” and eliminating its use is a public health priority. To that end, the policies and programs that have effectively reduced smoking rates over the last several decades (e.g., increased taxation, smoke-free air laws, public education, mass media campaigns, improved access to cessation treatments, marketing restrictions) should continue forcefully. In addition, more aggressive regulatory strategies are needed to combat use of combusted products that are heavily marketed to disparity populations. Indeed, the promotion of menthol cigarettes and inexpensive, flavored little cigars and cigarillos continues to target the African American community, a group disproportionately affected by the health consequences of smoking.⁷ Traditional tobacco control approaches, however, have not sufficiently reached vulnerable populations; conversely, they have resulted in more pronounced disparities over time. As policies related to cigarettes and other combusted products strengthen, health professionals and policymakers should consider strategies that facilitate migration to lower-risk, noncombusted products like ENDS for smokers who cannot or do not want to quit using nicotine. Concurrently, we must double down on efforts to prevent ENDS use among nonsmoking youths and adults, who have little to gain from an addictive product that poses its own set of health risks.

The idea that a new tobacco product could help minimize disparities is unconventional, controversial, and certainly has caveats, but harm-reduction approaches—in conjunction with existing, evidence-based policies and interventions—have the potential to accelerate the smoking “endgame” and reduce inequalities more rapidly and effectively than traditional tobacco control initiatives. Presently, however, ENDS adoption differs across sociodemographic groups of cigarette smokers, threatening the viability of this harm-reduction strategy to advance health equity. Though complete cessation from all tobacco products is the optimal outcome and should always be encouraged and supported as the first course of action, quitting remains particularly difficult among socially disadvantaged and marginalized groups, who are overrepresented among the 40 million remaining smokers in the United States.¹ The public health community may need to be more open minded to tobacco harm reduction as a way to reduce inequities when harm elimination is not happening as fast or as equally as it should. Without radical changes in our approach to tobacco control, unacceptable disparities in smoking-related disease and death may persist for decades.