Electronic Cigarette Use Among Heart Failure Patients: Findings from the Population Assessment of Tobacco and Health Study (Wave 1: 2013–2014)

Abstract

Background:

Smoking cessation is recommended for adults with heart failure (HF). The prevalence of e-cigarette use among adults with HF is unknown.

Objective:

To determine prevalence of and reasons for e-cigarette use among adults with HF.

Methods:

Data from the Population Assessment of Tobacco and Health Study (Wave 1) were examined.

Results:

Of 484 respondents with HF, 1% (weighted) reported current e-cigarette use, and 5% (weighted) reported dual cigarette/e-cigarette use. Adults with HF had higher odds of dual use (OR=1.76, 95% CI: 1.22–2.54) compared to those without HF, controlling for age, sex, race, and income. Dual users with HF reported using e-cigarettes because they may be less harmful to nearby people and to themselves than cigarettes.

Conclusions:

E-cigarette use should be assessed and monitored to understand the safety and potential efficacy of e-cigarettes as a harm reduction approach for HF patients.

INTRODUCTION

Cigarette smoking is the most important modifiable contributor to mortality among adults with heart failure (HF).¹ Adults with HF are advised to discontinue and/or abstain from smoking due to the numerous deleterious effects of smoking on the cardiovascular system and disease process.² Approximately 12% of adults with a HF hospitalization were recently documented to have tobacco use disorder.³ Given the increasing popularity of electronic cigarettes (e-cigarettes), HF patients may use e-cigarettes in an attempt to reduce or quit smoking. The prevalence, and reason for use, of e-cigarettes in HF patients is unknown.

To our knowledge, no studies have reported the prevalence of e-cigarette use among adults with HF. Although one report indicated higher odds of current e-cigarette use among smokers with cardiovascular disease (CVD) than those without medical comorbidity,⁴ other research suggests similar rates of e-cigarette use among CVD patients (4–6%)^5,6 compared to U.S. adults (5%).⁷ Evidence regarding the potential of e-cigarettes to safely support cessation is mixed.^8,9 Nonetheless, many smokers with CVD who are attempting smoking cessation are trialing e-cigarettes.¹⁰ Additionally, among adult smokers with CVD, former smokers and those reporting a recent quit attempt were more likely to report ever using an e-cigarette compared to those who had not attempted smoking cessation in the 2014 National Health Interview Survey.⁵

Recent data questions the safety of e-cigarettes for cardiovascular health. Daily (though not former and some-day use) was associated with increased likelihood of myocardial infarction (MI) history.¹¹ This data is concerning given that smokers have reported lower perception of harm to cardiac health associated with e-cigarette use compared to cigarettes.¹² These studies, however, did not indicate whether adults with HF were sampled. Prevalence rates of e-cigarette use may differ across medical sub-populations, such as those with more severe forms of CVD, and require more nuanced, condition-specific examination.

Adults with HF tend to be older, have poor physical symptom profiles characterized by dyspnea, fatigue, and edema, and experience high rates of re-hospitalization.¹³ Given that many smokers perceive e-cigarettes to be beneficial for smoking cessation,¹⁴ greater understanding of the prevalence and reasons for e-cigarette use among adults with advanced forms of CVD such as HF is imperative to support optimal public health efforts. Characterization of use patterns among those with HF can direct researchers and clinicians seeking to understand novel tobacco product use among patients and provide additional context surrounding intervention needs. Thus, the purpose of this study was to determine rates of and reasons for e-cigarette use among adults with HF.

METHOD

Participants’ self-reported HF status, e-cigarette, and cigarette use was obtained from the Population Assessment of Tobacco and Health (PATH) Study (Public Use Files, Wave 1).^15,16 The PATH study is an ongoing household-based, nationally representative longitudinal cohort study of 32,320 U.S. non-institutionalized adults ≥18 years of age. The first wave of data collection (“Wave 1”) was conducted from September 12, 2013 through December 15, 2014. The PATH study is sponsored by the National Institutes of Health/National Institute on Drug Abuse and the Food and Drug Administration’s Center for Tobacco Products. Respondents were recruited using probability sampling based on resident addresses. Oversampling of adults with higher tobacco use (e.g., young adults, African Americans, tobacco users) ensured adequate representation of tobacco users. Person-level weights were calculated to account for selection probability, non-response, and complex study design. Computer-assisted interviews were used to administer PATH survey questions. Because the present cross-sectional, secondary data analyses were focused on adults with HF, only the adult Wave 1 data were used. Westat (Rockville, MD), a research company that was contracted to conduct the study, oversaw the study teams, design and protocol, including provision of Institutional Review Board approval.

Variables and Measures

Sociodemographic Information and HF Status

Self-reported age, sex, race/ethnicity, educational attainment, and income were examined to characterize the current sample. HF status was determined based on the question, “Has a doctor or other health professional ever told you that you had any of the following heart conditions? Choose all that apply.” Adults who selected “Congestive heart failure” were coded as adults with HF in the present analyses.

Cigarette and E-cigarette Use

The PATH study defined variables were used to guide analyses of tobacco product users. Current cigarette users were defined as those who (a) report smoking >100 cigarettes in their lifetime and current use on some days or every day OR (b) report of smoking ≤100 cigarettes in their lifetime, and currently smoking every day or some days, and denied current e-cigarette use. Current e-cigarette use was defined as (a) report of fairly regular use and current every day or some days use, OR current every day or someday use without report of history of fairly regular use (e.g., “established” and “experimental” users), and denied current cigarette use. Dual cigarette/e-cigarette users were those who endorsed current e-cigarette and cigarette use (“dual users”). Participants also reported their reasons for use, quit attempts, and current use of nicotine replacement products (NRT; e.g., nicotine patch).

Statistical Analyses

To account for the sampling methods so that the estimates represent the adult U.S. civilian, non-institutionalized population, replicate weights were calculated based on Fay’s adjustment set to .3, which represents a variant of the balanced repeated replication (BRR) method. Frequencies, percentages, weighted percentages and confidence intervals were calculated to determine rates of current cigarette, e-cigarette, and dual use. Similarly, frequencies, percentages, and weighted percentages were calculated to examine reasons for e-cigarette use; analysis of reasons for use was restricted to current dual users. Percentages pertaining to cigarette, e-cigarette, and dual use prevalence reported in the text represent the weighted percentages.

The odds of whether HF status (HF versus no HF) was associated with cigarette, e-cigarette, and/or dual use were also examined. Chi-square tests were used to determine associations between sample characteristics and outcome variables. Logistic regression was performed to examine the odds of cigarette, e-cigarette, and dual use after controlling for age, sex, race, and income by HF status. Statistical significance was defined as p < .05. Analyses were limited to individuals with complete data on current cigarette and e-cigarette use and HF status. Individuals with missing demographic data but complete cigarette and e-cigarette data were included. Analyses accounted for survey design and were performed in Stata SE/15.¹⁷

RESULTS

Prevalence of Cigarette, E-Cigarette, and Dual Use

Of the 32,320 adult respondents, 484 (1.86% [weighted], 95% CI: 1.66–2.08) with complete cigarette and e-cigarette data reported receiving a HF diagnosis (48% [weighted] female; 59% [weighted] ≥ 65 years; 73% [weighted] white, non-Hispanic). Of those with HF, 433 (85% [weighted], 95% CI: 78.81–88.92) reported having heard of an e-cigarette and 167 (16% [weighted], 95% CI: 12.75–18.76) of these adults reported using an e-cigarette at least once or twice.

Approximately 1% (weighted; n=10) adults with a HF diagnosis endorsed current e-cigarette use without use of cigarettes and 18% (weighted; n=184) endorsed current cigarette use without use of e-cigarettes. Approximately 5% (weighted; n=60) reported dual use. In respondents without HF, 16.89% (weighted) reported cigarette use, 1.17% (weighted) reported e-cigarette use, and 4.36% (weighted) reported dual use (see Table 1 for unweighted and weighted values). Logistic regression analyses indicated that participants with HF had higher odds of dual use (OR: 1.76, 95% CI: 1.22 – 2.54) compared to those without HF controlling for age, sex, race, and income. HF status (reporting HF diagnosis versus reporting not having a HF diagnosis) was not associated with odds of cigarette (OR: .92, 95% CI: 0.75 – 1.14) or e-cigarette (OR: 1.49, 95% CI: 0.77 – 2.88) use.

Table 1.

Sociodemographic characteristics of adults with and without HF in the PATH study.

	Respondents without Heart Failure (n = 31,542)1		Respondents with Heart Failure (n = 484)1
	Unweighted sample size (%)	Weighted % (95% CI)	Unweighted sample size (%)	Weighted % (95% CI)	p
Age (years)2,3					<.001
18–34	15,318 (49%)	31.31 (30.83 – 31.79)	32 (7%)	3.35 (2.24 –4.99)
35–54	9,560 (30%)	34.84 (34.23 – 35.46)	118 (24%)	15.81 (12.05 – 20.47)
55 and older	6,659 (21%)	33.85 (33.42 – 34.28)	334 (69%)	80.84 (76.01 –84.89)
Women2	15,655 (50%)	52.04 (51.87 – 52.20)	218 (45%)	47.98 (41.81 – 54.21)	.21
Race2					<.001
White	23,348 (74%)	77.95 (77.64 – 78.26)	342 (71%)	79.69 (75.03 – 83.67)
Black/African American	4,876 (15%)	12.15 (11.99 – 12.31)	109 (23%)	16.34 (12.88 – 20.52)
Other	3,318 (11%)	9.90 (9.69 – 10.11)	33 (7%)	3.97 (2.58 – 6.05)
Ethnicity, % Hispanic	5,435 (17%)	14.98 (14.88 – 15.08)	43 (9%)	8.28 (5.33 – 12.66)	<.01
Education4					<.001
GED/High school graduate or less	13,553 (43%)	40.59 (40.30– 40.63)	288 (60%)	65.13 (59.35 – 70.50)
Some college or more	17,837 (57%)	59.54 (59.37 – 59.70)	191 (40%)	34.87 (29.50 – 40.65)
Current Cigarette Only Use	10,315 (33%)	16.89 (16.38 – 17.42)	184 (38%)	17.72 (14.99 – 20.83)	.58
Current E-Cigarette Only Use	732 (2%)	1.17 (1.06 – 1.29)	10 (2%)	.99 (.55 – 1.79)	.60
Dual Cigarette/E-Cigarette Use	2,818 (9%)	4.36 (4.16 – 4.58)	60 (12%)	5.32 (3.88 – 7.25)	.21
No use of cigarettes OR e-cigarettes	17,677 (56%)	77.58 (76.97 – 78.18)	230 (48%)	75.96 (72.07 – 79.46)	.38

Note. CI=Confidence Interval; GED= General Education Diploma.

p values calculated using Pearson χ2 tests.

¹Analyses restricted to adults without missing data on cigarette and e-cigarette use.

²Imputed variable was used

³Data was missing for five participants.

⁴Data was missing for 157 participants. Of the 157, 5 individuals with HF were missing education.

Reasons for Use, Quit Attempts, and Rates of NRT among Dual Users

The most common reasons for use reported by current dual users with HF were that e-cigarettes (a) may be less harmful to nearby people than cigarettes (90%), (b) may be less harmful than cigarettes (85%), (c) are used to help people quit smoking (83%), and (d) can be used in places where smoking is not allowed (83%) (see Table 2). Dual users with HF who endorsed at least one quit attempt in the past year reported an average of 4.51 (95% CI: 3.17–5.85; n = 33) tobacco product quit attempts (excluding e-cigarettes). Dual users without HF reported an average of 6.18 (95% CI = 2.50–9.91; n = 1,235) tobacco produce quit attempts. Most current established cigarette users with HF (i.e., those who have smoked >100 cigarettes in their lifetime and currently smoke some or every day) reported using e-cigarettes to reduce cigarette use (46/51 = 90%). Conversely, fewer established users without HF reported e-cigarette use specifically to reduce cigarette use 731/2,468 = 30%; p <.01). Seventy-five percent of HF established cigarette users (n=38/51) vs. 70% of established cigarette users without HF(n=1,737/2,468) reported e-cigarette use as an alternative to quitting tobacco altogether (p = .05). One-hundred and eighty-seven adults with HF reported ever using NRT; 11 who reported quitting or attempting to quit tobacco within the past year endorsed current NRT use, four of whom were dual users.

Table 2.

Reasons for Use Reported by Dual E-Cigarette/Cigarette Users with Heart Failure (n = 484).

	Unweighted sample size (%)	Weighted % (95% CI)
They might be less harmful to people around me than cigarettes	54 (90%)	90.94 (79.73 – 96.24)
They might be less harmful to me than cigarettes	51 (85%)	85.38 (72.91 – 92.68)
Using e-cigarettes helps people to quit smoking cigarettes.	50 (83%)	82.87 (70.08 – 90.9)
I can/could use e-cigarettes at times when or in places where smoking cigarettes isn’t/wasn’t allowed.	50 (83%)	82.27 (70.23 – 90.13)
They are more acceptable to non-tobacco users	42 (70%)	69.99 (57.45 – 80.11)
E-cigarettes don’t smell	40 (67%)	68.95 (53.55 – 81.06)
Using an e-cigarette feels/felt like smoking a regular cigarette	40 (67%)	64.8 (52.58 – 75.35)
They are/were affordable	34 (57%)	54.74 (40.97 – 67.82)
I like/liked socializing while using an e-cigarette	34 (57%)	56.09 (43.15 – 68.25)
E-cigarettes come/came in flavors I like/liked.	32 (53%)	50.89 (38.29 – 63.38)
People in the media or other public figures use/used e-cigarettes.	25 (42%)	38.84 (26.51 – 52.78)
The advertising for e-cigarettes appeals/appealed to me	21 (35%)	33.6 (22.53 – 46.82)
People who are important to me use/used e-cigarettes	16 (27%)	22.76 (13.03 – 36.68)

Note. Proportion do not sum to 100% because participants were asked to select as many reasons as applied. CI=Confidence Interval

DISCUSSION

The present analyses examined the prevalence of and reasons for e-cigarette use among adults with and without HF using a nationally representative survey. To our knowledge, these findings represent the first investigation of the prevalence of e-cigarette use among U.S. adults with HF. Overall, prevalence of cigarette, e-cigarette, and dual use among adults with HF were 18%, 1%, and 5% respectively. The rates in adults who had not been diagnosed with HF were 17%, 1%, and 4%, respectively. After controlling for age, sex, race, and income, HF status was associated with higher odds of dual use. Dual users with HF most often reported use of e-cigarettes for reasons related to reduced harm and smoking cessation. Few dual users with HF reported current use of NRT for quitting smoking.

Most adults with HF reported dual use of cigarettes and e-cigarettes, as opposed to e-cigarette use alone. The higher odds of dual use associated with HF status further highlights that adults with advanced forms of CVD are using cigarettes and e-cigarettes concurrently at high rates. Prevalence of e-cigarette use among adults with HF were similar to other forms of CVD. Prior analysis from the PATH study reported current e-cigarette use (not exclusive of cigarette use) among adults with history of MI to be 13% (6% weighted).⁶ Although limited work has previously investigated motivations for e-cigarette use among adults with CVD, it appears beliefs about harm reduction and smoking cessation may represent a consistent theme. In our study, current e-cigarette users commonly cited using e-cigarettes due to belief that e-cigarettes may be less harmful to themselves and those around them than cigarettes. Similarly, post-ACS patients perceived e-cigarette use to be associated with lower risk of MI than cigarette use, but higher risk of MI than no-nicotine use.¹⁰ In addition, post-ACS patients identified that their most frequent reason for e-cigarette trials was smoking cessation, as well as “curiosity.”¹⁰ Such beliefs and reasons for use appear consistent with e-cigarette marketing campaigns that have historically touted these messages. However, it is unclear whether respondents with HF in the current study, or others, are primarily receiving these messages, whether from the media or personal contacts.

Additional research is needed to determine effective methods of appropriately informing adults with HF about e-cigarette use in light of the current questions surrounding e-cigarette cardiac safety as well as some evidence for second-hand nicotine absorption from e-cigarettes.¹⁸ Research is also urgently needed to more clearly define the efficacy of e-cigarettes as a smoking cessation tool for individuals with CVD who are attempting to improve their cardiac risk profile. Recent MI was associated with increased odds of attempting smoking cessation or reduction, but not successful cessation in a prior analysis from the PATH study.⁶ However, over 15% of adults who reported a MI in the past year and combustible tobacco product (e.g., cigarettes, cigar, cigarillo, pipe, hookah) use noted initiation of non-combustible tobacco products (e.g., e-cigarettes, smokeless, snus, and dissolvables). Of potential concern, no individuals with a recent MI completely switched from combustible to non-combustible product use, whereas 9% of combustible tobacco product users who did not experience a change in health status did report discontinuation of combustible tobacco in favor of non-combustible products.⁶ In conjunction with the current results, many adults with CVD may be using e-cigarettes as smoking alternatives as part of an effort to cut down cigarette use rather than completely discontinue smoking. Future research specifically examining more thoroughly how adults with HF are using e-cigarettes within the context of quit attempts is needed. Greater understanding of detailed aspects of smoking patterns, such as the time since the last quit attempt, would be beneficial to guiding future interventions to support smokers who initiate e-cigarette use.

Clinically, much remains to be determined surrounding evidence-based clinical recommendations for e-cigarette use. At present healthcare providers may consider screening for both combustible and non-combustible tobacco product use when talking with HF patients about current smoking patterns and cessation efforts. Understanding use and patient beliefs associated with the harms and/or safety of e-cigarettes can provide clinicians a launching point for discussing the current state of the science surrounding novel tobacco products and reinforce clinical smoking cessation guidelines supported by prior research.¹⁹ For example, some organizations have recommended continuing to encourage evidence-based smoking cessation principles, but supporting patients who have failed first line therapies and independently initiated a trial e-cigarettes as part of a quit attempt.^20,21 However, clinicians should continue to closely monitor clinical symptoms and smoking cessation progress in such instances. As our understanding on e-cigarettes as a potential harm reduction approach continues to evolve, clinicians should remain apprised of changing guidance and recommendations by referring to relevant guidelines offered through healthcare organizations to correct any patient misperceptions.

These findings should be interpreted within the context of several limitations. First, the current analyses were cross-sectional, and do not present changes over time. Second, HF and tobacco product use was self-reported and may be subject to recall bias. Third, given the small number of e-cigarette only users, we were concerned that analysis of reported reasons for use from this sample may yield unstable results and we would be underpowered to detect differences in reasons for use between dual users and e-cigarette only users. Future research with a larger sample is needed to better understand reasons for use among e-cigarette only users with HF. Finally, the PATH questions assess a broad range of e-cigarette motives and not the most important reasons for e-cigarette use. For example, the PATH questions did not ask participants to rank their reasons for use. Cessation or reduction may be an important reason for use given that physicians strongly advise smoking cessation for all HF patients who use tobacco. However, it is unclear based on the current survey question whether supporting personal smoking cessation efforts may reflect the individual’s most important reason for use compared to other commonly endorsed reasons for use. The current findings should be replicated with more thorough validation of HF diagnosis and tobacco product use, and expanded response options that assesses finer grained motivations for use.

CONCLUSION

In conclusion, e-cigarette use among HF patients is similar to use reported among other CVD samples and the general population. Many HF patients identify harm reduction as a motivator for e-cigarette use. Additional research is needed to better understand what information adults with HF are currently receiving about e-cigarettes and through what means that information is provided. Future research should also examine e-cigarette preferences (e.g., brand, flavors, design features) to better understand factors that may influence use. Given that perception of harm reduction to oneself and those nearby were prominent reasons for use for HF patients, it is critical that research continue to understand the safety of e-cigarettes. Considering the lack of clear recommendations at present, healthcare providers may be uncertain on how to direct patients. Healthcare providers should screen for e-cigarette use and be prepared to discuss the current state of evidence with patients.

Highlights.

• Most adults with heart failure who use e-cigarettes also use cigarettes.

• Dual users reported using e-cigs because they may be less harmful than cigarettes.

• Assessment of e-cigarette use is encouraged in heart failure patients.