Table 4.

Integrated analysis of the relative harm from using modern ENDS devices relative to smoking tobacco in terms of health loss in HALYs by disease grouping

Disease grouping	% HALY loss (Table 2) [A]	Relative harm of ENDS use vs smoking (Table 3 plus adjusted for acrolein from other sources) [B]	Relative harm in terms of HALY loss (i.e., [A] x [B])
Chronic obstructive pulmonary disease (COPD)	48.9%	27.6%*	13.5%
Cancers (12 types)	28.3%	41.8%	11.8%
Cardiovascular disease	22.4%	34.7%*	7.8%
Lower respiratory tract infection	0.4%	27.6%* (as per COPD**)	0.1%
Total	100%		33.2%

*Adjusted for the best estimate of acrolein from non-smoking sources (e.g., diet) at 20.1% of the level in smokers [30] (see Supplementary Information)

**The basis for using the COPD approach is that “acrolein has powerful immune-suppressive effects on innate and adaptive immune cells” [18]. Furthermore, in the pathogen interaction studies in mice, exposure to acrolein after infection markedly worsened pulmonary immune defences [59]