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E-cigarettes, heated tobacco products and other modified risk products of tobacco: how to gauge use, dependency, and abuse?

Comment by Giuseppe Biondi-Zoccai, Ute Mons, Elena Cavarretta and Giacomo Frati

Preventive Cardiology
Risk Factors and Prevention

Modified risk products of tobacco (MRP), such as electronic vaping cigarettes (EVC) and heated tobacco products (HTP), have revolutionised the landscape of smoking worldwide. (1) While many consider these new forms of nicotine addiction a threat to public health, others see MRP as an opportunity to reduce the burden of combustible cigarette smoking (CCS), with its huge death toll. Recent works reported in the European Journal of Preventive Cardiology poignantly highlights the potential impact of EVC on endothelial function, while at the same time acknowledging their lower harm potential, and the careful reader should acquaint themselves with the subtleties of clinically overt as well as subclinical toxicity of MRP by perusing these works in detail. (2,3)

We hereby wish to stress the importance of explicitly questioning patients as well as candidates for primary cardiovascular prevention on their potential use of MRP. Indeed, individuals may use EVC, HTP, a combination of them, or one or more MRP together with CCS (Figure 1). (4,5) Furthermore, use patterns may differ substantially, ranging from regular daily use (e.g. use of 20 tobacco sticks for the IQOS HTP system) to occasional use (e.g. Saturday night use of customised liquids in large-volume EVC). Another issue worth exploring is the concomitant use of recreational drugs and drugs of abuse, from cannabinoids to more dangerous ones.

Open-ended and non-judgmental questions are most effective in obtaining detailed and truthful replies, and dedicated questionnaires and assessments can also be used when deemed appropriate with motivated people by careful practitioners, such as the Adolescent E-Cigarette Consequences Questionnaire (AECQ), E-cigarette Fagerström Test of Cigarette Dependence (e-FTCD), and the Comparing EC and Cigarettes Questionnaire (CEAC), for instance. (4,5) When considering any of the available questionnaires, it is important to focus on the age, ethnic, and cultural focus of target respondents. In addition, underlying theoretical framework, means of administration, number of items, and overall completion time are highly relevant. Furthermore, when these questionnaires are being perused for research purposes, careful attention should be paid to construct (eg attitude, expectance, and dependence), reliability (i.e. internal consistency and test-retest), and validity (i.e. construct, content and criterion). (4)

In conclusion, the expanding adoption of MRP calls for a comprehensive, attentive and constructive appraisal of their uptake among individuals in whom primary cardiovascular prevention is considered, as well as among patients in secondary prevention of cardiovascular disease, aiming at distinguishing use, abuse and dependency, with the ultimate goal of abstinence from any smoking or tobacco use habit.

Figure 1. Multidimensional appraisal of modified risk products.


Source: Provided by Giuseppe Biondi-Zoccai

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.


The authors commented on this article:

3. Münzel T, Daiber A, Hahad O. Are e-cigarettes dangerous or do they boost our health: no END(S) of the discussion in sight. Eur J Prev Cardiol. 2022 Nov 18:zwac266. doi: 10.1093/eurjpc/zwac266. Epub ahead of print. PMID: 36399388.

Other references:

1. Peruzzi M, Biondi-Zoccai G, Carnevale R, Cavarretta E, Frati G, Versaci F. Vaping Cardiovascular Health Risks: an Updated Umbrella Review. Curr Emerg Hosp Med Rep. 2020;8(3):103-109. doi: 10.1007/s40138-020-00219-0. Epub 2020 Jun 16. PMID: 32837803; PMCID: PMC7296287.
2. Meng XC, Guo XX, Peng ZY, Wang C, Liu R. Acute Effects of Electronic Cigarettes on Vascular Endothelial Function: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Eur J Prev Cardiol. 2022 Nov 1:zwac248. doi: 10.1093/eurjpc/zwac248. Epub ahead of print. PMID: 36316290.
4. Park E, Kwon M, Chacko T, Zhou Y, Chen C, Goniewicz ML, Li CS, Chang YP. Instruments to measure e-cigarette related constructs: a systematic review. BMC Public Health. 2022 Jun 7;22(1):1135. doi: 10.1186/s12889-022-13510-4. PMID: 35668485; PMCID: PMC9172158.
5. Piper ME, Baker TB, Benowitz NL, Smith SS, Jorenby DE. E-cigarette Dependence Measures in Dual Users: Reliability and Relations With Dependence Criteria and E-cigarette Cessation. Nicotine Tob Res. 2020 Apr 21;22(5):756-763. doi: 10.1093/ntr/ntz040. PMID: 30874804; PMCID: PMC7368344.

Notes to editor

Author information:

Giuseppe Biondi-Zoccai, 1,2
Ute Mons, 3
Elena Cavarretta, 1 ,2
Giacomo Frati, 1, 4

1 Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy;

2 Mediterranea Cardiocentro, Napoli, Italy;

3 Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany;

4 IRCCS NEUROMED, Pozzilli, Italy