By Tiffany Holman

Nicotine consumption has undergone transformative changes in recent years, igniting both fervent debate and sparking concern among public health authorities.

There were some key insights from studies and presentations at the recently held 2024 E-Cigarette Summit in Washington DC which examined transitions and perceptions shaping nicotine use behaviours.

This discourse can help shed further light on the implications for public health policy and intervention strategies. 

Nicotine use trends

Dr. Rafael Meza provided a sweeping overview of nicotine use trends among American adolescents and adults. Adolescent e-cigarette use soared until 2015, experienced a brief dip in 2016-2017, and surged again in 2018 with the proliferation of pod systems. This surge peaked in 2019, largely due to aggressive marketing and the appealing design of these devices. However, regulatory actions and public health campaigns have led to a decline in use since then. Notably, adolescent cigarette smoking has reached historical lows and continues to decrease, highlighting a shift in tobacco product preferences among younger populations. 

For adults, the e-cigarette uptake has been more gradual yet persistent. According to the study, young adults (18-24) saw a notable decrease in smoking yet a simultaneous increase in e-cigarette use. In 2022, the prevalence of e-cigarette use among young adults reflected a significant increase from previous years. In contrast, older adults (65+) exhibit minimal e-cigarette use and a stable smoking prevalence, with less than five per cent reporting e-cigarette use.  The statistics further underscore the need for targeted public health strategies that consider the diverse behaviours and motivations of different age groups. 

Meza’s research straddles the fields of epidemiology, biostatistics—and biomathematics, making significant contributions to lung cancer epidemiology and tobacco control. As an expert in these areas, his work aims to evaluate the effectiveness of disease prevention and control interventions, guiding stakeholders and policymakers in enhancing public health.

Relapse among former smokers

The study by Dr. Ruoyan Sun, assistant professor in the Department of Health Policy and Organisation at UAB casts a spotlight on relapse rates among recent former smokers who transitioned to e-cigarettes or other tobacco products. 

This research showed that individuals who switch to e-cigarettes are more prone to relapse compared to those who abstain from all tobacco products. In the discussion, it was noted that there is a distinction between what is considered as ‘slip vs relapse’. A ‘slip’ is a limited episode of smoking over a limited time. It does not necessarily constitute a resumption of smoking.  

This critical finding highlights the complex dynamics of abstinence and the need for nuanced cessation support strategies.

Misperceptions about nicotine

Andrea Villanti, deputy director of the Rutgers Institute for Nicotine & Tobacco Studies and associate professor in the Department of Health Behavior, Society, and Policy at the Rutgers School of Public Health, unveiled the pervasive misconceptions about nicotine.

Many falsely believe that nicotine is the primary cause of smoking-related health harms. These misperceptions can propel smoking uptake, particularly among young people transitioning from e-cigarettes to cigarettes due to erroneous beliefs about relative harms. Villanti’s research demonstrated that corrective messaging could significantly reduce these misperceptions, but only with repeated exposure. For example, in the survey conducted, a staggering 78 per cent of the adult participants incorrectly believed nicotine caused most smoking-related cancers, a figure that only declined with intensive corrective efforts.

Supporting e-cigarette users to quit

As e-cigarettes cement their position as the dominant form of tobacco use, aiding users who wish to quit becomes paramount. Benjamin Toll’s presentation emphasises the vital role of behavioural counselling and FDA-approved medications as first-line treatment. 

Pilot studies on nicotine replacement therapy (NRT) and varenicline have yielded promising outcomes, indicating their potential efficacy. However, the field urgently needs robust, large-scale clinical trials to solidify cessation strategies specifically tailored for e-cigarette users.

Toll also accentuates the crucial role of healthcare providers in guiding e-cigarette users. Clinicians must educate patients on the relative risks of various tobacco products and emphasise the health benefits of fully transitioning away from combustible tobacco. This is especially pertinent for young adults, among those who intend to quit e-cigarettes, yet only a lower percentage have made serious quit attempts, revealing a significant gap between intention and action.

Market dynamics and regulatory impact

Professor David T. Levy’s analysis sheds light on the interplay between market competition and FDA regulations in shaping nicotine product use. His research reveals that the rivalry between cigarette companies and independent firms significantly affects product availability and user adoption. The FDA’s stringent policies, especially those targeting flavoured e-cigarettes, play a pivotal role in market dynamics. Levy advocates for flexible, comprehensive regulatory policies that balance harm reduction objectives with market realities, ensuring effective products remain accessible while safeguarding public health.

The insights gleaned from these studies and presentations have profound implications for public health policy. To mitigate nicotine-related harm effectively, policies must be adaptive and evidence-based. 

Public health campaigns should be meticulously tailored to different demographic groups, acknowledging the unique behaviours and motivations of adolescents, young adults, and older adults. For instance, interventions for young adults should address the high e-cigarette usage rates and their significant quitting intentions.

Intensifying efforts to rectify nicotine misperceptions is crucial. Repeated exposure to accurate information about nicotine’s relative harms can shift public perceptions and curb smoking uptake. Studies show that corrective messaging can reduce misperceptions with sufficient exposure.

Enhanced cessation support for e-cigarette and combustible cigarette users is vital.  Regulatory policies should balance the need to curtail youth e-cigarette use with the harm-reduction benefits for adult smokers. Flexible, comprehensive regulations can support this balance, ensuring safer alternatives remain available while protecting vulnerable populations. Continuous monitoring of nicotine use trends and transitions is imperative. Ongoing research should inform policy adjustments and ensure public health strategies remain effective in a rapidly evolving landscape. Developing longitudinal studies and real-time data collection can deepen our understanding of nicotine use dynamics and inform timely interventions.

The insights from the 2024 E-Cigarette Summit reflected the necessity for adaptive policies and ongoing research to shape the future of nicotine use and public health. The nature of nicotine use demands a multifaceted approach that incorporates the latest research findings, considers the impact of regulatory policies, and addresses the diverse needs of nicotine users.