E-Cigarette Use on the Rise in US Adults With CVD

The patterns suggest vaping is being used as a smoking cessation tool—whether that’s a bad or good thing isn’t fully clear.

E-Cigarette Use on the Rise in US Adults With CVD

Use of e-cigarettes by people with cardiovascular disease had been on the decline for a few years but then rebounded in 2020 with the emergence of the COVID-19 pandemic, topping out at a prevalence of around 5%, according to an analysis of US survey data.

The findings were published online Tuesday as a research letter in JAMA Network Open.

“E-cigarettes have been considered a safe means of smoking cessation for combustible cigarettes. However, the evidence of cardiovascular harm of e-cigarettes has been accumulating in recent years, so it is necessary to understand the proportion and trend of e-cigarette use in people with CVD,” said Shanjie Wang, MD, PhD (Second Affiliated Hospital of Harbin Medical University, China), who shares senior authorship on the paper with Yiying Zhang, MD, PhD (Jiamusi University, China).

What they found, Wang told TCTMD in an email, is that adults below the age of 60, women, and former smokers are all more likely to use e-cigarettes. The data also show that people who currently smoke conventional cigarettes and those who’ve quit have a higher prevalence of vaping than those who’ve never smoked to begin with, “suggesting that the idea of replacing traditional cigarettes with e-cigarettes cannot be ignored,” he said.

Clinicians [should] pay more attention to the cardiovascular health of current tobacco users and former cigarette users who use e-cigarettes when asking about e-cigarette use. Shanjie Wang

Wang noted that e-cigarette use is more prevalent in CVD patients than in the general population.

Clinicians [should] pay more attention to the cardiovascular health of current tobacco users and former cigarette users who use e-cigarettes when asking about e-cigarette use. However, there is still no definitive conclusion on whether e-cigarettes can replace traditional cigarettes and relatively improve the cardiovascular health of patients,” he explained.

Holly R. Middlekauff, MD (UCLA Health, Los Angeles, CA), commenting on the results for TCTMD, said that the new data interestingly show that while e-cigarette use among people with CVD went up in the last year or so of the study period, the use of traditional cigarettes was on the decline. Moreover, only a tiny slice of the e-cigarette users classified themselves as “never smokers.” This points to the existence of a group—current smokers who wish to quit or cut back—“that would really benefit from doing almost anything besides smoking a tobacco cigarette. It’s that whole harm reduction idea,” she said.

Dual use is not so beneficial from the heart standpoint,” but it seems likely that completely eliminating smoked tobacco by switching to e-cigarettes would be a good move, Middlekauff noted. “We do know that if somebody smokes just one to two tobacco cigarettes a day, they have a similar cardiovascular risk as somebody who smokes one to two packs a day. It’s kind of an on/off thing. . . . The cancer risk is more related to duration of smoking and burden, but the cardiovascular risk is really related to whether you smoke at all. So if you’ve cut out 95% of your tobacco cigarettes, that’s good, but it’s not going to give you nearly the benefit as completely stopping smoking.”

There probably is going to be some cardiovascular harm from using electronic cigarettes, but it’s probably orders of magnitude less than tobacco cigarettes. Holly R. Middlekauff

The long-term cardiovascular effects of vaping are still unknown, said Middlekauff. Her own research, along with other studies, has shown that e-cigarettes can cause physiologic changes that might up the risk of a person developing cardiovascular disease. Still, if e-cigarettes can indeed help people quit smoking—as has been suggested by earlier research, including the randomized E3 trial—then the risks might be outweighed by the health gains, she suggested.

There probably is going to be some cardiovascular harm from using electronic cigarettes, but it’s probably orders of magnitude less than tobacco cigarettes. We know that those are bad for you, those kill you—they kill half the people that use them, yet people still use them because it’s such a powerful addiction,” Middlekauff said.

From Tobacco to E-Cigarettes

Led by Xin Wen, MD (Jiamusi University), the researchers analyzed data on 30,465 adults with CVD who responded to the National Health Interview Survey between 2014 and 2020. The mean age was 65 years, and 47.8% were women. Most of the participants (84.7%) self-identified as white, while 4.9% self-identified as Black, 4.9% as Hispanic, and 1.6% as Asian.

Among these patients with a history of cardiovascular disease, current use of e-cigarettes decreased initially, with the weighted prevalence dropping from 5.2% in 2014 to 3.1% in 2019. However, it then rebounded back to 5.2% in 2020.

E-cigarette use decreased over the years for those ages 60 or older (dropping from 2.9% in 2014 to 0.9% in 2020) but held steady for those younger than 60 (at 6.2% in 2014 and 7.2% in 2020). Before 2018, men were more apt to use e-cigarettes than were women, though this was no longer the case in 2019 and 2020, by which time 2.9% of men and 8.3% of women reported vaping. People with CVD who had quit smoking conventional cigarettes were, over the years, increasingly more likely to use e-cigarettes (rising from 3.2% in 2015 to 10.1% in 2020).

Adjusted for age, sex, region, race/ethnicity, education, and household income, several factors predicted higher or lower odds of e-cigarette use.

Predictors of E-Cigarette Use in Patients With CVD


Adjusted OR (95% CI)

Age (vs ≥ 60 Years)

    18-39 Years

    40-59 Years


5.2 (4.0-6.7)

3.2 (2.6-4.1)

Race/Ethnicity (vs White)




0.3 (0.2-0.4)

0.3 (0.3-0.5)

Education Level (vs ≥ College)

    < High School


1.6 (1.2-2.1)

Household Income (vs High)




1.7 (1.4-2.5)

2.2 (1.6-2.8)

Smoking Status (vs Current)

    Former, Quit ≤ 1 Year

    Former, Quit > 4 Years



1.8 (1.2-2.7)

0.2 (0.2-0.3)

0.1 (0.1-0.2)

Failed Attempt to Quit ≤ 1 Year

2.0 (1.5-2.6)

“More attention should be paid to young people, women, and former smokers with a history of cardiovascular disease. The trend of e-cigarette use in these groups is not optimistic,” Wang emphasized.

For Middlekauff, a few things leap out from the findings. Unlike in the general population, where men are more likely than women to use e-cigarettes, the opposite was seen here in the CVD population, though that difference disappeared after adjustment. Also, “usually people who use electronic cigarettes are better educated [with] higher socioeconomic status—in general,” she said. But in people with CVD, the same factors that typically predict smoking of tobacco cigarettes, such as low income and less education, were linked to vaping as well. This suggests that e-cigarettes in these instances are being used as a cessation aid.

Cardiologists counseling their patients can tell them that e-cigarettes might be a reasonable approach, said Middlekauff. Her own typical advice, she added, is: “Use the certified means to try to quit smoking first, the nicotine replacement [or] pharmacologic approaches. But if those don’t work, then I think it’s reasonable to try electronic cigarettes. Don’t become a dual user: switch completely, and then see if you can use the electronic cigarettes for the shortest amount of time possible and hope for the best. . . . It’s worth a try.”

Future studies, said Wang, should examine the relative risks and benefits for smokers with CVD who substitute vaping for conventional cigarettes, knowledge that will be critical when developing policies to manage e-cigarette use in the CVD population.

Caitlin E. Cox is News Editor of TCTMD and Associate Director, Editorial Content at the Cardiovascular Research Foundation. She produces the…

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  • The researchers report no relevant conflicts of interest.