Health impact of e-cigarettes and heated tobacco products in chronic obstructive pulmonary disease: current and emerging evidence

ABSTRACT

Introduction

Quitting is the only proven method to attenuate the progression of chronic obstructive pulmonary disease (COPD). However, most COPD smokers do not seem to respond to smoking cessation interventions and may benefit by lessening the negative health effects of long-term cigarette smoke exposure by switching to non-combustible nicotine delivery alternatives, such as heated tobacco products (HTPs) and e-cigarettes (ECs).

Areas covered

Compared with conventional cigarettes, HTPs and ECs offer substantial reduction in exposure to toxic chemicals and have the potential to reduce harm from cigarette smoke when used as tobacco cigarette substitutes. In this review, we examine the available clinical studies and population surveys on the respiratory health effects of ECs and HTPs in COPD patients.

Expert opinion

The current research on the impact of ECs and HTPs on COPD patients’ health is limited, and more high-quality studies are needed to draw definitive conclusions. However, this review provides a comprehensive overview of the available literature for health professionals looking to advise COPD patients on the use of these products. While ECs and HTPs may offer some benefits in reducing harm from cigarette smoke, their long-term effects on COPD patients’ health are still unclear.

KEYWORDS:

• Alternative nicotine delivery systems
• reduced risk product
• modified risk tobacco product
• heated tobacco products
• vaping
• electronic nicotine delivery systems
• electronic cigarettes
• chronic obstructive pulmonary disease
• tobacco harm reduction
• smoking cessation

Article highlights

• Patients with chronic obstructive pulmonary disease (COPD) who smoke find it very hard to quit smoking and many do not intend to quit smoking

• Most COPD patients who smoke rarely have success with standard cessation interventions, with many continuing to smoke despite their symptoms

• Compared with conventional cigarettes, e-cigarettes (ECs) and heated tobacco products (HTPs) offer substantial reductions in exposures to toxic chemicals

• For patients with COPD who are having difficulty stopping smoking, the alternative of lessening the negative health effects of smoking by switching from conventional cigarettes to EC or HTPs should be considered

• Relapse prevention may be an important mechanism by which EC or HTP use contributes to long-term smoking abstinence

• Clear conclusions on the impact of EC and HTP on COPD patients’ health long term cannot be reached due to limitations in the available studies

• Well-controlled clinical trials and large-scale prospective cohort studies with long-term follow-up are needed to obtain conclusive evidence for or against EC and HTPs use in patients with COPD.

Acknowledgments

The contents, selection, and presentation of facts, as well as any opinions expressed in this paper, are the sole responsibility of the authors and under no circumstances shall be regarded as reflecting the positions of industry and traders promoting combustion-free nicotine products. We wish to thank the five anonymous reviewers for their insightful comments and careful consideration of the manuscript.

Declaration of interest

J Morjaria has received honoraria for speaking and financial support to attend meetings/advisory boards from Wyeth, Chiesi, Pfizer, MSD, Boehringer Ingelheim, Teva, GSK/Allen & Hanburys, Napp, Almirall, AstraZeneca, Trudell, Cook Medical, Medela AG, and Novartis. J Morjaria has been an expert witness in a court case relating to the impact of smoking on illness severity, ITU admissions, and mortality from Covid-19 in South Africa in 2020. The entire proceeds of the work were donated to various charities. R Polosa is a full tenured professor of Internal Medicine at the University of Catania (Italy) and Medical Director of the Institute for Internal Medicine and Clinical Immunology at the same university. In relation to his recent work in the area of respiratory diseases, clinical immunology, and tobacco control, R Polosa has received lecture fees and research funding from Pfizer, GlaxoSmithKline, CV Therapeutics, NeuroSearch A/S, Sandoz, MSD, Boehringer Ingelheim, Novartis, Duska Therapeutics, and Forest Laboratories. Lecture fees from a number of European EC industries and trade associations (including FIVAPE in France and FIESEL in Italy) were directly donated to vaper advocacy no-profit organizations. R Polosa has also received grants from European Commission initiatives (U-BIOPRED and AIRPROM) and from the Integral Rheumatology & Immunology Specialists Network (IRIS) initiative. R Polosa has also served as a consultant for Pfizer, Global Health Alliance for treatment of tobacco dependence, CV Therapeutics, Boehringer Ingelheim, Novartis, Duska Therapeutics, ECITA (Electronic Cigarette Industry Trade Association, in the UK), Arbi Group Srl., Health Diplomats, and Sermo Inc. R Polosa has served on the Medical and Scientific Advisory Board

of Cordex Pharma, Inc., CV Therapeutics, Duska Therapeutics Inc., Pfizer, and PharmaCielo. R Polosa is also founder of the Center for Tobacco Prevention and Treatment (CPCT) at the University of Catania and of the Center of Excellence for the acceleration of HArm Reduction (CoEHAR) at the same university, which has received support from the Foundation for a Smoke Free World to conduct eight independent investigator-initiated research projects on harm reduction. R Polosa is currently involved in a patent application concerning an app tracker for smoking behavior developed for ECLAT Srl. R Polosa is also currently involved in the following pro bono activities: scientific advisor for LIAF, Lega Italiana Anti Fumo (Italian acronym for Italian Anti-Smoking League), the Consumer Advocates for Smoke-free Alternatives (CASAA), and the International Network of Nicotine Consumers Organizations (INNCO); Chair of the European Technical Committee for standardization on ‘Requirements and test methods for emissions of electronic cigarettes’ (CEN/TC 437; WG4). R O’Leary is supported with a contract from ECLAT Srl. ECLAT receives funding from the Foundation for a Smoke-Free World. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.