From the academic center of the city by the bay comes a new study on e-cigarettes – in this instance, looking at the modeled health costs. Is their conclusion that “healthcare utilization and expenditures attributable to e-cigarette use are substantial and likely to increase over time” true? I will give them a B for the math but, at best, a D for the underlying assumptions and narrative.
While the use of e-cigarettes by adults seems relatively stable at about 3%, e-cigarette use by youths has risen. In 2018, 7.6% of young adults (18-24) were “users.” For context, the CDC estimates that 12.5% of the population smokes, predominantly those aged 24 to 64. It is undeniable that smoking cigarettes negatively impacts your health and drives up the use and cost of healthcare. E-cigarette use more than likely also negatively impacts your health, but to a lesser degree – that is why we believe they are a form of harm reduction.  The researchers sought to put a price tag on the health costs of e-cigarette use, certainly a reasonable component in the policy trade-offs over the use of e-cigarettes.
To get at those numbers, they developed a model. They used the National Health Interview Survey (NHIS), a household survey of the general population in the US that included detailed questions on health and use of tobacco products. They defined four groups:
- Never tobacco users
- Exclusive e-cigarette users
- Dual-users – those using combustible and vapable tobacco products
- Users of other tobacco products – cigars, chewing tobacco, etc.
The model incorporated the sociodemographics of roughly 109,000 NHIS participants.  Their cost data was from the Medical Expenditure Panel Survey, representative of costs and utilization.
All models are simplifications. The researchers began with the assumption that e-cigarette use would negatively impact an individual’s health and that this negative impact would increase utilization and cost. Since they had both a self-reported assessment of their health (excellent, very good, good, fair, or poor) and of their health utilization, they created a model of what health care expenditures might be given smoking, BMI, gender, education, income, drinking, insurance coverage, race, marital status, and insurance coverage.
The model needed a control group, termed a counterfactual, representing the putative health costs of the same individuals who were all never smokers. They used the same model but left out the variable of smoking. That is a tricky assumption because smoking has fellow travelers, like drinking and education, creating interactions that a model misses.
A more significant assumption is that all health impacts and, therefore, utilization are instantaneous. Smoking for one year is as deleterious as smoking for 30 years. That, of course, is nearly always untrue. While combustible and e-cigarette use will immediately alter our physiologic responses, the health impacts requiring doctor, ER, and hospital visits take some time. The average age for a heart attack is roughly 65, although 10% are seen as early as age 45. Similar ages apply to strokes and lung cancer. COPD is often seen in an individual’s 40s.
E-cigarettes have been marketed for 15 years and have been the tobacco product of choice for young adults for eight years. I find the assumption that e-cigarettes alone have manifested increased health costs at this point debatable.
Let’s start with the factuals. 48% of the respondents were never smokers, 48% used other forms of tobacco, 3.5% were dual users (e-cigarettes and combustibles), and 0.2% were exclusive users of e-cigarettes. That means that the following costs were based on 186 e-cigarette users and 3845 dual users – not the 109,000 initial respondents. This reduction in sample size increases the uncertainty of the model’s findings, but let’s take them as being in the ballpark.
“The per-user attributable healthcare expenditures were $1796 per current exclusive e cigarette user, $2050 per current dual/poly e-cigarette user, and $2024 per all current e cigarette user.”
They also expressed the model’s results in aggregate costs, but I will stick with the per-user expenditures. I would argue that their research demonstrates that exclusive e-cigarette use results in harm reduction; it certainly seems to reduce costs. Dual-users have the health harms of combustibles and e-cigarettes; there is a more significant impact and combining them as all current e-cigarette users is wordsmithing, not an apt aggregation.
The researchers point to a study using NHIS data that per-smoker (meaning combustible) attributable health care expenditures are $5602. The finding of this study, for both those exclusively using e-cigarettes and the dual users, is roughly a third as much. E-cigarettes reduce health care utilization and costs.
The researchers point out that exclusive e-cigarette users had “higher odds of reporting poor health status than never tobacco users.” That would be no surprise; no one is claiming e-cigarettes do no harm; they are less harmful than the alternative. Just like the prescription of buprenorphine is less harmful than the free-market acquisition of fentanyl.
Are exclusive e-cigarette healthcare costs significant? In 2018 they represented $1.3 billion in expenditures based upon this model. In 2018 our total healthcare expenditures were $3.6 trillion. According to the model, the healthcare costs for dual users were $13.8 billion – tenfold greater than exclusive e-cigarette use.
Are e-cigarette healthcare costs going to grow? That remains unclear, although the use by the young suggests they might. But when compared to the costs of dual use or the sole use of combustible tobacco products, the net healthcare costs will drop.
Smoking in any form is stupid and carries health consequences. Despite the explicit bias of the researchers and their conclusions, the study demonstrates that the use of e-cigarettes appears to be an effective form of harm reduction. It should be marketed in that manner, just as it is in the UK.
There is more to this story. Cameron English helps to complete the tale, discussing how the FDA, through funding by Big Tobacco "user fees" continues to fund anti-e-cigarette research, including this study.
 As an aside, methadone or Buprenorphine as a means of harm reduction concerning opioid addiction doesn’t garner as much attention or concern.
 In the study's opening it frames concern about the increased use of e-cigarettes by our young, those 15 to 24. The Truth Initiative, an anti-smoking group funded by money from the Tobacco Settlement, reports that those 15 to 17 are "16 times more likely to vape than people age 25 to 34." Among the limitations of the study the researchers indicate that the young, those we should be most concerned about were not included in the study, "We did not include youth in the analysis due to their low healthcare utilisation."
Source: Healthcare utilisation and expenditures attributable to current e-cigarette use among US adult Tobacco Control DOI: 10.1136/tobaccocontrol-2021-057058