Cardiovascular Outcomes among Combustible-Tobacco and Electronic Nicotine Delivery System (ENDS) Users in Waves 1 through 5 of the Population Assessment of Tobacco and Health (PATH) Study, 2013–2019

Martin C. Mahoney, Cheryl Rivard, Heather L. Kimmel, Hoda T. Hammad, Eva Sharma, Michael J. Halenar, Jim Sargent, K. Michael Cummings, Ray Niaura, Maciej L. Goniewicz, Maansi Bansal-Travers, Dorothy Hatsukami, Diann Gaalema, Geoffrey Fong, Shannon Gravely, Carol H. Christensen, Ryan Haskins, Marushka L. Silveira, Carlos Blanco, Wilson ComptonCassandra A. Stanton, Andrew Hyland

Research output: Contribution to journalArticlepeer-review


Background: Prior studies have not clearly established risk of cardiovascular disease (CVD) among smokers who switch to exclusive use of electronic nicotine delivery systems (ENDS). We compared cardiovascular disease incidence in combustible-tobacco users, those who transitioned to ENDS use, and those who quit tobacco with never tobacco users. Methods: This prospective cohort study analyzes five waves of Population Assessment of Tobacco and Health (PATH) Study data, Wave 1 (2013–2014) through Wave 5 (2018–2019). Cardiovascular disease (CVD) incidence was captured over three intervals (Waves 1 to 3, Waves 2 to 4, and Waves 3 to 5). Participants were adults (40+ years old) without a history of CVD for the first two waves of any interval. Change in tobacco use status, from exclusive past 30 day use of any combustible-tobacco product to either exclusive past 30 day ENDS use, dual past 30 day use of ENDS and combustible-tobacco, or no past 30 day use of any tobacco, between the first two waves of an interval was used to predict onset of CVD between the second and third waves in the interval. CVD incidence was defined as a new self-report of being told by a health professional that they had congestive heart failure, stroke, or a myocardial infarction. Generalized estimating equation (GEE) analyses combined 10,548 observations across intervals from 7820 eligible respondents. Results: Overall, there were 191 observations of CVD among 10,548 total observations (1.7%, standard error (SE) = 0.2), with 40 among 3014 never users of tobacco (1.5%, SE = 0.3). In multivariable models, CVD incidence was not significantly different for any tobacco user groups compared to never users. There were 126 observations of CVD among 6263 continuing exclusive combustible-tobacco users (adjusted odds ratio [AOR] = 1.44; 95% confidence interval (CI) 0.87–2.39), 15 observations of CVD among 565 who transitioned to dual use (AOR = 1.85; 0.78–4.37), and 10 observations of CVD among 654 who quit using tobacco (AOR = 1.18; 0.33–4.26). There were no observations of CVD among 53 who transitioned to exclusive ENDS use. Conclusions: This study found no difference in CVD incidence by tobacco status over three 3 year intervals, even for tobacco quitters. It is possible that additional waves of PATH Study data, combined with information from other large longitudinal cohorts with careful tracking of ENDS use patterns may help to further clarify this relationship.

Original languageEnglish (US)
Article number4137
JournalInternational Journal of Environmental Research and Public Health
Issue number7
StatePublished - Apr 1 2022
Externally publishedYes


  • cardiovascular disease
  • electronic cigarette
  • electronic nicotine delivery systems (ENDS)
  • health survey
  • tobacco use

ASJC Scopus subject areas

  • Pollution
  • Public Health, Environmental and Occupational Health
  • Health, Toxicology and Mutagenesis


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