Cigarette smoking in adults has declined globally by about 33% from 2000-2018.1 These trends have created pressure on the tobacco industry which is now mostly consolidated among 3 global players – Philip Morris International, British American Tobacco, and Japan Tobacco International.1 This has led to the emergence of electronic nicotine delivery systems (ENDs), heated tobacco products (HTPs), and oral nicotine products (ONPs).1,2 Some of these products were originally marketed under a “reduced-harm” message but industry strategies continue to evolve which creates a need for the continued scientific study of the nicotine landscape, marketing, and appeal of ENDs, HTPs, and ONPs.
Many consumers falsely believe these products are less harmful or without risk.3,4 Restrictions on indoor use, sales, and marketing also make cigarette use less appealing.1 A significant portion of adults report using ENDs to quit or reduce smoking since flavors tend to be a positive factor for usage among youth and adults. Design elements, packaging and price, social acceptability, and perceived safety of bystanders are considered other usage factors.1 At the same time, the tobacco industry has created new and creative marketing messages with terms such as ‘chic’ and ‘pure,’ ‘alternative,’ ‘clean,’ and ‘reduced risk’ for broader appeal with other messaging about providing freedom of choice among users.1
Despite the above, recent data reported by the Centers for Disease Control revealed that ENDs usage has decreased among middle and high-school students from 14.1% to 10.0% nationally between 2022-2023.5 This same nationally representative survey showed that, of users, 25.2% report daily usage and 89.4% prefer flavoring. The continued study of trends, policies, and especially the short- and long-term health consequences of alternative delivery mechanisms is justified.
Novel tobacco products, especially ENDs, have been shown to be associated with cardiometabolic disease indicators, including obesity, high blood pressure, and glucose intolerance.6-10 Tobacco products may influence cardiometabolic health through alterations in physiological function and health behaviors. Extant research shows that nicotine spikes blood sugar and modifies glucose regulation and cholesterol.7,9,11 In addition sugar and sugar substitutes, which are often added to ENDs and ONPs,12 can have negative impacts on glucose, insulin resistance, and cholesterol level imbalance13-14 In addition to the cardiometabolic effects of novel tobacco products, use of tobacco products may affect eating behavior and physical activity, which could have implications for cardiometabolic health outcomes. Given the availability of products in fruit and candy flavors, flavored tobacco products could function as meal replacements or as a way to satisfy cravings for unhealthy foods.15 Alternatively, flavored products could also potentiate food urges and cravings, especially in at-risk individuals.16 In addition, use of tobacco products may limit one’s ability to be physically active by negatively impacting one’s respiratory and cardiovascular functioning.17
These emerging and evolving products present challenges for scientists, public health advocates, and practitioners related to multi-morbidities and multiple health behaviors, including cardiometabolic health and related health behaviors. Insofar, much of the research stems from preliminary rat models7 so experimental research in humans is needed to understand the impact of novel tobacco products on acute and chronic cardiometabolic disease indicators as well as eating and physical activity behaviors. Ultimately, further research will support appropriate regulatory, prevention, and intervention efforts to improve cardiometabolic health.