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In Korea, the prevalence of cigarette smoking has declined over several decades, from 35.1% in 1998 to 17.7% in 2022 [1]. Conversely, the prevalence of tobacco products, including cigarettes, e-cigarettes, and heated tobacco products, was 22.1%, which is 4.5% points higher. This discrepancy suggests that the use of noncombustible nicotine and tobacco products is increasing. According to the Korea Community Health Survey, the prevalence of ecigarette use increased from 4.5% in 2020 to 9.4% in 2024, and the prevalence of heated tobacco product use increased from 3.3% in 2020 to 6.6% in 2024 [2].
Smokers who use noncombustible nicotine and tobacco products often seek reassurance by asking whether these products are less harmful than combustible cigarettes. However, physicians cannot provide a definitive answer because of insufficient evidence. A growing body of evidence indicates that the use of e-cigarettes and heated tobacco products has harmful health effects. The study in our current issue involved 4,404 Korean adults aged 20 years or older, who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) between 2019 and 2020. It examined the association between e-cigarette use and insulin resistance using the triglyceride-glucose (TyG) index [3]. The use of e-cigarettes was associated with higher TyG index values (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.03–1.84) compared to never smoking. Similarly, another study revealed that the use of heated tobacco products was associated with higher levels of low-density lipoprotein cholesterol than never smoking [4].
Compared with combustible cigarettes, e-cigarettes generally emit lower levels of toxic compounds such as ammonia, formaldehyde, carbon monoxide, and aromatic amines [5]. However, a reduction in toxicant emissions does not necessarily cause a proportionate reduction in health risks. The relationship between exposure to toxic substances from tobacco and health risks is nonlinear; that is, even lower levels of exposure may exert a substantial detrimental impact [6]. Furthermore, e-cigarettes could pose unexpected risks, such as e-cigarette or vaping product use-associated lung injury, a severe pulmonary illness related to the use of vitamin E acetate and tetrahydrocannabinol-containing eliquids [7].
Further investigations that directly compare the health effects of combustible and noncombustible tobacco products are warranted. In this issue, the authors compared health-related quality of life (HRQoL) among 16,429 Korean men according to tobacco use using KNHANES data collected between 2013 and 2020 [8]. They found that any tobacco users had a significantly higher risk of impaired HRQoL compared to those who had never smoked (OR, 1.42; 95% CI, 1.05–1.92). Interestingly, this association remained significant only among combustible cigarette smokers and not among users of noncombustible nicotine or tobacco products.
In conclusion, the rapid increase in the use of noncombustible nicotine and tobacco products raises important public health concerns. Current evidence clearly shows that e-cigarettes and heated tobacco products are harmful alternatives. Their long-term risks remain uncertain, which may not be evident until several decades later. Therefore, longitudinal studies are urgently needed to clarify the health risks associated with noncombustible nicotine and tobacco products [9].
Article Information
Conflict of interest
Su-Min Jeong is an Associate Editor of the journal but was not in volved in the peer reviewer selection, evaluation, or decision process of this article. Except for that, no other potential conflicts of interest relevant to this article were reported.
Funding
None.
Data availability
Not applicable.
Author contribution
All the work was done by Su-Min Jeong.
References
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