E-Cigarette Use Among Persons With Diagnosed HIV in the U.S.

HIGHLIGHTS • E-cigarette use among persons with HIV may be higher than among the general U.S. population.• About 1 in 20 persons with HIV use E-cigarettes, which may be an emerging health concern.• Development of interventions may be needed to deter the use of E-cigarettes among persons with HIV.


INTRODUCTION
In the late 2000s, E-cigarettes emerged in the U.S. market and were initially advertised as a cessation aid to those who smoke cigarettes. 1 These battery-powered devices deliver nicotine, flavoring, and other additives through an inhaled aerosol. 1 Since the emergence of Ecigarettes in the U.S. and world markets, minimal information exists about potential long-term health effects.
However, there are studies on the short-term effects of E-cigarettes. 2 Studies have linked E-cigarette use to adverse cardiovascular and respiratory outcomes. 3,4otably, ingredients in E-cigarettes vary, including various nicotine concentrations, carcinogens, and toxic substances found in tobacco cigarettes. 1 Although there are some common carcinogens in E-cigarettes and cigarettes, overall, E-cigarettes appear to contain fewer amounts of carcinogens 5−8 and may benefit those trying to quit smoking, if used as a complete substitute for combustible tobacco products. 9ver time, the use of E-cigarettes has increased among various population groups, especially youth (aged 13−18 years), young adults (aged 18−24 years), and those who currently smoke cigarettes. 10,11During 2018−2019, E-cigarette use among U.S. adults was 2.3% and was higher among some population groups. 12About 39% of adults who currently use E-cigarettes also currently smoke cigarettes (dual users), 12,13 which may lead to increased nicotine dependency and higher risks of tobacco-related morbidity and mortality. 3,14ince 2009, cigarette smoking among persons with diagnosed HIV (PWH) has decreased; however, usage remains significantly higher, and PWH are less likely to quit than the general U.S. population (33.6% vs. 16.8%). 15Risks of HIV-and non-HIV-related morbidity and mortality due to cigarette smoking are higher for PWH, including those taking antiretroviral medications (ARTs). 16Even though E-cigarettes can serve as a bridge to tobacco cessation among persons who currently smoke cigarettes, the health effects, such as lung diseases, associated with their use may pose similar health risks among PWH, similar to that of the general population. 3,6,14At present, estimates of E-cigarette use among PWH are scarce.The purpose of this study is to describe the national estimates of E-cigarette use among PWH by selected sociodemographic, behavioral, and clinical characteristics.

METHODS Study Population
Data were obtained from the Medical Monitoring Project (MMP), an annual cross-sectional survey designed to produce nationally representative estimates of behavioral and clinical characteristics of U.S. adults diagnosed with HIV.Briefly, the 2018 and 2019 MMP data cycles used a 2-stage sampling method that has been described elsewhere. 17MMP data collection has been determined to be nonresearch. 18Participating states or territories obtained local IRB approval, when necessary, on the basis of local requirements to collect data and obtained informed consent from all participants.Data were weighted on the basis of known probabilities of selection at state/territory and person levels and to adjust for person-level nonresponse and were poststratified to National HIV Surveillance System population totals. 17Data were combined from participant interviews and medical record abstraction collected during MMP's 2018 and 2019 data cycles (n=8,150) to assess the prevalence of E-cigarette use among PWH.

Measures
Persons who currently use E-cigarettes were defined as persons who reported having used ≥1 E-cigarettes in their lifetime and in the past 30 days.Persons who have ever tried E-cigarettes were defined as individuals who had used ≥1 E-cigarettes in their lifetime but not in the past 30 days.Persons who have never tried Ecigarettes were defined as individuals who had never used an Ecigarette.
Self-reported information on sociodemographic and behavioral characteristics from participants was included.Sociodemographic variables included sex, sexual orientation, race/ethnicity, age, educational attainment, health insurance or other coverage for medical expenses, and annual household income.Household income and the number of household dependents were used to determine participants' poverty level on the basis of guidelines and thresholds published by the HHS, Census Bureau for 2017−2019. 19ealth insurance was categorized on the basis of participant's self-report regarding the type of coverage during the 12 months before the interview.Behavioral characteristic variables included the use of cigarettes, alcohol, and other substances as well as diagnosis of depression.Utilizing an established definition for smoking, 15 persons who currently smoke were individuals who smoked at least 100 cigarettes in their lifetime and currently smoked daily, weekly, monthly, or less than monthly.Persons who formerly smoked were individuals who reported that they had smoked ≥100 cigarettes in their lifetime and currently did not smoke, whereas persons who never smoke were individuals who reported that they had smoked 0 to <100 cigarettes in their lifetime.Any alcohol use was defined as having consumed ≥1 alcoholic beverage during the 12 months before the interview.Any drug use was defined as having used injected or noninjected drugs during the past 12 months.Drugs assessed include both illicit and prescription drugs.Prescription drugs could have been nonprescribed or prescribed but taken more than directed.As described elsewhere, self-reported responses to the Patient Health Questionnaire depression scale were used to determine whether participants had major, other, or no depression. 20lso included were HIV clinical variables abstracted from participants' medical records.These variables included time since HIV diagnosis, HIV disease stage at diagnosis, prescribed ART, and recent or sustained viral suppression.Recent viral suppression was defined as the most recent viral load measurement in the past 12 months <200 copies/mL.Sustained viral suppression was defined as having viral load measurements <200 copies/mL on all viral load measurements in the past 12 months.

Statistical Analysis
Weighted percentages and associated 95% CIs were computed.Statistical estimations were suppressed if the sample size was <30 or the relative coefficient of variation was >0.30.Statistically significant differences (p<0.05) were determined using chi-square tests.All analyses accounted for complex sample design and unequal selection probabilities and were conducted using SAS, Version 9.4.Data were analyzed in 2021.suppression (CI=58.9,64.2).At least 32% of the study population were persons who currently smoke cigarettes (CI=30.0,33.9), 62.1% used alcohol in the last 12 months (CI=59.9,64.2), and 33.0%used injection or noninjection drugs in the last 12 months (CI=30.9,35.0).In the study population, 5.9% currently used E-cigarettes (CI=5.2,6.5), 27.1% ever used (but not currently) an Ecigarette (CI=24.6,29.7), and 72.9% had never used Ecigarettes (CI=70.3, 75.4).Current E-cigarette use among PWH was about 2 times higher among males (6.7%, CI=5.9, 7.5) than among females (3.3%, CI=2.3, 4.2).Current E-cigarette use among PWH was also about 2 times higher among those who reported being homosexual or gay (8.0%, Non-Hispanic White: participants who self-identify as non-Hispanic and White only.Non-Hispanic Black: participants who self-identify as non-Hispanic and Black/African American only¡Hispanic participants who self-identify as Hispanic, even if other race/ethnicity categories were selected.
Other participants include those who selected Asian, Native Hawaiian/other Pacific Islander, American Indian/Alaska Native, or multiple race/ethnicity categories.
f Never smoker: respondents who said that they have not smoked at least 100 cigarettes in their entire life.Current smokers: respondents who said that they have smoked at least 100 cigarettes in their entire life and who now smoke daily, weekly, monthly, and less than monthly.Former smoker: respondents who said that they have smoked at least 100 cigarettes in their entire life and who now never smoke.
g E-cigarette ever use was defined as respondents who said that they have used an E-cigarette even just 1 time in their entire life.Current E-cigarette use was defined as respondents who said that they have used an E-cigarette even just 1 time in their entire life and have used E-cigarettes during the past 30 days.h Includes all drugs that were injected and not injected (i.e., administered by any route other than injection), including legal drugs that were not used for medical purposes.Current E-cigarette use was about 5 times higher among those who currently smoke cigarettes (11.1%,CI=9.7, 12.4) and 2 times higher among those who formerly smoked cigarettes (6.5%, CI=5.1, 7.9) than among those who never smoked cigarettes (2.0%, CI=1.4,2.7).Current E-cigarette use was higher among people who used substances than among people who did not.Among persons who had used any alcohol or who used injectable and noninjectable drugs in the past 12 months, E-cigarette use was 7.2% (CI=6.3,8.0) and 9.7% (CI=8.5, 11.0), respectively.Current use of E-cigarettes was higher among PWH who had major depression (10.8%,CI=8.1, 13.6) and other forms of depression (6.1%, CI=3.7, 8.6) than among PWH who did not have depression (5.3%, CI=4.6, 6.0).
Ever E-cigarette use was higher among persons who currently smoke cigarettes (51.0%,CI=47.2, 54.8) and persons who formerly smoked cigarettes (30.2%, CI=27.4,32.9) than among persons who never smoked cigarettes (9.5%, CI=8.1, 11.0).Ever E-cigarette use was higher among people who used substances than among people who did not.Among persons who had used any alcohol or who used injectable and noninjectable drugs in the past 12 months, E-cigarette use was 31.7% (CI=29.2,34.1) and 44.8% (CI=42.0,47.6), respectively.Ever use of E-cigarettes was higher among those who had major depression (41.9%,CI=37.5, 46.4) than among those who had no depression (25.0%,CI=22.4,27.6).

DISCUSSION
To our knowledge, these are the first nationally representative prevalence estimates of E-cigarette use among U.S. PWH.These findings suggest that current and ever use of E-cigarettes among PWH is higher than among the general U.S. population. 12Findings showed that nearly 1 in 4 PWH had tried using E-cigarettes and that 1 in 20 PWH were current users.Even though E-cigarettes have only been in the U.S. market for about 10 years, evidence is emerging that E-cigarette use may cause deleterious health effects, especially for young users. 3,4lthough this study group was an older cohort, with a median age of 50 years, only 2% were between the ages of 18 years and 24 years; we also found that current E-cigarette use varied among subgroups of PWH.Specifically, current and ever usage was higher among PWH who self-identified as bisexual, homosexual, or gay; males; non-Hispanic white people or others; those aged 25−34 years; those who had more than a high-school diploma; those who used any alcohol or drugs in the past 12 months; and those who have not sustained viral suppression.
Even though E-cigarettes were originally marketed as effective cessation aids to persons who smoke conventional cigarettes, they contain nicotine, the main ingredient, and other toxic ingredients also found in conventional cigarettes. 1 While the emissions from Ecigarettes generally contain lower levels of harmful ingredients than the smoke from regular cigarettes, they are not necessarily safer. 21Research shows that dual use of E-cigarettes and conventional cigarettes increases nicotine exposure and intake, which may prolong tobacco substance use disorder and negate cessation efforts. 6,14he finding that approximately 11% of PWH who currently smoke conventional cigarettes had also tried E-  a E-cigarette ever use was defined as respondents who said that they have used an E-cigarette even just 1 time in their entire life.Current E-cigarette use was defined as respondents who said that they have used an E-cigarette even just 1 time in their entire life and have used E-cigarettes during the past 30 days.Non-Hispanic White: participants who self-identify as non-Hispanic and White only.Non-Hispanic Black: participants who self-identify as non-Hispanic and Black/African American only; Hispanic participants who self-identify as Hispanic, even if other race/ethnicity categories were selected.Other participants include those who selected Asian, Native Hawaiian/other Pacific Islander, American Indian/ Alaska Native, or multiple race/ethnicity categories.h Never smoker: respondents who said that they have not smoked at least 100 cigarettes in their entire life.Current smokers: respondents were defined as those who said that they have smoked at least 100 cigarettes in their entire life and who now smoke daily, weekly, monthly, and less than monthly.Former smoker: respondents who said that they have smoked at least 100 cigarettes in their entire life and who now never smoke.
i Includes all drugs that were injected and not injected (i.e., administered by any route other than injection), including legal drugs that were not used for medical purposes.NA estimates are not presented because the coefficient of variance ≥30%.www.ajpmfocus.orgcigarettes is consistent with general population studies regarding the dual use of E-cigarettes and conventional cigarettes. 12,13It is noteworthy that persons with HIV who smoke make fewer quit attempts and have lower rates of smoking cessation success than the general population. 15Similar to that of the general population, several behavioral risk factors such as alcohol, substance use, and mental health issues have been identified as barriers to successful smoking cessation among PWH. 22hese barriers combined with perceptions that E-cigarettes are effective cessation aids may partially explain the higher prevalence of E-cigarette use among persons with HIV who currently smoke than among the general population.Despite the fact that E-cigarettes are not Food and Drug Administration approved for smoking cessation coupled with the uncertainty of long-term health impacts, PWH are interested in their use. 23Ecigarettes may have the potential to benefit non-pregnant adults who smoke conventional cigarettes if used as a complete substitute for regular cigarettes and other smoked tobacco products. 21In order for adults who smoke conventional cigarettes to achieve any meaningful health benefits from e-cigarettes, they must fully switch to E-cigarettes and completely stop smoking conventional cigarettes and other tobacco products. 21Even though less harmful cessation aids exist (e.g., nicotine replacement, pharmaceutical treatment, and cessation counseling), 24 there is literature to suggest that PWH may use them as a bridge to tobacco cessation or a safer substitute for combustible tobacco products. 23ver the past 30 years, achievements in the HIV epidemic resulting in PWH living longer and healthier lives have occurred. 25Considering amplified health effects caused by the use of conventional cigarettes for PWH compared with that for persons in the general population, 16,24

Limitations
This study has limitations.First, the analysis is limited to persons diagnosed with HIV in the U.S.; the results do not provide E-cigarette estimates among persons with undiagnosed HIV in the U.S. Second, our estimates of E-cigarette and conventional cigarette use were based on self-report and were not biochemically validated; however, studies have shown good correlation between self-reported tobacco use behaviors and biochemical measures such as cotinine. 26Third, although MMP used data-weighting methods to mitigate nonresponse bias, nonresponse bias is still possible.In addition, there are differences between MMP and general population surveys (e.g., National Health Interview Survey) in the definition of current E-cigarette use.Fourth, owing to population sample size and unstable estimates, we were unable to perform a multivariable regression. 27For example, for current E-cigarette use by age, the estimate of the proportion of current E-cigarette use in the age group 18−24 years had a coefficient variation >0.30, so it is suppressed for reporting and cannot be modeled. 27

CONCLUSIONS
These findings suggest that current and ever use of Ecigarettes among PWH was at a greater proportion than among the general U.S. population, 12 suggesting that Ecigarette use may be a potential issue for PWH if they are being used with other tobacco products and not solely used as a substitute for conventional cigarettes and other smoked tobacco products.It is unclear at this time whether health effects related to E-cigarettes are amplified in the presence of HIV infection as it is for cigarette smoking. 16E-cigarette use may be a preventable health threat; therefore, usage should be discouraged among adults who do not smoke conventional cigarettes.Persons interested in quitting smoking should be encouraged to first try Food and Drug Administrationapproved smoking cessation aids, especially among PWH.

Table 1 .
Sociodemographic and HIV Clinical Characteristics of Adults With Diagnosed HIV, MMP, 2018−2019 (continued) a Numbers are unweighted.Numbers might not add to total because of missing data.bPercentages are weighted column percentages.Percentages might not sum to 100 because of rounding.cCIs incorporate weighted percentages.dVariable definition has been described in detail in the study Centers for Disease Control and Prevention.Behavioral and Clinical Characteristics of Persons with Diagnosed HIV Infection: Medical Monitoring Project, United States 2016 Cycle (June 2016 − May 2017).In: HIV Surveillance Special Report 21; Revised edition.https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.Published June 2019.e Among the HIV clinical characteristics, current E-cigarette use was almost 2 times higher among PWH who were not in HIV disease Stage 3 than among those who were (7.1%, CI=6.1, 8.0 vs. 4.9%, CI=4.1, 5.7).Current E-cigarette use was also high among PWH who did not have sustained viral suppression (6.7%, CI=5.6, 7.8, p<0.05).
ART, antiretroviral therapy; HS, high school; MMP, Medical Monitoring Project; RW/ADAP, Ryan White HIV/AIDS or AIDS Drug Assistance Coverage; VL, viral load.

Table 2 .
Sociodemographic and HIV Clinical Characteristics Among E-cigarette Adult Users With Diagnosed HIV, MMP 2018−2019

Table 2 .
Sociodemographic and HIV Clinical Characteristics Among E-cigarette Adult Users With Diagnosed HIV, MMP 2018−2019 (continued)

Table 2 .
Sociodemographic and HIV Clinical Characteristics Among E-cigarette Adult Users With Diagnosed HIV, MMP 2018−2019 (continued) Statistical significance within demographic, HIV clinical, and behavior characteristics using chi-square tests.f Variable definition has been described in detail in the study Centers for Disease Control and Prevention.Behavioral and Clinical Characteristics of Persons with Diagnosed HIV Infection: Medical Monitoring Project, United States 2016 Cycle (June 2016 − May 2017).In: HIV Surveillance Special Report 21; Revised edition.https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.Published June 2019.
b Numbers are unweighted.c Percentages are weighted row percentages.d CIs incorporate weighted percentages.e g ART, antiretroviral therapy; HS, high school; MMP, Medical Monitoring Project; NA, not applicable; RW/ADAP, Ryan White HIV/AIDS or AIDS Drug Assistance Coverage; VL, viral load.
E-cigarette use among PWH merits close attention.To avoid a rapid increase in E-cigarette use among PWH and to sustain PWH living longer and healthier lives, monitoring efforts for E-cigarette use among PWH and interventions to deter tobacco use for PWH should continue.