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Impact of electronic cigarette and heated tobacco product on conventional smoking: an Italian prospective cohort study conducted during the COVID-19 pandemic
  1. Silvano Gallus1,
  2. Chiara Stival1,
  3. Martin McKee2,
  4. Giulia Carreras3,
  5. Giuseppe Gorini3,
  6. Anna Odone4,5,
  7. Piet A van den Brandt6,7,
  8. Roberta Pacifici8,
  9. Alessandra Lugo1
  1. 1 Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
  2. 2 London School of Hygiene & Tropical Medicine, London, UK
  3. 3 Oncologic Network, Prevention and Research Institute, Florence, Italy
  4. 4 Department of Public Health, Experimental and Forensic Medicine, University of Pavia Faculty of Medicine and Surgery, Pavia, Italy
  5. 5 School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
  6. 6 Department of Epidemiology, GROW—School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
  7. 7 Department of Epidemiology, CAPHRI—School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
  8. 8 National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
  1. Correspondence to Dr Silvano Gallus, Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy; silvano.gallus{at}


Objective Debate continues about whether electronic cigarettes (e-cigarettes) and heated tobacco products (HTP) reduce or increase the probability of smoking, with many studies compromised by stated or unstated conflicts of interest. We undertook a longitudinal study in Italy.

Methods 3185 Italian participants aged 18–74 years provided baseline (April–May) and follow-up (November–December) responses in 2020, reporting smoking status and use of e-cigarettes and HTP. We tracked transitions over that period and reported risk ratios (RR) and corresponding 95% CIs for changes in smoking in relation to baseline use of e-cigarettes and HTPs.

Results Never cigarette smokers who used e-cigarettes at baseline were much more likely to start smoking (compared with never users, RR 8.78; 95% CI: 5.65 to 13.65) and current HTP users (RR 5.80; 95% CI: 3.65 to 9.20). Among ex-smokers, relapse (17.2%) at follow-up was more likely among e-cigarette (RR 4.25; 95% CI: 2.40 to 7.52) and HTP users (RR 3.32; 95% CI: 2.05 to 5.37). Among current smokers at baseline, those who had continued smoking at follow-up were 85.4% overall. These were more frequently current novel product users (compared with non-users, RR 1.10; 95% CI: 1.02 to 1.19 for e-cigarette users; RR 1.17; 95% CI: 1.10 to 1.23 for HTP users).

Conclusions Both e-cigarette and HTP use predict starting smoking and relapse, and appear to reduce smoking cessation. Due to the limited sample size within specific strata, the association with quitting smoking should be confirmed by larger prospective studies. These findings do not support the use of e-cigarettes and HTPs in tobacco control as a consumer product, at least in Italy.

  • electronic nicotine delivery devices
  • non-cigarette tobacco products
  • cessation
  • global health

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  • Twitter @SilvanoGallus, @martinmckee, @GiuseppeGorini, @alessandra_lugo

  • Contributors SG had the original study idea; RP and AO obtained the funding. AL and CS did the statistical analysis; SG drafted the article in collaboration with CS and AL; all other authors made substantial contributions to conception, design and data interpretation; all the authors approved the final version of the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding The survey was co-funded by the Italian National Institute of Health (ISS) and Fondazione Cariplo. The work of SG, AL, CS and AO is partially supported by a research grant of the DG-Welfare of Lombardy Region (Call: Progetti di ricerca in ambito sanitario connessi all’emergenza COVID 19; DGR n. XI/3017). The work of GC and GG is partially supported by the Tuscany Region within the Lost in Toscana Project. The research leading to these results has received funding from AIRC under IG 2021 - ID. 25987 project – P.I. Gallus Silvano.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.