As cigarette smoking rates reach historic lows in the United States, new research from MUSC Hollings Cancer Center suggests that fundamental changes in cigarette use are driving the trend. Young people are increasingly switching to non-flammable nicotine products, especially e-cigarettes, also known as electronic cigarettes.
The findings, published in JNCI Cancer Spectrum, provide new insights into how tobacco use is evolving and what those changes mean for the incidence of tobacco-related cancers. Because combustible tobacco products, primarily cigarettes, account for the majority of cancer deaths, understanding not just whether or not people use tobacco, but also what types of tobacco products they use, is increasingly important in predicting the future burden of tobacco-related cancer.
In this study, we will peel off another layer of the onion. We wanted to understand how patterns of tobacco use are changing. Our results show that exclusive use of cigarettes is replacing exclusive use of other combustible products, primarily e-cigarettes, especially among young people. ”
Dr. K. Michael Cummings, lead study author, tobacco control researcher
A closer look at tobacco use
National surveys show that the smoking rate among young people is less than 2% and is steadily decreasing among adults. Although overall tobacco use has remained relatively stable, the decline in the number of smokers appears to have accelerated in recent years. This raises an important question. If fewer people smoke cigarettes, what are they using instead?
This question builds on years of research by Cummings and Hollings colleagues, who investigated the health effects of switching from combustible cigarettes to e-cigarettes. Their previous research has shown that smokers who switch to e-cigarettes have far less exposure to carcinogenic chemicals and are more likely to quit than smokers who continue to use cigarettes.
To look at those patterns at a population level, the study’s researchers analyzed data from the National Health Interview Survey, a nationally representative survey of U.S. adults from 2015 to 2023. Unlike previous national reports that tracked overall tobacco use, this study distinguished between combustible products such as cigarettes, cigars, pipes, and hookahs; Non-flammable products such as electronic cigarettes, smokeless tobacco, and nicotine pouches. Dual use of both product types.
“We chose 2015 as a starting point because that’s when e-cigarettes started to become popular,” Cummings explained.
This research combines expertise in tobacco control, behavioral science, and population modeling. Hollings researchers Dr. Avery Roberson and Dr. Tracy Smith contributed to the study, along with collaborators from Rutgers University, Georgetown University, the University of Michigan, and the University of British Columbia.
The analysis showed that combustible tobacco-only use has declined in nearly every age group, with the sharpest decline among young adults ages 18 to 34. During the same period, the proprietary use of non-flammable products increased, mainly due to e-cigarettes. Using both product types together was uncommon, reported by only 2% to 3% of adults.
“One of the most surprising findings was that dual use was not increasing,” Cummings said. “The hope is that as cigarette smoking declines, more people will use both cigarettes and e-cigarettes. If anything, the use of e-cigarettes alone has increased, while the combination has remained remarkably stable.”
This trend also reveals important differences by age. Although younger adults are increasingly moving away from combustible cigarettes, adults age 55 and older continue to smoke and consume fewer non-combustible tobacco products.
“For me, the red flag, the take-home message, is that we’re ignoring older people who smoke,” Cummings said. “These people have been smoking for decades and are less likely than younger adults to switch to lower-risk non-combustible tobacco products. They are the group that stands to gain the most immediate health benefits from quitting smoking tobacco.”
Population changes with long-term effects
These changing patterns have raised the broader question: Is tobacco use no longer harmful at the population level?
To more fully understand the tobacco situation, researchers developed the Population Harm Reduction Index. Rather than simply measuring overall tobacco use, the new index compares the prevalence of non-combustible tobacco use only with the prevalence of combustible tobacco use. As this ratio increases, it suggests that more people are replacing tobacco-burning products with alternative products that have significantly less exposure to carcinogenic chemicals.
The strongest evidence of the change was seen among adults aged 18 to 24, who used only non-combustible cigarettes more than combustible cigarettes.
“If we believe, as scientific evidence increasingly suggests, that non-combustible nicotine products expose people to significantly less carcinogenic chemicals than combustible cigarettes, then this indicator provides a way to measure whether that substitution is occurring at the population level,” Cummings said. “Among young people, combustible tobacco use is rapidly being replaced by non-combustible tobacco use only. This is a positive trend for the health of the population.”
Because combustible tobacco products are responsible for nearly a third of cancer deaths and 90% of lung cancer deaths, the recent shift away from cigarettes will reshape the population’s cancer burden in the future, but the full impact will take decades to become visible, researchers say.
Cummings stressed that tobacco and nicotine products are not completely safe. The healthiest choice is to never start using tobacco or nicotine or stop using those products completely. But he said studies like this highlight the importance of looking beyond tobacco use as a whole to understand how tobacco use is changing and what that change means for future generations.
“As cigarette smoking continues to decline, it is important to understand what will replace it. If young people continue to wean themselves off combustible cigarettes, the incidence of smoking-related cancers should decrease significantly in the coming decades.”
sauce:
Medical University of South Carolina
Reference magazines:
Cummings, K.M. others. (2026) Trends in adult-only and dual use of combustible and non-combustible tobacco products in the United States. JNCI Cancer Spectrum. DOI: 10.1093/jnics/pkag062. https://academic.oup.com/jnics/article/10/4/pkag062/8740538
