Heterogeneous associations between cigarette and e-cigarette use patterns and chronic disease burden: A population-based study

Background Cigarette smoking is a major contributor to chronic disease and multimorbidity, but less is known about how morbidity burden varies across contemporary nicotine-use profiles, particularly among people who use e-cigarettes with and without a history of smoking. This study examined associations between mutually exclusive nicotine-use groups and long-standing condition burden in a population-based sample of adults in England. Methods We analysed cross-sectional data from 7625 adults aged ≥16 years in the 2022 Health Survey for England. Participants were classified into six mutually exclusive groups: never users, exclusive cigarette smokers, former smokers, current e-cigarette users who had never smoked, current e-cigarette users who had ever smoked, and dual users. Outcomes included seven self-reported long-standing condition groups, a composite indicator of any condition, and ordinal multimorbidity, defined as 0, 1, 2, or ≥3 condition groups. Survey-weighted logistic and ordered logistic regression models accounted for sampling weight, clustering, and stratification. Adjusted models controlled for age group, sex, ethnicity, area-level deprivation, educational attainment, alcohol consumption, and physical activity. Results Compared with never users, adjusted odds of reporting any of the seven long-standing conditions were higher among exclusive cigarette smokers (aOR 1.87, 95% CI 1.51–2.31), former smokers (aOR 1.44, 95% CI 1.27–1.65), current e-cigarette users who had ever smoked (aOR 2.13, 95% CI 1.61–2.82), and dual users (aOR 2.35, 95% CI 1.59–3.45). Current e-cigarette users who had never smoked did not show clear evidence of higher overall morbidity, but estimates were imprecise (aOR 1.24, 95% CI 0.58–2.63). Similar patterns were observed for ordinal multimorbidity, with higher adjusted odds among exclusive cigarette smokers (aOR 1.84, 95% CI 1.51–2.25), former smokers (aOR 1.48, 95% CI 1.31–1.68), current e-cigarette users who had ever smoked (aOR 2.14, 95% CI 1.67–2.75), and dual users (aOR 2.27, 95% CI 1.63–3.18), but not among current e-cigarette users who had never smoked (aOR 1.11, 95% CI 0.57–2.17). Mental health, respiratory, and musculoskeletal conditions showed the most robust disease-specific associations after false discovery rate correction. No disease-specific association involving current e-cigarette users who had never smoked remained significant after correction for multiple comparisons. Conclusions Morbidity burden was unevenly distributed across nicotine-use groups and was most consistently elevated among adults with current or previous combustible cigarette exposure, including former smokers, dual users, and current e-cigarette users with a smoking history. Current e-cigarette users who had never smoked did not show clear evidence of higher morbidity, but this subgroup was small and estimates were imprecise. Distinguishing smoking history is essential when interpreting the health profiles of people who use e-cigarettes. Longitudinal studies with larger samples of never-smoker e-cigarette users and more detailed exposure histories are needed.