The following are key points to remember from this joint opinion article about the tobacco endgame—eradicating a worsening epidemic:

1. Approximately 8 million people experience tobacco-related deaths each year. This includes 1.2 million nonsmokers who experience secondhand tobacco exposure. Globally, 21% of adults, >1 billion people, are current smokers, with the majority residing in low- and middle-income countries. The life expectancy for smokers is approximately 10 years less than for nonsmokers.
2. The World Health Organization (WHO) aims to support 100 million smokers to quit as part of the “Commit to Quit” campaign. The WHO MPOWER framework can reduce tobacco consumption through increased price of products, counter-marketing campaigns, and availability of programs to promote cessation.
3. The rate of electronic cigarette (e-cigarette) use among adolescents has grown worldwide. Rates are highest of e-cigarette use for 13–15-year-olds in 23.4% in Poland, 18.4% in Ukraine, 18% in Latvia, and 17.5% in Italy. In the United States, as of 2020, over 3.6 million adolescents reported using e-cigarettes.
4. Nicotine is the main addictive substance in tobacco products. Nicotine poses risks to the cardiovascular system, including causing an increase in blood pressure, heart rate, the flow of blood to the heart, and a narrowing of the arteries. Nicotine may also contribute to the hardening of the arterial walls, which in turn can lead to a heart attack. Nicotine also impacts brain development and poses dangers to youth, pregnant women, and the developing fetus. During pregnancy, nicotine can cross the placenta and result in multiple adverse consequences, including sudden infant death syndrome.
5. Smoking is associated with increased disease severity for coronavirus disease 2019 (COVID-19), and with increased risk for death during a COVID-19–related hospitalization.
6. As with cigarettes, e-cigarette products include toxic substances beyond just nicotine. Compared with the use of combustible tobacco cigarettes, a very high-risk comparator, e-cigarette use likely poses less risk. However, there is growing evidence that e-cigarettes and their aerosol constituents, nicotine, vaporizing solvents, particulate matter, metals, and flavorings, can have deleterious effects on the cardiovascular system, respiratory system, and brain.
7. Many e-cigarette users also continue to smoke cigarettes, and dual use of e-cigarettes while continuing to smoke traditional cigarettes is not associated with higher rates of quitting. More research is needed to understand the efficacy of e-cigarettes in promoting quitting relative to approved pharmacotherapies.
8. Heated tobacco, nicotine pouch products, and other novel tobacco products loosely represent an emerging class of tobacco products being marketed by the industry as reduced exposure or modified-risk products. There is currently limited evidence regarding either the long-term individual health risks posed by these products or their potential public health impact.
9. Among adolescents and young adults, flavored tobacco products, including menthol cigarettes and flavored e-cigarettes, are consumed at higher rates than in older adults. The difference in favored products also exists by race/ethnicity.
10. The American College of Cardiology, American Heart Association, World Heart Federation, and European Society of Cardiology are committed to ending the global tobacco epidemic through advocacy for policies proven to reduce tobacco use and encourage bolder government actions to protect public health. Efforts will include: a) continuing to monitor and draw attention to tobacco industry practices that promote its addictive and deadly products; b) governmental policies and actions that more rapidly reduce the use of combustible tobacco products; c) call for lowering nicotine concentrations in all combustible tobacco products; d) recommend raising the price of tobacco products; e) eliminate the sale of flavored products; f) establish and enforce bans on tobacco industry advertising, and restrict or prohibit sales of tobacco products; and g) continued support for research on tobacco products and effective cessation programs.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, COVID-19 Hub, Dyslipidemia, Prevention, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, Lipid Metabolism, Smoking

Keywords: Adolescent, Aerosols, Blood Pressure, Coronavirus, COVID-19, Electronic Nicotine Delivery Systems, Life Expectancy, Menthol, Myocardial Infarction, Nicotine, Particulate Matter, Placenta, Pregnancy, Primary Prevention, Public Health, Respiratory System, Smoking, Sudden Infant Death, Tobacco, Tobacco Use, Tobacco Industry, Tobacco Products

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