Association of Electronic Cigarette Use with Chronic Kidney Disease in NHANES 2017-2020: A Cross-Sectional Replication Study

Abstract

Combustible cigarettes (CCs) are a modifiable risk factor for chronic kidney disease (CKD) however the impact of electronic cigarettes (ECs) is not well defined. A recent cross-sectional analysis of NHANES 2017-2020 data reported 2.5-fold higher CKD odds in current EC users, with risk increasing with use frequency (Li et al ., 2025). However, methodological concerns—including failure to segment by CC current, former, and never use; sampling irregularities; and sensitivity analyses on insufficient harm events—called the validity into question and prompted this replication study. Using the complete NHANES 2017-2020 pre-pandemic dataset (N = 8109 adults), we stratified participants by CC use history to minimize confounding from non-independent tobacco exposures. EC use was defined as past 5-day use—the only consistent metric across cycles. CKD was assessed using Li et al .’s binary definitions and the KDIGO CKD Heat Map for graded risk of progression. Analyses progressed through unweighted, population-weighted, and propensity-matched case-control stages, adjusting for age, sex, race, diabetes, hypertension, obesity, and CC duration/cessation timing. Results showed no evidence of an association between current EC use and CKD prevalence or risk progression across all segments and definitions (CC current and former users: p s>0.05; CC never users: only 1 CKD diagnosis among EC users), contrasting the original findings. Unadjusted lower CKD rates in EC users were driven by younger age and lower comorbidity burden; frequent EC use reflected recent CC cessation. Limitations include cross-sectional design, single-timepoint measurements, and sparse harm events in EC cohorts which limited the statistical power. This study underscores the critical importance of precise exposure characterization and segmentation in tobacco-related observational research to avoid misattribution of CC-related risks to ECs. It highlights systematic flaws in prior NHANES analyses and advocates for enhanced survey metrics—such as EC duration, past 30-day use, and time since CC cessation—in future waves. These findings reinforce the need for methodological rigor to most precisely evaluate associations between risk and use of nicotine products.