Impact of Electronic Cigarettes on the Cardiovascular System

An Epidemic Supplanted by a Pandemic: Vaping-Related Illness and COVID-19

Before the coronavirus disease 2019 (COVID-19) pandemic, vaping-related illness was the prevailing public health concern. The incidence of vaping-related illnesses from vaping product use–associated lung injury declined with the arrival of COVID-19, but e-cigarette, or vaping, product use–associated lung injury should still be considered as a differential diagnosis for people with COVID-19 for reasons outlined in this review. This narrative review describes vaping devices, summarizes the adverse health effects of vaping on the lungs and other systems, considers the potential interplay between vaping and COVID-19, and highlights gaps in knowledge about vaping that warrant further research.

Before the coronavirus disease 2019 (COVID-19) pandemic, vaping-related illness was the prevailing public health concern. The incidence of vaping-related illnesses—mainly e-cigarette, or vaping, product use–associated lung injury (EVALI)—went from a peak in September 2019 to a low in February 2020, and the Centers for Disease Control and Prevention decided to discontinue the collection of EVALI case reports. Despite the decrease in EVALI with the arrival of COVID-19, EVALI should still be considered a differential diagnosis for people with COVID-19 for reasons outlined in this review. This narrative review describes vaping devices, summarizes the adverse health effects of vaping on the lungs and other systems, considers the potential interplay between vaping and COVID-19, and highlights gaps in knowledge about vaping that warrant further research.

E-Cigarettes: A New Threat to Cardiovascular Health - A World Heart Federation Policy Brief

Tobacco is widely recognized as a leading cause of cardiovascular morbidity and mortality, accounting for approximately seventeen percent of all cardiovascular disease deaths globally. Electronic nicotine delivery systems such as e-cigarettes have been developed and advertised as safer alternatives to traditional tobacco cigarettes. Aggressive marketing strategies, as well as misleading claims by manufacturers, have largely contributed to the belief that e-cigarettes are harmless.

In reality, e-cigarettes are far from innocuous. E-cigarette solutions and aerosols generally contain harmful substances that are commonly found in tobacco cigarette emissions. A growing body of literature suggests that e-cigarettes are associated with an increased risk of cardiovascular morbidity and mortality. In addition, the effectiveness of e-cigarettes as smoking cessation tools has yet to be determined. Concerningly, most smokers do not give up on tobacco cigarettes and eventually become dual users.

Unregulated, e-cigarettes constitute a serious threat to established tobacco control policies. Fortunately, many countries have demonstrated that strong regulations were effective in protecting their populations from the dangers of e-cigarettes. The World Heart Federation recommends applying the precautionary principle and a set of measures to protect vulnerable populations, prevent exposure to second-hand smoking, and address misleading claims.

In this regard, we recommend that governments, policymakers, and other relevant stakeholders enact or support the following measures, among others:

Prohibit the sale and distribution of e-cigarettes to minors, as well as the use of flavouring agents.

Prohibit the use of e-cigarettes anywhere tobacco cigarettes have been banned.

Prohibit marketing, advertising, and misleading claims regarding e-cigarettes.

Apply excise taxes on e-cigarettes.

Conduct more research regarding the long-term effects of e-cigarettes on cardiovascular health.

Lastly, countries that have banned the commercialization of e-cigarettes should maintain these measures.

Characteristics of and User Engagement With Antivaping Posts on Instagram: Observational Study

BACKGROUND

Although government agencies acknowledge that messages about the adverse health effects of e-cigarette use should be promoted on social media, effectively delivering those health messages is challenging. Instagram is one of the most popular social media platforms among US youth and young adults, and it has been used to educate the public about the potential harm of vaping through antivaping posts.

OBJECTIVE

We aim to analyze the characteristics of and user engagement with antivaping posts on Instagram to inform future message development and information delivery.

METHODS

A total of 11,322 Instagram posts were collected from November 18, 2019, to January 2, 2020, by using antivaping hashtags including #novape, #novaping, #stopvaping, #dontvape, #antivaping, #quitvaping, #antivape, #stopjuuling, #dontvapeonthepizza, and #escapethevape. Among those posts, 1025 posts were randomly selected and 500 antivaping posts were further identified by hand coding. The image type, image content, and account type of antivaping posts were hand coded, the text information in the caption was explored by topic modeling, and the user engagement of each category was compared.

RESULTS

Analyses found that antivaping images of the educational/warning type were the most common (253/500; 50.6%). The average likes of the educational/warning type (15 likes/post) were significantly lower than the catchphrase image type (these emphasized a slogan such as "athletesdontvape" in the image; 32.5 likes/post; P<.001). The majority of the antivaping posts contained the image content element text (n=332, 66.4%), followed by the image content element people/person (n=110, 22%). The images containing people/person elements (32.8 likes/post) had more likes than the images containing other elements (13.8-21.1 likes/post). The captions of the antivaping Instagram posts covered topics including "lung health," "teen vaping," "stop vaping," and "vaping death cases." Among the 500 antivaping Instagram posts, while most posts were from the antivaping community (n=177, 35.4%) and personal account types (n=182, 36.4%), the antivaping community account type had the highest average number of posts (1.69 posts/account). However, there was no difference in the number of likes among different account types.

CONCLUSIONS

Multiple features of antivaping Instagram posts may be related to user engagement and perception. This study identified the critical elements associated with high user engagement, which could be used to design antivaping posts to deliver health-related information more efficiently.

Racial Disparities of E-Cigarette Use Among US Youths: 2014‒2019

Objectives To evaluate disparities in youth e-cigarette use patterns and flavor use by race/ethnicity over time. Methods We used data from the US 2014-2019 National Youth Tobacco Survey (NYTS) to examine trends in dual use (co-use of e-cigarettes and cigarettes or other tobacco products), occasional (≤ 5 days) versus frequent use (≥ 20 days) in the past 30 days, and flavor use among current (past-30-day) e-cigarette users (n = 13 178) across racial/ethnic groups (non-Hispanic Whites, non-Hispanic Blacks, Hispanics/Latinos, and non-Hispanic others). Results Among current e-cigarette users, dual use and occasional use decreased significantly from 2014 to 2019 across racial and ethnic groups except for non-Hispanic Blacks; frequent use and flavored e-cigarette use increased among non-Hispanic Whites, Hispanics/Latinos, and non-Hispanic others but not among non-Hispanic Blacks. In 2019, non-Hispanic Black e-cigarette users were more likely to report dual use (adjusted odds ratio [AOR] = 2.2; 95% confidence interval [CI] = 1.5, 3.2; P < .001) and occasional use of e-cigarettes (AOR = 3.7; 95% CI = 2.3, 5.9; P < .001) but less likely to report frequent use (AOR = 0.2; 95% CI = 0.1, 0.4; P < .001) and flavored e-cigarette use (AOR = 0.4; 95% CI = 0.3, 0.5; P < .001) than their White peers. Conclusions Youth e-cigarette use patterns differed considerably across racial/ethnic groups, and tailored strategies to address disparities in e-cigarette use are needed. (Am J Public Health. 2021;111(11):2050-2058. https://doi.org/10.2105/AJPH.2021.306448).

Electronic cigarettes consumption and associated factors among general population in Western Saudi Arabia

Background: In recent years, consumption of e-cigarettes has increased dramatically. Several studies have focused on the prevalence of e-cigarettes among specific groups of people, using it as a substitute to traditional cigarettes, or the participant knowledge regarding risks. This research was aimed on E-cigarettes’ prevalence and its association to several factors in the general population of Western Saudi Arabia.

Design and methods: Using an observational cross-sectional study, data were collected from (n=465) above 18 years old smokers during the survey at public attractions. A validated self-administered questionnaire acquired from previous studies was employed to insure the suitability for the general population of Jeddah Saudi Arabia. Sample size was calculated via Raosoft^® and adults of either gender were included in the study. Descriptive or inferential statistical analysis was performed using SPSS.

Results: The preponderance of e-cigarette smokers used entertainment as the reason for smoking, with an average of (33.9%). Although one reason for e-cigarette consumption was to cease traditional smoking, results showed an average of (49.4%), which is the majority of those who attempted to cease traditional smoking via e-cigarette, did not succeed in quitting traditional smoking. This study also demonstrated that participant that believed that ecigarette is beneficial had a higher chance to cease conventional smoking than who did not (32.1% versus 14.6%) which is significant (p<0.001).

Conclusions: In conclusion, this study estimated the prevalence of e-cigarette consumption among the population of Jeddah, Saudi Arabia along with assessment of elements which help increase the overall e-cigarette consumption in Jeddah.

An association between electronic nicotine delivery systems use and a history of stroke using the 2016 behavioral risk factor surveillance system

Electronic nicotine delivery systems (ENDS) are growing in use and many of the health implications with these devices remain unknown. This study aims to assess, using a survey representative of the USA general population, if an association exists between a history of ENDS use and a history of stroke.This cross-sectional study was a secondary data analysis using the 2016 behavioral risk factor surveillance system survey. The main exposure variable of the study was a self-reported history of ENDS use. The main outcome was a self-reported history of stroke. Covariates included sex, race, traditional cigarette use, smokeless tobacco use, chronic kidney disease, diabetes, myocardial infarction, and coronary artery disease. Unadjusted and adjusted logistic regression analyses were done. Adjusted odds ratios (AOR) and their corresponding 95% confidence intervals (CI) were calculated.Of the 486,303 total behavioral risk factor surveillance system survey participants, 465,594 met the inclusion criteria for this study of ENDS use and stroke. This study shows that current ENDS use was positively associated with a history of stroke. AOR of some daily ENDS use with stroke was 1.28 (95% CI: 1.02-1.61) and AOR of current daily ENDS use with stroke was 1.62 (95% CI: 1.18-2.31). The majority (55.9%) of current daily ENDS users reported former traditional cigarette smoking. Female sex, non-white ethnicity, elderly age, chronic kidney disease, coronary artery disease, diabetes, and traditional cigarette use characteristics were all also associated with increased odds of reporting a stroke.This study found a statistically significant and positive association between ENDS use and a history of stroke. Further research is warranted to investigate the reproducibility and temporality of this association. Nevertheless, this study contributes to the growing body of knowledge about the potential cardiovascular concerns related to ENDS use and the need for large cohort studies.

Environmental and individual exposure to secondhand aerosol of electronic cigarettes in confined spaces: Results from the TackSHS Project†

Secondhand electronic cigarette (e-cigarette) aerosol (SHA) might impair indoor air quality and expose bystanders. This study aims to investigate exposure to SHA in controlled conditions of enclosed settings simulating real-world scenario. An experiment was performed in a car and in a room, in which SHA was generated during a 30-minute ad libitum use of an e-cigarette. The experiment was replicated on five consecutive days in each setting. We measured PM_2.5 , airborne nicotine concentrations, and biomarkers of exposure to SHA, such as nicotine metabolites, tobacco-specific nitrosamines, propylene glycol, and glycerol in bystanders' saliva samples before, during, and after the exposure period. Self-reported health symptoms related to exposure to SHA were also recorded. The results showed that the highest median PM_2.5 concentration was recorded during the exposure period, being 21 µg/m³ in the room setting and 16 µg/m³ in the car setting-about twofold increase compared to the baseline. Most concentrations of the airborne nicotine and all biomarkers were below the limit of quantification in both settings. Bystanders in both settings experienced some short-term irritation symptoms, expressed as dry throat, nose, eyes, and phlegm. In conclusion, short-term use of an e-cigarette in confined spaces increased indoor PM_2.5 level and caused some irritation symptoms in bystanders.

Ameliorating Effect of Combined Cinnamon and Ginger Oils against the Neurotoxicity of Nicotine Administration on the Prefrontal Cortex of Adult Albino Rats: Immunohistochemical and Ultrastructural Study

Background: Nicotine is the active alkaloid in cigarettes. It was reported that tobacco smoking has many hazards; one of these hazards is the effect on the cognitive function of the prefrontal cortex. The aim of our study is to investigate the antioxidant effects of ginger, cinnamon oils, and their combination on morphological changes in the prefrontal cortex that were induced by nicotine. Materials and methods: Fifty adult male albino rats were divided into five groups: group I (control group), group II (nicotine), group III (nicotine + cinnamon), group IV (nicotine + ginger), and group V (nicotine + cinnamon + ginger). The coronal sections from the anterior part of the rat brain at the site of prefrontal cortex were examined by light microscope for (H&E and immunohistochemical staining with TNF-α and GFAP), while the ultrastructure morphology was examined by transmission electron microscopy. Levels of the oxidative stress markers (MDA, GSH) in the rats’ brain tissue homogenate were biochemically assessed. Results: Compared to the control group, the rats that were treated with nicotine (group II) showed a significant oxidative stress in the form of marked elevation of MDA and decrease in GSH, apoptotic changes especially in the pyramidal cells in the form of neuronal cell degeneration and pyknosis, and an elevation in the inflammatory marker TNF-α and GFAP expressions. These changes were observed to a lesser degree in rat group (III) and group (IV), while there was a marked improvement achieved by the combined usage of cinnamon and ginger oils, together compared to the nicotine group. Conclusions: Ginger and cinnamon are powerful antioxidants which ameliorate the degenerative and oxidative effects produced by nicotine on a rat’s prefrontal cortex.

Toxicological interaction between tobacco smoke toxicants cadmium and nicotine: An in-vitro investigation

Cigarettes and other tobacco products are used to obtain nicotine that is responsible for their stimulating effects. However, a lot of other organic and inorganic chemicals are also released along with nicotine. Cadmium (Cd) is one of the several heavy metals that are health hazards and is one of the inorganic elements released in tobacco smoke. The in-vitro investigation focused on exploring the effects of nicotine hydrogen tartrate (NHT) and cadmium (Cd) and their toxic interactions in the A549 cell line. In cell viability assay NHT exhibited its IC50 at 11.71 mM concentration, and the IC50 of Cd was found to be 83 µM after a 24 h exposure. Toxic effects of NHT (5 mM and 10 mM), Cd (50 µM and 100 µM), and their combination were also investigated by flowcytometry. The investigation included apoptotic and necrotic events, the effect on different cell cycle phases, and generation of reactive oxygen species by NHT, Cd, and their combination of different concentrations. Data reveal evident toxic effects of NHT, Cd, and NHT + Cd. It also indicates that the toxic interaction of NHT and Cd is not additive and appears to be minimal when compared with NHT or Cd exposures alone.

The effect of electronic cigarettes exposure on learning and memory functions: behavioral and molecular analysis

Objective: Electronic cigarettes (ECIGs) are battery-powered devices that emit vaporized solutions for the user to inhale. ECIGs are marketed as a less harmful alternative to combustible cigarettes. The current study examined the effects of ECIG aerosol exposure on learning and memory, expression of brain derived neurotrophic factor (BDNF), and the activity of antioxidant enzymes in the hippocampus.Methods: Male Wistar rats were exposed to ECIG aerosol, by a whole-body exposure system, 1 h/day for 1 week, 4 weeks, and 12 weeks. Spatial learning and memory were tested using the Radial Arm Water Maze (RAWM). Hippocampal BDNF protein level, and oxidative stress biomarkers (GPx, SOD, GSH, GSSG, GSH/GSSG ratio) were also assessed.Results: ECIG aerosol exposure for 4 and 12 weeks impaired both short- and long- term memory and induced reductions in the hippocampus BDNF, SOD and GPx activities, and GSH/GSSG ratio (p < 0.05). No changes in any examined biomarkers were observed after 1-week exposure to ECIG aerosol (p > 0.05).Conclusions: ECIG aerosol exposure impaired functional memory and elicited changes in brain chemistry that are consistent with reduced function and oxidative stress.

Exploratory Analysis of Electronic Cigarette-Related Videos on YouTube: Observational Study

BACKGROUND

Electronic cigarette (e-cigarette) use has become more popular than cigarette smoking, especially among youth. Social media platforms, including YouTube, are a popular means of sharing information about e-cigarette use (vaping).

OBJECTIVE

This study aimed to characterize the content and user engagement of e-cigarette-related YouTube videos.

METHODS

The top 400 YouTube search videos related to e-cigarettes were collected in January 2020. Among them, 340 valid videos were classified into provaping, vaping-warning, and neutral categories by hand coding. Additionally, the content of e-cigarette videos and their user engagement (including average views and likes) were analyzed and compared.

RESULTS

While provaping videos were dominant among e-cigarette-related YouTube videos from 2007 to 2017, vaping-warning videos started to emerge in 2013 and became dominant between 2018 and 2019. Compared to vaping-warning videos, provaping videos had higher average daily views (1077 vs 822) but lower average daily likes (12 vs 15). Among 161 provaping videos, videos on user demonstration (n=100, 62.11%) were dominant, and videos on comparison with smoking had the highest user engagement (2522 average daily views and 28 average daily likes). Conversely, among 141 vaping-warning videos, videos on potential health risks were the most popular topic (n=57, 40.42%) with the highest user engagement (1609 average daily views and 33 average daily likes).

CONCLUSIONS

YouTube was dominated by provaping videos, with the majority of videos on user demonstrations before 2018. The vaping-warning videos became dominant between 2018 and 2019, with videos on potential health risks being the most popular topic. This study provides updated surveillance on e-cigarette-related YouTube videos and some important guidance on associated social media regulations.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

The Immediate Physiological Effects of E-Cigarette Use and Exposure to Secondhand E-Cigarette Vapor

BACKGROUND

Vaping continues to grow as an alternative to smoking and as a recreational activity for people of all ages, including minors. The billion-dollar industry offers users a plethora of flavors, nicotine concentrations, e-juice combinations, and devices. While some studies suggest vaping is beneficial for certain ailments and as a smoking cessation tool, many studies report concerning health outcomes associated with vape use. Recent FDA regulations have banned certain vaping products following an increase of vaping-related lung injuries reported in 2019. Health care providers need to better understand the physiological effects of vaping-specific products and the impact of secondhand vapor. The specific aims of the present study were to understand the immediate effects on heart rate, breathing frequency, blood pressure, blood sugar, [Formula: see text], pulmonary function, and oral temperature following e-cigarette use and secondhand vapor exposure.

METHODS

A total of 149 volunteers participated in this study; 76 subjects vaped mint-flavored e-cigarettes with 5% nicotine for 20 min while seated next to 73 nonvaping subjects who agreed to be exposed to the vapor. Health variables including heart rate, blood pressure, breathing frequency, blood glucose, FVC, [Formula: see text], and oral temperature were obtained prior to vaping or exposure to vapor and again after 20 min.

RESULTS

Subjects who vaped had significantly higher heart rate, breathing frequency, and oral temperature, and significantly lower blood oxygenation levels (ie, [Formula: see text]) after vaping for 20 min. Nonvaping subjects exposed to vapor had significantly higher oral temperature after 20 min of exposure. Blood sugar and FVC were not significantly affected by vaping or exposure to vapor.

CONCLUSIONS

Vaping with mint-flavored e-cigarettes with 5% nicotine for 20 min resulted in significant immediate physiological changes. Exposure to e-cigarette vapor significantly increased oral temperature within the same amount of time.

National Trends of Tobacco, Alcohol, and Drug Use in Patients Admitted With Acute Myocardial Infarction

BACKGROUND

Acute myocardial infarction (AMI) is a significant health and economic burden in the US. Tobacco, alcohol, and drug use are established risk factors. We sought to evaluate the national trend of use of each substance in patients admitted with AMI.

METHODS

We used the National Inpatient Sample between 2005 and 2017. We included adult patients hospitalized with AMI. International Classification of Diseases, Ninth and Tenth Revisions codes were used to define tobacco, alcohol, cocaine, opioid, cannabis and other drug use. Trends of each substance use were assessed using multivariable Poisson regression, and were expressed as annual percent change (APC) with their 95% confidence intervals (CIs).

RESULTS

A total of 10,796,844 hospitalizations with AMI were included. Among all substances used, tobacco was the most common (32.7%), followed by alcohol (3.2%). Between 2005 and 2017, the prevalence ratio of tobacco use increased from 21.5% to 44.5% with an APC +6.2% (95%CI 6.2%-6.2%). Tobacco users had more percutaneous coronary intervention (41%vs25%) and coronary artery bypass surgery (6.9%vs4.9%), p < 0.001. Further, there were positive trends in alcohol (APC +3.1%; 95%CI 3.0%-3.2%), opioid (APC +9.0%; 95%CI 8.7%-9.2%), cannabis (APC + 7.2; 95% CI 7%-7.4%), and combined all drug use (+7.1%; 95%CI 7%-7.2%). Meanwhile, there was a slight negative trend in cocaine use.

CONCLUSIONS

This analysis outlines the national trends of substance use in patients admitted with AMI and reveals an increasing prevalence of tobacco use, alcohol and drug use. More effective cessation measures are necessary to reduce the risk for AMI and its burden on the healthcare system and economy.

The Cardiovascular Effects of Electronic Cigarettes

PURPOSE OF REVIEW

Electronic cigarettes (e-cigarettes) are gaining rapid popularity among all age groups, especially among youth. They have evolved into technologically advanced devices capable of delivering nicotine concentration and other substances. In addition to nicotine, e-cigarettes' constituents possess variety of toxic chemicals that have adverse effects on human body.

RECENT FINDINGS

In recent years, steady downward trend in tobacco usage has been observed; however, e-cigarette use is on upward trend. E-cigarettes are advertised as "safer" alternatives to conventional smoking and as an aid to smoking cessation. Emerging studies have, however, shown that e-cigarettes have harmful effects on the cardiovascular system and that most of the e-cigarette users are dual users, concurrently using e-cigarettes and smoking conventional cigarettes. Despite a gap in clinical studies and randomized trials analyzing adverse cardiovascular effects of e-cigarette use, the existing literature supports that different constituents of e-cigarettes such as nicotine, carbonyls, and particulate matters carry potential risk for cardiovascular diseases (CVD) on its users.

Association between vaping and health outcomes in patients with opioid use disorder: a systematic review protocol

INTRODUCTION

Vaping behaviour has increased in popularity and is particularly important to examine how it effects health outcomes in vulnerable populations, including those with opioid use disorder (OUD). With polysubstance use including cigarette and cannabis use being highly prevalent in the OUD population and cannabis/nicotine increasingly being consumed by vaping, vaping may have an important contribution to health outcomes in these individuals. The primary objective of this review is to systematically assess the literature related to patients with OUD and the effects vaping has shown on their physical and mental health.

METHOD AND ANALYSIS

A systematic search of databases including MEDLINE, Embase, PsycINFO, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Cochrane Clinical Trials Registry, the National Institutes for Health Clinical Trials Registry and the WHO International Clinical Trials Registry Platform from inception to 31 December 2020 will be conducted. Identified citations will be screened by two reviewers to determine eligibility at the title and abstract level, and then at the full text and data extraction phases. Any disagreements in inclusion will be resolved through unblinded discussion by these reviewers, with any remaining disagreements being resolved by a third reviewer. Data collection from eligible studies will be conducted according to the data extraction form tested prior to abstraction. Included studies will be examined for quality and bias and will be meta-analysed where applicable. This protocol is reported in keeping with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines.

ETHICS AND DISSEMINATION

The results for this review will be disseminated through publications in peer-reviewed journals, posters and presentations at scientific conferences. Additionally, we are collaborating with the Canadian Addiction Treatment Centre clinics to help disseminate the findings for this review. As this is a systematic review, no ethics approval is needed.

REVIEW REGISTRATION NUMBER

CRD42020178441.

Association of electronic cigarette use with self-reported difficulty concentrating, remembering, or making decisions in US youth

INTRODUCTION

Electronic cigarette use (vaping) has become increasingly popular among youth. The aim of this study is to determine the cross-sectional association of vaping, smoking, and dual use of these tobacco products with self-reported serious difficulty concentrating, remembering, or making decisions (DCRMD), because of a physical, mental, or emotional condition (PMEC) in US youth.

METHODS

The 2018 National Youth Tobacco Survey (NYTS) data with 18535 youth were used for analysis. All included youth who answered whether they have serious DCRMD and stated their vaping and smoking status. Multivariable weighted logistics regression models were used to examine the association of vaping and smoking with the risk of DCRMD in youth, considering a complex sampling design.

RESULTS

Ever dual users (AOR=4.19; 95% CI: 2.97-5.92), exclusive ever cigarette smokers (AOR=1.50; 95% CI: 1.18-1.91) and exclusive ever e-cigarette users (AOR=3.13; 95% CI: 2.25-4.34) had significantly higher odds of self-reported DCRMD than never users in youth. Subgroup analysis on exclusive ever e-cigarette users who started vaping in middle school or earlier had significantly higher odds of self-reported DCRMD compared to those who started vaping in high school (AOR=1.77; 95% CI: 1.27-2.45). Meanwhile, male youth who were exclusive ever e-cigarette users had higher odds of self-reported DCRMD than female youth who were exclusive ever e-cigarette users (AOR=1.67; 95% CI: 1.25-2.22).

CONCLUSIONS

Vaping, smoking and dual use were associated with self-reported serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition in youth, which provided initial evidence on the cross-sectional association between vaping and self-reported cognitive problems.

Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes

Tobacco smoking is a leading cause of non-communicable disease globally and is a major risk factor for cardiovascular disease (CVD) and lung disease. Importantly, recent data by the World Health Organizations (WHO) indicate that in the last two decades global tobacco use has significantly dropped, which was largely driven by decreased numbers of female smokers. Despite such advances, the use of e-cigarettes and waterpipes (shisha, hookah, narghile) is an emerging trend, especially among younger generations. There is growing body of evidence that e-cigarettes are not a harm-free alternative to tobacco cigarettes and there is considerable debate as to whether e-cigarettes are saving smokers or generating new addicts. Here, we provide an updated overview of the impact of tobacco/waterpipe (shisha) smoking and e-cigarette vaping on endothelial function, a biomarker for early, subclinical, atherosclerosis from human and animal studies. Also their emerging adverse effects on the proteome, transcriptome, epigenome, microbiome, and the circadian clock are summarized. We briefly discuss heat-not-burn tobacco products and their cardiovascular health effects. We discuss the impact of the toxic constituents of these products on endothelial function and subsequent CVD and we also provide an update on current recommendations, regulation and advertising with focus on the USA and Europe. As outlined by the WHO, tobacco cigarette, waterpipe, and e-cigarette smoking/vaping may contribute to an increased burden of symptoms due to coronavirus disease 2019 (COVID-19) and to severe health consequences.

Electronic cigarettes — myocardial infarction, hemodynamic compromise during pregnancy, and systolic and diastolic dysfunction: Minireview

The aim of this study was to review the most recent literature on the safety of electronic cigarettes (ECs) in the context of cardiovascular disease and in the context as a tool for smoking cessation and recreational purposes. The format of this review begins with relevant research from the basic sciences and follows through with a pertinent review of clinical trials. Daily use of ECs has implications in myocardial infarction (MI) with an odds ratio of 1.70 compared to healthy, nonsmokers and even worse risk for MI with dual use of combustible cigarettes together with EC with an odds ratio of 4.62. Studies measuring cardiac function with echocardiography reported both systolic and diastolic dysfunction along with reduced ejection fractions. Platelet aggregation, endothelial function, and hemodynamics during pregnancy were all but some of the pernicious cardiovascular implications of EC exposure. Though more studies need to be done on the topic of EC use and cardiovascular disease, the majority of studies considered in this review concluded some level of harm albeit in some instances less than that of traditional combustible cigarettes. ECs are toxic to human beings and their harmful effects cannot be overlooked. There is some favorable evidence of efficacy in smoking cessation though mixed with concern of chronic EC use. It will take decades to collect data for chronic EC use on long term sequelae, such as lung cancer. Though more and more reports of acute lung injury and hospitalizations related to EC use have been reported. Due to undergoing investigations of possible harm and life threatening complications of EC use, we cannot recommend ECs as safer or a more efficacious method of smoking cessation to traditional nicotine replacement therapies. A notable consideration for much of the literature reviewed are that standardization of EC use is difficult as device generation and battery voltage, frequency of use, and contents of EC liquid are just some of the vast complicating factors that limit the ability to effectively compare data.

Breath analysis of smokers, non-smokers, and e-cigarette users

Solid phase micro extraction-Gas Chromatography/Mass Spectrometry (SPME-GC/MS) analysis was performed in exhaled breath samples of 48 healthy volunteers: 20 non-smokers, 10 smokers and 18 e-cigarette (EC, vape) users. Each volunteer provided 1 L of exhaled breath in a pre-cleaned Tedlar bag, in which an SPME fiber was exposed to absorb the emitted breath volatile organic compounds (VOCs). The acquired data were processed using multivariate data analysis (MDA) methods in order to identify the characteristic chemicals of the three groups. The results revealed that the breath of non-smokers demonstrated inverse correlation with a variety of molecules related to the breath from smokers including furan, toluene, 2-butanone and other organic substances. Vapers were distinguished from smokers by the chemical speciation of the e-liquids, such as that of esters (e.g. ethyl acetate), terpenes (e.g. α-pinene, β-pinene, d-limonene, p-cymene, etc.) and oxygenated compounds (e.g. 3-hexen-1-ol, benzaldehyde, hexanal, decanal, etc). Two classification models were developed (a) using principal component analysis (PCA) with hierarchical cluster analysis (HCA) and (b) using partial least squares-discriminant analysis (PLS-DA). Both models were validated using 8 new samples (4 vapers and 4 smokers), collected in addition to the 48 samples of the calibration set. The combination of GC/MS breath analysis and MDA contributed successfully in classifying the volunteers into their respective groups and highlighted the relevant characteristic VOCs. The respective dynamic combination (SPME-GC/MS and MDA) provides a means for long term non-invasive monitoring of the population's health status for early detection purposes.

Cardiovascular risk of electronic cigarettes: a review of preclinical and clinical studies

Cigarette smoking is the most preventable risk factor related to cardiovascular morbidity and mortality. Tobacco usage has declined in recent years; however, the use of alternative nicotine delivery methods, particularly e-cigarettes, has increased exponentially despite limited data on their short- and long-term safety and efficacy. Due to their unique properties, the impact of e-cigarettes on cardiovascular physiology is not fully known. Here, we summarize both preclinical and clinical data extracted from short- and long-term studies on the cardiovascular effects of e-cigarette use. Current findings support that e-cigarettes are not a harm-free alternative to tobacco smoke. However, the data are primarily derived from acute studies. The impact of chronic e-cigarette exposure is essentially unstudied. To explore the uniqueness of e-cigarettes, we contemplate the cardiovascular effects of individual e-cigarette constituents. Overall, data suggest that exposure to e-cigarettes could be a potential cardiovascular health concern. Further preclinical research and randomized trials are needed to expand basic and clinical investigations before considering e-cigarettes safe alternatives to conventional cigarettes.

Could E-cigarette vaping contribute to heart disease?

INTRODUCTION

E-cigarettes have become a controversial topic. While their benefits are questioned by the scientific community, a part of the medical profession is still supporting them as an effective harm reduction tool for smoking cessation. The impact of E-cigarettes on the cardiovascular system is still elusive.

AREAS COVERED

We assessed results from animal, pre(clinical), and epidemiological studies to critically evaluate and synthesize evidence relevant to the cardiovascular effects of E-cigarettes. Animal studies have demonstrated that E-cigarette vapor exposure can cause endothelial and cardiac dysfunction. However, there have also been reports on the less harmful effects of E-cigarette vapor exposure in comparison to classical tobacco cigarettes. Measurements of flow-mediated dilation in acute human exposure settings have mostly demonstrated that E-cigarettes cause vascular endothelial dysfunction. Epidemiological studies have shown that E-cigarette use is associated with an increased risk for cardiovascular disease, although switching from classical tobacco cigarettes to E-cigarettes can have beneficial cardiovascular effects. Misinterpretation of scientific data by activists on either side is another problem.

EXPERT OPINION

In conclusion, we need more and better (pre)clinical data comparing the health effects of E-cigarette vaping as compared with tobacco cigarette smoking, in order to counsel the legislation for better health policies.

Association between electronic cigarette use and metabolic syndrome in the Korean general population: A nationwide population-based study

Objectives

Although smoking is known to have a negative impact in patients with metabolic syndrome (MetS), only a few studies have examined the association between electronic cigarette (e-cig) use and MetS.

Methods

Among 22,948 participants in the 6th Korea National Health and Nutrition Examination Survey, 14,738 (13,459 [91.3%] never, 954 [6.5%] ever, and 325 [2.2%] current e-cig users) were selected. The relationship between e-cig exposure and MetS (based on the National Cholesterol Education Program Adult Treatment Panel [NCEP-ATP] III criteria) was evaluated using a multivariable logistic regression analysis. An unweighted analysis was performed to evaluate this association without a sampling weight. A subgroup analysis was performed among active smokers to compare dual users with never e-cig users.

Results

Among current e-cig users, 85.0% were dual users, 12.7% were former cigarette users, and 2.2% were only e-cig users. After adjustment for covariates, abdominal obesity and hypertriglyceridemia were significantly associated with current e-cig exposure (odds ratio [OR]: 1.88, 95% confidence interval [CI]: 1.41–2.50 and OR: 1.32, 95% CI: 1.00–1.74 respectively [compared with the never e-cig users group]). Compared with never e-cig users, current e-cig users showed an OR of 1.27 (95% CI: 0.96–1.70, P_trend = 0.01) for MetS. In the unweighted analysis, the OR for MetS in current e-cig users was 1.40 (95% CI: 1.08–1.81, P_trend <0.01). Compared with never e-cig users, dual users showed a higher OR for abdominal obesity (OR: 1.71, 95% CI: 1.25–2.34, P_trend <0.001).

Conclusions

Current e-cig exposure was associated with an increased risk of MetS. Dual use of e-cigs and cigarettes was associated with abdominal obesity. Further longitudinal studies and better assessment of e-cig use and type are needed to clarify this relationship.

Knowledge and Beliefs of Jordanian Community Toward E-cigarettes: A National Survey

Electronic nicotine delivery systems were promoted publically as a healthier replacement for conventional cigarettes. Knowledge and beliefs of the public can drive their behaviours to adapt or reject the new habit. No previous research was conducted in Jordan to assess electronic cigarettes (e-cigarettes) prevalence, and limited data are available on public opinions and orientation toward this new habit. To assess prevalence of, knowledge, attitude and beliefs about e-cigarettes, and examine factors associated with plans of quitting or initiating e-cigarettes among adults in Jordan. A large cross-sectional face-to-face survey on a random sample of adult population aged ≥ 18 years was conducted over two months to include 1820 adults in Jordan. A representative sample was collected using proportionate random sampling technique, which enabled us to geographically categorise the study population. Reliability and validity measures were taken to ensure a comprehensive and appropriate study tool. The Statistical Package for Social Science (SPSS®) version 24 was used to conduct descriptive analysis, logistic regression, and Rao-Scott chi-square. Findings were considered statistically significant at p value < 0.05 (with a confidence limit at 95%). Of 2164 adults approached, 1820 completed the questionnaire (84.1% response rate). The prevalence of current e-cigarette smokers and dual smokers were 11.7% and 4.0%, respectively. Quitting conventional smoking (38.8%) and enjoying the flavour (32.5%) were the most common reasons to start vaping. Friends were the major source of information about e-cigarettes. There was evidence that adults aged 45-59 years were less likely to be dual smokers (OR 0.51; 95%CI 0.29-0.66; p = 0.03). Poor knowledge about the content (23.7%) and types of e-cigarettes (14.5%) was reported. Plans to reduce or quit e-cigarettes were significantly associated with three factors: smokers' knowledge about its content, social impression, smokers' satisfaction with e-cigarettes. Social impression was also associated with plans of initiating e-cigarettes. Most participants thought vaping cannot be harmful to children and pregnant women (73.1%) and cannot be addictive (58.2%). Electronic cigarettes were considered helpful in smoking cessation by 69.1% of participants. The proportions of adults who were currently electronic cigarette and dual smokers were 11.7% and 4.0%, respectively. Our research may provide insight to product and individual factors that were associated with plans to sustain, quit or initiate electronic smoking.

A Case-Based Review of Vaping-Induced Injury-Pulmonary Toxicity and Beyond

The last 10 years has seen a steady rise in the use of electronic cigarettes ("e-cigarettes" or ECIGs) or "vape pens." Though initially developed to assist with smoking cessation, use among adolescents has been particularly high. A concomitant rise in ECIG-related injuries disproportionately affecting young patients has been recognized. This unique case series highlights both pulmonary and extra-pulmonary ECIG-induced injuries including vape tip ingestion, maxillofacial fractures after vape pen explosion, myocarditis, and several different manifestations of vaping-associated lung injury. Becoming familiar with expected imaging findings in the wide array of ECIG-induced complications will help radiologists recognize these findings, recommend further imaging as needed, facilitate early diagnosis by help referring clinicians elicit the relevant history from patients, and expedite appropriate treatment.

The JUUL E-Cigarette Elevates the Risk of Thrombosis and Potentiates Platelet Activation

BACKGROUND

Smoking is the main preventable cause of death in the United States and worldwide and is associated with serious cardiovascular health consequences, including thrombotic diseases. Recently, electronic cigarettes (e-cigarettes) and, in particular JUUL, have attained wide popularity among smokers, nonsmokers, pregnant females, and even the youth, which is alarming. Interestingly, there is/are no information/studies regarding the effect of JUUL on cardiovascular diseases, specifically in the context of modulation of platelet activation. Thus, it is important to discern the cardiovascular disease health risks associated with JUUL.

METHODS AND RESULTS

We used a passive e-vape vapor inhalation system where C57BL/6J mice (10-12 weeks old) were exposed to JUUL e-cigarette vape. Menthol flavored JUUL pods containing 5% nicotine by weight were used as the e-liquid. Mice were exposed to a total of 70 puffs daily for 2 weeks; 3-second puff duration, and 25-second puff interval. The effects of JUUL relative to clean air were analyzed, on mouse platelet function in vitro (eg, aggregation) and in vivo (eg, FeCl₃-induced carotid artery injury thrombosis model). Our results indicate that short-term exposure to JUUL e-cigarette causes hyperactivation of platelets and shortens the thrombus occlusion as well as hemostasis/bleeding times, relative to clean air (medians of 14 vs. 200 seconds, P < .01 and 35 vs. 295 seconds, P < .001, respectively).

CONCLUSION

Our findings document-for the first time-that short-term exposure to the JUUL e-cigarette increases the risk of thrombotic events, in part by modulating platelet function, such as aggregation and secretion, in mice.

The Impact of Dietary Supplementation of Whole Foods and Polyphenols on Atherosclerosis

The purpose of this review is to highlight current research on the benefits of supplementation with foods with a diverse polyphenol composition, including fruits, vegetables, nuts, grains, oils, spices, and teas in blunting atherosclerosis. We searched PubMed for publications utilizing whole food or polyphenols prepared from whole foods in Apolipoprotein E (ApoE) or Low-Density Lipoprotein Receptor (LDLR) knockout mice, and identified 73 studies in which plaque was measured. The majority of the studies reported a reduction in plaque. Nine interventions showed no effect, while three using Agaricus blazei mushroom, HYJA-ri-4 rice variety, and safrole-2', 3'-oxide (SFO) increased plaque. The mechanisms by which atherosclerosis was reduced include improved lipid profile, antioxidant status, and cholesterol clearance, and reduced inflammation. Importantly, not all dietary interventions that reduce plaque showed an improvement in lipid profile. Additionally, we found that, out of 73 studies, only 9 used female mice and only 6 compared both sexes. Only one study compared the two models (LDLR vs. ApoE), showing that the treatment worked in one but not the other. Not all supplementations work in both male and female animals, suggesting that increasing the variety of foods with different polyphenol compositions may be more effective in mitigating atherosclerosis.

Is Canadian federal legislation effective in preventing youth access to vaping initiation products? A study using secret shoppers and online access in three Alberta cities

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120 ‘improper’ secret shopper visits, 3 cities, to buy nicotine vaping initiation products.

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Vendors willing to sell in 42.5% of shop visits.

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Minors’ online purchasing attempts aided by deliverers and non-descriptive packaging.

The Tobacco and Vaping Products Act (Canada, 1997) (the “TVPA”) aims to protect the health of young persons by restricting access to vaping products. We studied whether the TVPA achieves this goal by sending young ‘secret shoppers’ to 120 shops in Calgary, Edmonton, and Red Deer to attempt to buy nicotine-based vaping-initiation products, and by asking minors to purchase the same product online. We used three ‘improper’ shop scenarios: 1. a minor or minors; 2. a young adult with no or invalid identification (“ID”); and 3. a young adult with valid ID but clearly buying for an accompanying minor. Of total vendors, 42.5% (51/120) were willing to sell to the young people (p < .001). Most vendors requested ID in all scenarios (97/120, 80.8%). Of these, 28 vendors (28.9% of those requesting ID), were still willing to sell the product. All vendors who did not request ID (23/120, 19.2%) were willing to sell; vape shops were more likely than convenience stores not to request ID (25.4% v. 13.1%). In five online purchase attempts, 60% of deliverers did not meet the TVPA’s ID verification requirements. The TVPA does not require packages to reveal their contents; one parent inadvertently signed for the parcel. To prevent youth access, the TVPA should require: a minimum nicotine product purchase age of 21, positive obligations on vendors to request ID, prohibition of sales to adults buying for minors, and that manufacturers disclose the product on posted or delivered parcels. The TVPA should be strictly enforced.

Recent findings in the pharmacology of inhaled nicotine: Preclinical and clinical in vivo studies

INTRODUCTION

The rise of vaping in adolescents, the recent entrance of new inhaled nicotine products such as iQOS on the market and e-cigarette or vaping product use-associated lung injury cases has created concern for the use of inhaled non-combustible nicotine products. This narrative review discusses recent experimental in vivo studies that utilize human, rat and mouse models to understand the pharmacological impact of nicotine from non-combustible products.

METHODS

The search engine PubMed was utilized with the following search terms: inhaled nicotine, nicotine e-cigarette, heated tobacco products, iQOS, electronic cigarette, nicotine inhaler, nicotine vaping. This review highlights recent primary in vivo studies of inhaled nicotine administration experimental paradigms that occurred in laboratory settings using human and rodent (rats and mice) models that have been published from January 2017-December 2019.

RESULTS

The pharmacokinetics of nicotine via e-cigarettes is influenced by the PG/VG and flavor constituents in e-liquids, the presence of nicotine salts in e-liquids, puff topography of nicotine and tobacco product users and the power of the e-cigarette device. The pharmacodynamic impact of inhaled nicotine has cardiovascular, pulmonary and central nervous system implications.

CONCLUSION

The articles reviewed here highlight the importance of both animal and human models to fully understand the impact of inhaled nicotine pharmacology There is a need for more rodent pharmacokinetic inhaled nicotine studies to understand the influences of factors such as flavor and nicotine salts. Additionally, consensus on nicotine measurement in both human and rodent studies is greatly needed.

A Social Media Study on the Associations of Flavored Electronic Cigarettes With Health Symptoms: Observational Study

Background

In recent years, flavored electronic cigarettes (e-cigarettes) have become popular among teenagers and young adults. Discussions about e-cigarettes and e-cigarette use (vaping) experiences are prevalent online, making social media an ideal resource for understanding the health risks associated with e-cigarette flavors from the users’ perspective.

Objective

This study aimed to investigate the potential associations between electronic cigarette liquid (e-liquid) flavors and the reporting of health symptoms using social media data.

Methods

A dataset consisting of 2.8 million e-cigarette–related posts was collected using keyword filtering from Reddit, a social media platform, from January 2013 to April 2019. Temporal analysis for nine major health symptom categories was used to understand the trend of public concerns related to e-cigarettes. Sentiment analysis was conducted to obtain the proportions of positive and negative sentiment scores for all reported health symptom categories. Topic modeling was applied to reveal the topics related to e-cigarettes and health symptoms. Furthermore, generalized estimating equation (GEE) models were used to quantitatively measure potential associations between e-liquid flavors and the reporting of health symptoms.

Results

Temporal analysis showed that the Respiratory category was consistently the most discussed health symptom category among all categories related to e-cigarettes on Reddit, followed by the Throat category. Sentiment analysis showed higher proportions of positive sentiment scores for all reported health symptom categories, except for the Cancer category. Topic modeling conducted on all health-related posts showed that 17 of the top 100 topics were flavor related. GEE models showed different associations between the reporting of health symptoms and e-liquid flavor categories, for example, lower association of the Beverage flavors with Respiratory compared with other flavors and higher association of the Fruit flavors with Cardiovascular than other flavors.

Conclusions

This study identified different potential associations between e-liquid flavors and the reporting of health symptoms using social media data. The results of this study provide valuable information for further investigation of the health effects associated with different e-liquid flavors.

Smoke and Heart Should Stay Apart: A Look at E Cigarettes and Other Alternatives to Conventional Cigarettes, and Their Impact on Cardiovascular Health

The leading cause of preventable death in the world is smoking; leading to 7 million deaths attributable to tobacco use per year worldwide and 480,000 deaths per year in the United States. Though the actual rates of smoking in the United States have been on the decline, the advent of electronic cigarettes (E cigs) in 2007 was met with immense reception especially among the youth. Though initially thought to be a means to facilitate smoking cessation, recent evidence and the E cigs epidemic suggest its implications in significant morbidity and mortality. The other alternatives for conventional tobacco cigarettes have also been implicated in cardiovascular diseases. This manuscript aims to review E cigarettes and other alternatives to conventional cigarettes, and their impact on cardiovascular health. We conducted a Medline search using various combinations of "Cigarettes," "E cigarettes," "Smokeless tobacco," "hookah", and "cardiovascular risk" to identify pivotal trials published before May 10, 2020, for inclusion in this review. Concurrently, major practice guidelines, trial bibliographies, and pertinent reviews were examined to ensure inclusion of relevant trials. A consensus among the authors was used to choose items for narrative inclusion. The following section reviews data from pivotal trials to review the effects of E cigarettes, smokeless tobacco, hookah, nicotine replacement therapy on cardiovascular mortality and morbidity. There are many alternatives to conventional tobacco cigarette smoking, but none can be attributed as absolutely safe from a cardiovascular health perspective. The abundance of evidence regarding its impact on cardiovascular mortality and morbidity does not position it as a safe alternative, but an alternative means of smoking nicotine. The humongous rise in popularity and its gain in favor among the younger population poses a serious threat to the cardiovascular well-being of the exposed. Thus, E cigs and other alternatives of cigarette smoking do impart differing risks in cardiovascular mortality and morbidity, with the possible exception of nicotine replacement therapy.

Electronic cigarettes: A narrative review of the implications for the pediatric anesthesiologist

The use of electronic cigarettes (EC) is increasing and the number of EC publications is rapidly growing. While some health organizations focus on the harmful effects of using EC (vaping), others promote the benefits of ECs as a less harmful alternative to smoking tobacco. There is concern that vaping might have adverse respiratory consequences for pediatric patients facing anesthesia and intensive care. This narrative review summarizes current knowledge and recommendations regarding the risks of EC relevant to the anesthesiologist and the use of ECs as a step-down option from tobacco. We provide guidance on the management of vaping patients in the perioperative period.

Cannabinoids for fibromyalgia pain: a critical review of recent studies (2015-2019)

INTRODUCTION

Fibromyalgia is a chronic health condition characterized by widespread, severe musculoskeletal pain that affects an estimated 5-7% of the global population. Due to the highly comorbid nature of fibromyalgia, patients with the disorder often respond poorly to traditional pain treatments. Recent studies suggest that patient response may be more favorable to alternative analgesics, such as cannabis. However, the therapeutic potential of cannabis-based pain treatment for fibromyalgia remains unclear. The present study examined the most recent cannabis literature (2015-2019) and provides a critical review of current research on the safety and efficacy of medical cannabis treatments for fibromyalgia.

METHODS

We followed Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines in searching the PubMed and Medline databases using the search terms "cannabis + fibromyalgia" and then "cannabinoids + fibromyalgia." Inclusion criteria were a) English language, b) published in peer review journals, c) published from 2015 to 2019, d) all study designs except for systematic reviews and meta-analyses, and e) all cannabis preparations.

RESULTS

The search identified five applicable studies involving 827 participants that used six different treatments. Review suggested several methodological problems pertaining to generalizability and validity.

CONCLUSION

Although the critically reviewed studies superficially suggest that medical cannabis is a safe and effective treatment for fibromyalgia pain, serious methodological limitations prevent a definitive conclusion regarding the use of cannabinoids for pain management in fibromyalgia patients at this time.

Electronic Cigarette and JUUL Use Among Adolescents and Young Adults

IMPORTANCE

The increasing use rates of electronic cigarettes (e-cigarettes) among young people in the United States have been largely associated with the emergence of high-nicotine-delivery device JUUL. Relevant data are needed to monitor e-cigarette, specifically JUUL, use to help inform intervention efforts.

OBJECTIVE

To estimate the prevalence, patterns, and factors associated over time with e-cigarette use among adolescents and younger adults in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Two nationally representative longitudinal samples of adolescents and younger adults aged 15 to 34 years were drawn from the Truth Longitudinal Cohort, a national, probability-based cohort. Participants in this cohort were recruited through address-based sampling, and subsamples were recruited from a probability-based online panel. The present cohort study used data from follow-up online surveys, specifically, wave 7 (N = 14 379; collected from February 15, 2018, to May 25, 2018) and wave 8 (N = 12 114; collected from February 10, 2019, to May 17, 2019). Respondents reported their use of e-cigarettes, JUUL, and combustible tobacco products as well as their harm perceptions, household smoking status, sensation-seeking, friends' e-cigarette use, and demographic information.

MAIN OUTCOMES AND MEASURES

The main outcomes were ever and current (past 30 days) JUUL use. χ2 Analyses assessed differences in JUUL use by psychosocial and demographic characteristics. Logistic regression models identified the significant factors associated with wave 8 ever and current JUUL use among wave 7 e-cigarette-naive participants.

RESULTS

A total of 14 379 participants (mean [SD] age, 24.3 [0.09] years; 8142 female [51.0%]) were included in wave 7 and 12 114 (mean [SD] age, 24.5 [0.10] years; 6835 female [50.1%]) in wave 8. JUUL use statistically significantly increased from wave 7 to wave 8 among ever users (6.0% [n = 1105] to 13.5% [2111]; P < .001) and current users (3.3% [680] to 6.1% [993]; P < .001). JUUL use increased among every age group and was highest among those aged 18 to 20 years (23.9% [491] ever users and 12.8% [340] current users) and 21 to 24 years (18.1% [360] ever users and 8.2% [207] current users). Users reported a higher prevalence of frequent use in wave 8 compared with wave 7 (37.6% vs 26.1%; P < .01). Significant factors associated with future JUUL use among e-cigarette-naive participants included younger age, combustible tobacco use, lower harm perceptions, sensation seeking, and friends' e-cigarette use.

CONCLUSIONS AND RELEVANCE

This study found that the e-cigarette device JUUL appears to be associated with the youth e-cigarette epidemic, attracting new users and facilitating frequent use with their highly addictive nicotine content and appealing flavors. Findings of this study underscore the critical need for increased e-cigarette product regulation at the federal, state, and local levels.

Association Between E-Cigarette Use and Chronic Obstructive Pulmonary Disease by Smoking Status: Behavioral Risk Factor Surveillance System 2016 and 2017

INTRODUCTION

The association between e-cigarette use and chronic bronchitis, emphysema, and chronic obstructive pulmonary disease has not been studied thoroughly, particularly in populations defined by concomitant combustible smoking status.

METHODS

Using pooled 2016 and 2017 data from the Behavioral Risk Factor Surveillance System, investigators studied 705,159 participants with complete self-reported information on e-cigarette use, combustible cigarette use, key covariates, and chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. Current e-cigarette use was the main exposure, with current use further classified as daily or occasional use. The main outcome was defined as reported ever having a diagnosis of chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. For all the analyses, multivariable adjusted logistic regression was used, with the study population stratified by combustible cigarette use status (never, former, or current). All the analyses were conducted in 2019.

RESULTS

Of 705,159 participants, 25,175 (3.6%) were current e-cigarette users, 64,792 (9.2%) current combustible cigarette smokers, 207,905 (29.5%) former combustible cigarette smokers, 432,462 (61.3%) never combustible cigarette smokers, and 14,036 (2.0%) dual users of e-cigarettes and combustible cigarettes. A total of 53,702 (7.6%) participants self-reported chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. Among never combustible cigarette smokers, current e-cigarette use was associated with 75% higher odds of chronic bronchitis, emphysema, or chronic obstructive pulmonary disease compared with never e-cigarette users (OR=1.75, 95% CI=1.25, 2.45), with daily users of e-cigarettes having the highest odds (OR=2.64, 95% CI=1.43, 4.89). Similar associations between e-cigarette use and chronic bronchitis, emphysema, or chronic obstructive pulmonary disease were noted among both former and current combustible cigarette smokers.

CONCLUSIONS

The results suggest possible e-cigarette-related pulmonary toxicity across all the categories of combustible cigarette smoking status, including those who had never smoked combustible cigarettes.

Risk of Stroke With E-Cigarette and Combustible Cigarette Use in Young Adults

INTRODUCTION

Rising trends in stroke incidence and hospitalizations because of combustible cigarette smoking have been noted among younger adults. However, the association between e-cigarette use and stroke in this population remains largely unknown. This study examines the association between e-cigarette use with or without a history of previous or concurrent combustible cigarette use and stroke among young adults.

METHODS

Pooled data (2016-2017) were analyzed from the Behavior Risk Factor Surveillance System, a nationally representative, cross-sectional telephone survey, in 2019. The sample size was 161,529 participants aged 18-44 years. The association between e-cigarette use and stroke was examined using logistic regression adjusting for patient demographics, relevant comorbidities without or with history, and concurrent use of combustible cigarette use.

RESULTS

Current dual use of e-cigarettes and combustible cigarettes was associated with 2.91 times higher odds of stroke versus nonsmokers (AOR=2.91, 95% CI=1.62, 5.25) and 1.83 times higher odds versus current sole combustible cigarette users (AOR=1.83, 95% CI=1.06, 3.17). Compared with nonsmokers, current sole e-cigarette users did not show significantly different odds of stroke (AOR=0.69, 95% CI=0.34, 1.42). However, odds of stroke were lower for sole e-cigarette users versus current sole combustible cigarette users (AOR=0.43, 95% CI=0.20, 0.93).

CONCLUSIONS

Sole e-cigarette use is not associated with greater odds of stroke in young adults. However, if young adults have former or current combustible cigarette use, odds of stroke are significantly increased even compared with current sole combustible cigarette use. Switching from combustible cigarettes to e-cigarettes does not confer stroke benefits.

Association Between Electronic Cigarette Use and Levels of High-Sensitivity C-Reactive Protein and Uric Acid

The present study investigated whether electronic cigarette use, which is becoming increasingly common, was related to systemic inflammation that may lead to cardiovascular disease, similar to conventional cigarette smoking. The study included 1208 men (19-65 years old) who participated in the 7^th Korean National Health and Nutrition Examination Survey (2016). The participants were categorized as electronic cigarette users, conventional cigarette users, and nonsmokers. Serum high-sensitivity C-reactive protein was used as an inflammatory index, and uric acid level was used as a metabolic indicator. After adjusting for confounding factors, electronic cigarette use was significantly associated with elevated serum high-sensitivity C-reactive protein levels (β = 1.326, P = .002), uric acid levels (β = 0.400, P = .042), and hyperuricemia (uric acid level of >7 mg/mL; odds ratio = 2.67, 95% confidence interval = 1.27-5.58). These findings suggest that electronic cigarette use may be associated with systemic inflammation markers, similar to conventional cigarette use.

Short-Term Exposure to Waterpipe/Hookah Smoke Triggers a Hyperactive Platelet Activation State and Increases the Risk of Thrombogenesis

OBJECTIVE

Cardiovascular disease is a major public health problem. Among cardiovascular disease's risk factors, tobacco smoking is considered the single most preventable cause of death, with thrombosis being the main mechanism of cardiovascular disease mortality in smokers. While tobacco smoking has been on the decline, the use of waterpipes/hookah has been rising, mainly due to the perception that they are less harmful than regular cigarettes. Strikingly, there are few studies on the negative effects of waterpipes on the cardiovascular system, and none regarding their direct contribution to thrombus formation. Approach and Results: We used a waterpipe whole-body exposure protocol that mimics real-life human exposure scenarios and investigated its effects, relative to clean air, on platelet function, hemostasis, and thrombogenesis. We found that waterpipe smoke (WPS)-exposed mice exhibited both shortened thrombus occlusion and bleeding times. Further, our results show that platelets from WPS-exposed mice are hyperactive, with enhanced agonist-induced aggregation, dense and α-granule secretion, αIIbβ3 integrin activation, phosphatidylserine expression, and platelet spreading, when compared with clean air-exposed platelets. Finally, at the molecular level, it was found that Akt (protein kinase B) and ERK (extracellular signal-regulated kinases) phosphorylation are enhanced in the WPS and in nicotine-treated platelets.

CONCLUSIONS

Our findings demonstrate that WPS exposure directly modulates hemostasis and increases the risk of thrombosis and that this is mediated, in part, via a state of platelet hyperactivity. The negative health impact of WPS/hookah, therefore, should not be underestimated. Moreover, this study should also help in raising public awareness of the toxic effects of waterpipe/hookah.

Patterns of cigarette, e-cigarette, and cannabis use among adult smokers in primary care 2014-2015

BACKGROUND

Poly-use of tobacco, cannabis, and electronic cigarettes (e-cigarettes) is an emerging problem in the general population. The current study investigated poly-use of these products and receipt of smoking cessation counseling in a primary care setting.

METHODS

We conducted a cross-sectional secondary data analysis from a trial of a tablet intervention to increase provider delivery of the 5As (Ask, Advise, Assess, Assist, Arrange follow-up), a brief counseling intervention for smoking cessation, in 3 diverse primary care clinics in San Francisco, CA from 2014 to 2015. Participants were currently smoking cigarettes (N = 601; mean age = 50.8; 38.1% female) and reported information on past 30-day cigarette and e-cigarette use and past 3-month cannabis use. We classified participants into 4 groups: (1) cigarette-only, (2) dual-use of cigarettes and e-cigarettes, (3) dual-use of cigarettes and cannabis, (4) poly-use of cigarettes, e-cigarettes, and cannabis, and examined correlates of use.

RESULTS

Only cigarette smoking was reported by 48.6% of participants, 30.4% reported use of cigarettes and cannabis, 10.5% reported use of cigarettes and e-cigarettes, and 10.5% reported use of cigarettes, e-cigarettes, and cannabis. Cigarette-only smokers did not differ from other groups by cigarette smoking behavior and motivation to quit. Patients reporting dual-use of cigarettes and e-cigarettes had a higher likelihood of receiving the Arrange step and all 5As compared to cigarette-only smokers.

CONCLUSIONS

Providers should screen for co-use of cigarettes and other nicotine/cannabis products and consider co-use when delivering smoking cessation treatment and evaluating treatment outcomes. Development of guidelines to help facilitate provider training is needed.

Systemic biomarkers in electronic cigarette users: implications for noninvasive assessment of vaping-associated pulmonary injuries

Background

Electronic cigarettes (e-cigs) were introduced as electronic nicotine delivery systems, and have become very popular in the USA and globally. There is a paucity of data on systemic injury biomarkers of vaping in e-cig users that can be used as a noninvasive assessment of vaping-associated lung injuries. We hypothesised that characterisation of systemic biomarkers of inflammation, anti-inflammatory, oxidative stress, vascular and lipid mediators, growth factors, and extracellular matrix breakdown may provide information regarding the toxicity of vaping in e-cig users.

Methods

We collected various biological fluids, i.e. plasma, urine, saliva and exhaled breath condensate (EBC), measured pulmonary function and vaping characteristics, and assessed various biomarkers in e-cig users and nonusers.

Results

The plasma samples of e-cig users showed a significant increase in biomarkers of inflammation (interleukin (IL)-1β, IL-6, IL-8, IL-13, interferon (IFN)-γ, matrix metalloproteinase-9, intercellular cell adhesion molecule-1) and extracellular matrix breakdown (desmosine), and decreased pro-resolving lipid mediators (resolvin D₁ and resolvin D₂). There was a significant increase in growth factor (endothelial growth factor, vascular endothelial growth factor, β-nerve growth factor, platelet-derived growth factor-AA, stem cell factor, hepatocyte growth factor and placental growth factor) levels in plasma of e-cig users versus nonusers. E-cig users showed a significant increase in levels of inflammatory biomarker IFN-γ, oxidative stress biomarker 8-isoprostane and oxidative DNA damage biomarker 8-oxo-dG in urine samples, and of inflammatory biomarker IL-1β in saliva samples. EBC showed a slight increase in levels of triglycerides and 8-isoprostane in e-cig users compared with normal nonusers.

Conclusion

E-cig users have increased levels of biomarkers of inflammation and oxidative stress, reduced pro-resolving anti-inflammatory mediators, and endothelial dysfunction, which may act as risk factors for increasing susceptibility to systemic diseases. The identified noninvasive biomarkers can be used for determining e-cig vaping-associated lung injuries, and for regulatory and diagnostic aspects of vaping in humans.

E-cig use adversely affects oxidative stress and inflammatory responses, and induces tissue remodelling. The identified biomarkers can be used for assessment of vaping-associated lung injuries, and for regulatory and diagnostic aspects of vaping in humans.http://bit.ly/2nxZQ8R

Genotoxic and Carcinogenic Potential of Compounds Associated with Electronic Cigarettes: A Systematic Review

Background

Many studies, comparing the health associated risks of electronic cigarettes with conventional cigarettes focus mainly on the common chemical compounds found between them.

Aim

Review chemical compounds found exclusively in electronic cigarettes and describe their toxic effects, focusing on electronic-cigarette-only and dual electronic-cigarette and conventional cigarette users.

Data Sources

Literature search was carried out using PubMed.

Study Eligibility Criteria

Articles related exclusively to conventional and electronic cigarettes' chemical composition. Articles which reported to be financed from tobacco or electronic cigarettes industries, not reporting source of funding, not related to the chemical composition of electronic and conventional cigarettes and not relevant to tobacco research were excluded.

Methods and Results

Chemical compounds reported in the selected studies were tabulated using the Chemical Abstracts Service registry number for chemical substances information. A total of 50 chemical compounds were exclusively reported to be present in electronic cigarettes. Crucial health risks identified were: eye, skin, and respiratory tract irritation, with almost 50% of incidence, an increment of 10% in cytotoxic effects, when compared to compounds in common with conventional cigarettes and around 11% of compounds with unknown effects to human health.

Limitations

Articles reporting conflicts of interest.

Conclusions and Implications of Key Findings

Despite being considered as less harmful for human health, compounds found in electronic cigarettes are still a matter of research and their effects on health are yet unknown. The use of these devices is not recommended for first time users and it is considered hazardous for dual users.