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Izquierdo-Condoy JS, Naranjo-Lara P, Morales-Lapo E, Hidalgo MR, Tello-De-la-Torre A, Vásconez-Gonzáles E, Salazar-Santoliva C, Loaiza-Guevara V, Rincón Hernández W, Becerra DA, González MBD, López-Cortés A, Ortiz-Prado E. Direct health implications of e-cigarette use: a systematic scoping review with evidence assessment. Front Public Health 2024; 12:1427752. [PMID: 39135931 PMCID: PMC11317248 DOI: 10.3389/fpubh.2024.1427752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 07/15/2024] [Indexed: 08/15/2024] Open
Abstract
Background E-cigarettes are often marketed as a less harmful alternative to traditional tobacco cigarettes. Despite their popularity, the evidence regarding their effects on human health remains unclear and is filled with complexities. Objectives This systematic review aims to elucidate the direct effects of electronic cigarette use on human health, carefully distinguishing between the specific characteristics of the populations studied. Methodology Adhering to the PRISMA guidelines, we conducted a comprehensive search in PubMed/Medline, Web of Science, Scopus, and Google Scholar databases without date restrictions, including articles in both Spanish and English. This approach enabled the identification and analysis of primary studies to understand the direct effect of electronic cigarettes on human health. Results A total of 33 studies were included that evaluated cardiovascular, pulmonary, renal, weight and fertility effects. Only five studies analyzed e-cigarettes in healthy populations and seven studies compared healthy individuals against smokers. The effects evaluated on smokers or former tobacco smokers were apparently positive, however, among healthy individuals, increased heart rate, mean arterial pressure, oxidative stress, alteration of respiratory epithelial cells and increased airflow resistance were found. Conclusion Smokers or former smokers who switch to e-cigarettes may reduce their exposure to carcinogens and lower their risk of developing severe health issues associated with conventional smoking. However, in healthy individuals who have never smoked traditional cigarettes, the use of e-cigarettes introduces several cardiovascular and respiratory adverse effects. These findings suggest that while e-cigarettes can be a strategic harm reduction tool for smokers, they are not a safe option for non-smokers.
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Affiliation(s)
| | - Patricio Naranjo-Lara
- One Health Research Group, Faculty of Medicine, Universidad de las Américas, Quito, Ecuador
| | - Estefanía Morales-Lapo
- One Health Research Group, Faculty of Medicine, Universidad de las Américas, Quito, Ecuador
| | - Marlon R. Hidalgo
- One Health Research Group, Faculty of Medicine, Universidad de las Américas, Quito, Ecuador
| | | | | | | | | | | | | | | | - Andrés López-Cortés
- Cancer Research Group (CRG), Faculty of Medicine, Universidad de las Americas, Quito, Ecuador
| | - Esteban Ortiz-Prado
- One Health Research Group, Faculty of Medicine, Universidad de las Américas, Quito, Ecuador
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Qananwah Q, Khader A, Al-Hashem M, Mumani A, Dagamseh A. Investigating the impact of smoking habits through photoplethysmography analysis. Physiol Meas 2024; 45:015003. [PMID: 38176078 DOI: 10.1088/1361-6579/ad1b10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 01/04/2024] [Indexed: 01/06/2024]
Abstract
Smoking is widely recognized as a significant risk factor in the progression of arterial stiffness and cardiovascular diseases. Valuable information related to cardiac arrhythmias and heart function can be obtained by analyzing biosignals such as the electrocardiogram (ECG) and the photoplethysmogram (PPG). The PPG signal is a non-invasive optical technique that can be used to evaluate the changes in blood volume, and thus it can be linked to the health of the vascular system.Objective. In this study, the impact of three smoking habits-cigarettes, shisha, and electronic cigarettes (e-cigarettes)-on the features of the PPG signal were investigated.Approach. The PPG signals are measured for 45 healthy smokers before, during, and after the smoking session and then processed to extract the morphological features. Quantitative statistical techniques were used to analyze the PPG features and provide the most significant features of the three smoking habits. The impact of smoking is observed through significant changes in the features of the PPG signal, indicating blood volume instability.Main results. The results revealed that the three smoking habits influence the characteristics of the PPG signal significantly, which presentseven after 15 min of smoking. Among them, shisha has the greatest impact on PPG features, particularly on heart rate, systolic time, augmentation index, and peak pulse interval change. In contrast, e-cigarettes have the least effect on PPG features. Interestingly, smoking electronic cigarettes, which many participants use as a substitute for traditional cigarettes when attempting to quit smoking, has nearly a comparable effect to regular smoking.Significance. The findings suggest that individuals who smoke shisha are more likely to develop cardiovascular diseases at an earlier age compared to those who have other smoking habits. Understanding the variations in the PPG signal caused by smoking can aid in the early detection of cardiovascular disorders and provide insight into cardiac conditions. This ultimately contributes to the prevention of the development of cardiovascular diseases and the development of a health screening system.
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Affiliation(s)
- Qasem Qananwah
- Department of Biomedical Systems and Informatics Engineering, Hijjawi Faculty for Engineering Technology, Yarmouk University, Irbid, Jordan
| | - Ateka Khader
- Department of Biomedical Systems and Informatics Engineering, Hijjawi Faculty for Engineering Technology, Yarmouk University, Irbid, Jordan
| | - Munder Al-Hashem
- Department of Biomedical Systems and Informatics Engineering, Hijjawi Faculty for Engineering Technology, Yarmouk University, Irbid, Jordan
| | - Ahmad Mumani
- Department of Industrial Engineering, Hijjawi Faculty for Engineering Technology, Yarmouk University, Irbid, Jordan
| | - Ahmad Dagamseh
- Department of Electronics Engineering, Hijjawi Faculty for Engineering Technology, Yarmouk University, Irbid, Jordan
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Lindson N, Butler AR, McRobbie H, Bullen C, Hajek P, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Livingstone-Banks J, Morris T, Hartmann-Boyce J. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2024; 1:CD010216. [PMID: 38189560 PMCID: PMC10772980 DOI: 10.1002/14651858.cd010216.pub8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review. OBJECTIVES To examine the safety, tolerability and effectiveness of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments and no treatment. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register to 1 February 2023, and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2023, and reference-checked and contacted study authors. SELECTION CRITERIA We included trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention as these studies have the potential to provide further information on harms and longer-term use. Studies had to report an eligible outcome. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA). MAIN RESULTS We included 88 completed studies (10 new to this update), representing 27,235 participants, of which 47 were randomized controlled trials (RCTs). Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 58 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There is high certainty that nicotine EC increases quit rates compared to nicotine replacement therapy (NRT) (RR 1.59, 95% CI 1.29 to 1.93; I2 = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more). There is moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs is similar between groups (RR 1.03, 95% CI 0.91 to 1.17; I2 = 0%; 5 studies, 2052 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.20, 95% CI 0.90 to 1.60; I2 = 32%; 6 studies, 2761 participants; low-certainty evidence). There is moderate-certainty evidence, limited by imprecision, that nicotine EC increases quit rates compared to non-nicotine EC (RR 1.46, 95% CI 1.09 to 1.96; I2 = 4%; 6 studies, 1613 participants). In absolute terms, this might lead to an additional three quitters per 100 (95% CI 1 to 7 more). There is moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 9 studies, 1412 participants; low-certainty evidence). Due to issues with risk of bias, there is low-certainty evidence that, compared to behavioural support only/no support, quit rates may be higher for participants randomized to nicotine EC (RR 1.88, 95% CI 1.56 to 2.25; I2 = 0%; 9 studies, 5024 participants). In absolute terms, this represents an additional four quitters per 100 (95% CI 2 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low-certainty evidence; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.89, 95% CI 0.59 to 1.34; I2 = 23%; 10 studies, 3263 participants; very low-certainty evidence). Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes, and there was no indication of inconsistency within the networks. Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but the longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Tom Morris
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Jamie Hartmann-Boyce
- Department of Health Promotion and Policy, University of Massachusetts, Amherst, MA, USA
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Kale D, Tattan-Birch H, Brown J, Cox S, Dawkins L, Goniewicz ML, Morris K, Shahab L. Examining acute psychopharmacological effects of nicotine vaping versus heated tobacco products in a randomised crossover study of product naïve adult smokers. Sci Rep 2023; 13:22676. [PMID: 38114686 PMCID: PMC10730620 DOI: 10.1038/s41598-023-49602-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023] Open
Abstract
Nicotine vaping products (NVPs) and heated tobacco products (HTPs) are designed to replicate the sensory and behavioural aspects of smoking cigarettes while avoiding combustion. The success of these products as harm reduction tools will partially depend on their ability to satisfy smokers and alleviate nicotine-related withdrawal symptoms. This study aims to compare short-term effects of NVPs (Juul and Aspire PockeX) versus HTPs (IQOS) on smoking-related withdrawal relief, product satisfaction, intention to switch to NVP/HTP, perceptions and attitudes in UK adult cigarette smokers naïve to these products. In a randomized cross-over study, 45 participants visited the lab twice, at each visit trying one of the two products (NVP/HTP) and completing a questionnaire. Responses were normalized on a 0-100% scale and mean differences (MD) between NVP and HTP scores computed, with positive and negative MD values indicating greater endorsement for NVP and HTP, respectively. Cigarette cravings were reduced similarly (~ 20.0%) by both products (MD = 4.5%, 95%Confidence Interval (CI) - 4.8, 13.8). Direct positive effects (MD = - 3.5%, 95%CI - 7.2, 0.2) and adverse side effects (MD = 1.8%, 95%CI - 0.3, 3.8) were comparable after each product use, though marginally favouring HTPs. HTPs were perceived as more satisfying overall (MD = - 13.2%, 95%CI - 20.3 - 6.1) than NVPs but both were perceived as similarly addictive (MD = 3.6%, 95%CI - 4.6, 11.8), relative to cigarettes. Intention to switch to either product was comparable (MD = 4.0%, 95%CI - 5.7, 13.8). Comparison of acute use of NVP versus HTP in a sample of UK smokers naïve to these products suggests that HTPs are perceived as more satisfying than NVPs, though still less satisfying than cigarettes.Registration: The analysis plan was pre-registered, and it is available at https://osf.io/6ymdu.
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Affiliation(s)
- Dimitra Kale
- Department of Behavioural Science and Health, University College London, London, UK.
- SPECTRUM Consortium, London, UK.
| | - Harry Tattan-Birch
- Department of Behavioural Science and Health, University College London, London, UK
- SPECTRUM Consortium, London, UK
| | - Jamie Brown
- Department of Behavioural Science and Health, University College London, London, UK
- SPECTRUM Consortium, London, UK
| | - Sharon Cox
- Department of Behavioural Science and Health, University College London, London, UK
- SPECTRUM Consortium, London, UK
| | - Lynne Dawkins
- Centre for Addictive Behaviours Research, School of Applied Sciences, London South Bank University, London, UK
| | - Maciej L Goniewicz
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Kierra Morris
- Department of Behavioural Science and Health, University College London, London, UK
| | - Lion Shahab
- Department of Behavioural Science and Health, University College London, London, UK
- SPECTRUM Consortium, London, UK
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5
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Rose JJ, Krishnan-Sarin S, Exil VJ, Hamburg NM, Fetterman JL, Ichinose F, Perez-Pinzon MA, Rezk-Hanna M, Williamson E. Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association. Circulation 2023; 148:703-728. [PMID: 37458106 DOI: 10.1161/cir.0000000000001160] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Vaping and electronic cigarette (e-cigarette) use have grown exponentially in the past decade, particularly among youth and young adults. Cigarette smoking is a risk factor for both cardiovascular and pulmonary disease. Because of their more limited ingredients and the absence of combustion, e-cigarettes and vaping products are often touted as safer alternative and potential tobacco-cessation products. The outbreak of e-cigarette or vaping product use-associated lung injury in the United States in 2019, which led to >2800 hospitalizations, highlighted the risks of e-cigarettes and vaping products. Currently, all e-cigarettes are regulated as tobacco products and thus do not undergo the premarket animal and human safety studies required of a drug product or medical device. Because youth prevalence of e-cigarette and vaping product use was as high as 27.5% in high school students in 2019 in the United States, it is critical to assess the short-term and long-term health effects of these products, as well as the development of interventional and public health efforts to reduce youth use. The objectives of this scientific statement are (1) to describe and discuss e-cigarettes and vaping products use patterns among youth and adults; (2) to identify harmful and potentially harmful constituents in vaping aerosols; (3) to critically assess the molecular, animal, and clinical evidence on the acute and chronic cardiovascular and pulmonary risks of e-cigarette and vaping products use; (4) to describe the current evidence of e-cigarettes and vaping products as potential tobacco-cessation products; and (5) to summarize current public health and regulatory efforts of e-cigarettes and vaping products. It is timely, therefore, to review the short-term and especially the long-term implications of e-cigarettes and vaping products on cardiopulmonary health. Early molecular and clinical evidence suggests various acute physiological effects from electronic nicotine delivery systems, particularly those containing nicotine. Additional clinical and animal-exposure model research is critically needed as the use of these products continues to grow.
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Mendelsohn CP, Hall W, Borland R, Wodak A, Beaglehole R, Benowitz NL, Britton J, Bullen C, Etter JF, McNeill A, Rigotti NA. A critique of the Australian National Health and Medical Research Council CEO statement on electronic cigarettes. Addiction 2023; 118:1184-1192. [PMID: 36808672 DOI: 10.1111/add.16143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/13/2023] [Indexed: 02/23/2023]
Abstract
This paper critically analyses a statement by Australia's National Health and Medical Research Council (NHMRC) on e-cigarettes in May 2022 that will be used to guide national policy. We reviewed the evidence and the conclusions drawn in the NHMRC Statement. In our view, the Statement is not a balanced reflection of the benefits and risks of vaping because it exaggerates the risks of vaping and fails to compare them to the far greater risks of smoking; it uncritically accepts evidence of harms from e-cigarettes while adopting a highly sceptical attitude towards evidence of their benefits; it incorrectly claims that the association between adolescent vaping and subsequent smoking is causal; and it understates the evidence of the benefits of e-cigarettes in assisting smokers to quit. The Statement dismisses the evidence that vaping is probably already having a positive net public health effect and misapplies the precautionary principle. Several sources of evidence supporting our assessment were published after the NHMRC Statement's publication and are also referenced. The NHMRC Statement on e-cigarettes does not present a balanced assessment of the available scientific literature and fails to meet the standard expected of a leading national scientific body.
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Affiliation(s)
| | - Wayne Hall
- National Centre for Youth Substance Use Research, The University of Queensland, St Lucia, Queensland, Australia
| | - Ron Borland
- Melbourne Centre for Behaviour Change, School of Psychological Sciences, The University of Melbourne, Victoria, Australia
| | - Alex Wodak
- Emeritus Consultant, Alcohol and Drug Service, St Vincents' Hospital, Sydney, Australia
| | | | - Neal L Benowitz
- Department of Medicine, University of California San Francisco, California, USA
| | - John Britton
- University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Chris Bullen
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Jean-François Etter
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ann McNeill
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Nancy A Rigotti
- Harvard Medical School, Director, Tobacco Research and Treatment Center, Massachusetts General Hospital, Massachusetts, Boston, USA
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Hirschtick JL, Cook S, Patel A, Barnes GD, Arenberg D, Bondarenko I, Levy DT, Jeon J, Jimenez Mendoza E, Meza R, Fleischer NL. Longitudinal Associations Between Exclusive and Dual Use of Electronic Nicotine Delivery Systems and Cigarettes and Self-Reported Incident Diagnosed Cardiovascular Disease Among Adults. Nicotine Tob Res 2023; 25:386-394. [PMID: 35907264 PMCID: PMC9910147 DOI: 10.1093/ntr/ntac182] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/14/2022] [Accepted: 07/21/2022] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The cardiovascular health effects of electronic nicotine delivery systems (ENDS) use are not well characterized, making it difficult to assess ENDS as a potential harm reduction tool for adults who use cigarettes. AIMS AND METHODS Using waves 1-5 of the Population Assessment of Tobacco and Health Study (2013-2019), we analyzed the risk of self-reported incident diagnosed myocardial infarction (MI; 280 incident cases) and stroke (186 incident cases) associated with ENDS and/or cigarette use among adults aged 40 + using discrete time survival models. We employed a time-varying exposure lagged by one wave, defined as exclusive or dual established use of ENDS and/or cigarettes every day or some days, and controlled for demographics, clinical factors, and past smoking history. RESULTS The analytic samples (MI = 11 031; stroke = 11 076) were predominantly female and non-Hispanic White with a mean age of 58 years. At baseline, 14.2% of respondents exclusively smoked cigarettes, 0.6% exclusively used ENDS, and 1.0% used both products. Incident MI and stroke were rare during follow-up (< 1% at each wave). Compared to no cigarette or ENDS use, exclusive cigarette use increased the risk of MI (aHR 1.99, 95% CI = 1.40-2.84) and stroke (aHR 2.26, 95% CI = 1.51-3.39), while exclusive ENDS use (MI: aHR 0.61, 95% CI = 0.12-3.04; stroke: aHR 1.74, 95% CI = 0.55-5.49) and dual use (MI: aHR 1.84, 95% CI = 0.64-5.30; stroke: aHR 1.12, 95% CI = 0.33-3.79) were not significantly associated with the risk of either outcome. CONCLUSIONS Compared to non-use, exclusive cigarette use was associated with an increased risk of self-reported incident diagnosed cardiovascular disease over a 5-year period, while ENDS use was not associated with a statistically significant increase in the outcomes. IMPLICATIONS Existing literature on the health effects of ENDS use has important limitations, including potential reverse causation and improper control for cigarette smoking. We accounted for these issues by using a prospective design and adjusting for current and former smoking status and cigarette pack-years. In this context, we did not find that ENDS use was associated with a statistically significant increase in self-reported incident diagnosed myocardial infarction or stroke over a 5-year period. While more studies are needed, this analysis provides an important foundation and key methodological considerations for future research on the health effects of ENDS use.
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Affiliation(s)
- Jana L Hirschtick
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Steven Cook
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Akash Patel
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Douglas Arenberg
- Pulmonary Clinic, Department of Internal Medicine, University of Michigan Health System, Northville, MI, USA
| | - Irina Bondarenko
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - David T Levy
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, D.C., USA
| | - Jihyoun Jeon
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Evelyn Jimenez Mendoza
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Rafael Meza
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Nancy L Fleischer
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
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Luca AC, Curpăn AȘ, Iordache AC, Mîndru DE, Țarcă E, Luca FA, Pădureț IA. Cardiotoxicity of Electronic Cigarettes and Heat-Not-Burn Tobacco Products-A Problem for the Modern Pediatric Cardiologist. Healthcare (Basel) 2023; 11:healthcare11040491. [PMID: 36833024 PMCID: PMC9957306 DOI: 10.3390/healthcare11040491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/27/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023] Open
Abstract
Electronic nicotine delivery systems (ENDS) have become increasingly popular among adolescents, either as an alternative to conventional cigarettes (CCs) or as a newly acquired recreational habit. Although considered by most users as a safer option for nicotine intake, these devices pose significant health risks, resulting in multisystem damage. Heat-not-burn products, which, unlike ENDS, contain tobacco, are also alternatives to CCs that consumers use based on the idea that their safety profile is superior to that of cigarettes. Recent studies in the USA and EU show that adolescents are particularly prone to using these devices. Pediatric cardiologists, as well as other healthcare professionals, should be aware of the complications that may arise from acute and chronic consumption of these substances, considering the cardiovascular damage they elicit. This article summarized the known data about the impact of ENDS on the cardiovascular system, with emphasis on the pathophysiological and molecular changes that herald the onset of systemic lesions alongside the clinical cardiovascular manifestations in this scenario.
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Affiliation(s)
- Alina-Costina Luca
- Sfânta Maria’ Emergency Children’s Hospital, 700309 Iași, Romania
- Department of Pediatric Cardiology, Faculty of Medicine, Gr. T. Popa’ University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Alexandrina-Ștefania Curpăn
- Department of Biology, Faculty of Biology, “Alexandru Ioan Cuza” University of Iași, Bd. Carol I, 20A, 700505 Iași, Romania
- Correspondence: (A.-Ș.C.); (E.Ț.)
| | - Alin-Constantin Iordache
- Department of Mother and Child Medicine–Pediatric Cardiology, “Grigore T. Popa”, University of Medicine and Pharmacy of Iasi, 16 Universitatii Str., 700115 Iași, Romania
| | - Dana Elena Mîndru
- Department of Pediatric Cardiology, Faculty of Medicine, Gr. T. Popa’ University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Elena Țarcă
- Sfânta Maria’ Emergency Children’s Hospital, 700309 Iași, Romania
- Department of Surgery II—Pediatric Surgery, Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iași, Romania
- Correspondence: (A.-Ș.C.); (E.Ț.)
| | - Florin-Alexandru Luca
- Department BMTM, “Gheorghe Asachi” Technical University of Iasi, 700050 Iaşi, Romania
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La Rosa G, Vernooij R, Qureshi M, Polosa R, O'Leary R. Clinical testing of the cardiovascular effects of e-cigarette substitution for smoking: a living systematic review. Intern Emerg Med 2023; 18:917-928. [PMID: 36609804 PMCID: PMC10081981 DOI: 10.1007/s11739-022-03161-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/20/2022] [Indexed: 01/08/2023]
Abstract
Some persons who smoke have substituted e-cigarettes for tobacco cigarettes, either completely or partially. What effect does this have on cardiovascular functioning? We conducted a living systematic review on human clinical studies measuring the cardiovascular effects of e-cigarette substitution for smoking. The Scopus, PubMed, and CENTRAL Cochrane Library databases were searched on January 31 and April 29, 2021. Three secondary searches and a grey literature search were conducted. Included study designs were randomized controlled trials, quasi-experimental clinical trials, and cohort studies. Risk of bias and study quality were evaluated with the JBI Critical Appraisal tools and the Oxford Catalogue of Bias. The systematic review covered 25 studies comprising 1810 participants who smoked. Twenty studies were rated at high risk of bias, and five as some concerns. A tabular synthesis by direction of effect was conducted due to heterogeneity in the data. Nearly two-thirds of the test analyses indicated that e-cigarette use had no significance difference compared with tobacco cigarettes on heart rate, blood pressure, and in other cardiovascular tests. In two studies, participants with hypertension experienced a clinically relevant reduction in systolic blood pressure after 1 year of e-cigarette use. E-cigarette substitution incurs no additional cardiovascular risks, and some possible benefits may be obtained, but the evidence is of low to very low certainty. An update search on May 30, 2022 retrieved five studies that did not alter our conclusion.Registration PROSPERO #CRD42021239094.
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Affiliation(s)
- Giusy La Rosa
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Robin Vernooij
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maria Qureshi
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Center for the Acceleration of Harm Reduction, University of Catania, Catania, Italy
| | - Riccardo Polosa
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Center for Excellence for the Acceleration of Harm Reduction, University of Catania, Via Santa Sofia, 89 Torre Biologica 11 Piano, 95123, Catania, Italy
| | - Renée O'Leary
- Center for Excellence for the Acceleration of Harm Reduction, University of Catania, Via Santa Sofia, 89 Torre Biologica 11 Piano, 95123, Catania, Italy.
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Hartmann-Boyce J, Lindson N, Butler AR, McRobbie H, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2022; 11:CD010216. [PMID: 36384212 PMCID: PMC9668543 DOI: 10.1002/14651858.cd010216.pub7] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, although some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review. OBJECTIVES To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2022, and reference-checked and contacted study authors. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants, or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses. MAIN RESULTS We included 78 completed studies, representing 22,052 participants, of which 40 were RCTs. Seventeen of the 78 included studies were new to this review update. Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (RR 1.63, 95% CI 1.30 to 2.04; I2 = 10%; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6). There was moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs was similar between groups (RR 1.02, 95% CI 0.88 to 1.19; I2 = 0%; 4 studies, 1702 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.12, 95% CI 0.82 to 1.52; I2 = 34%; 5 studies, 2411 participants). There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 8 studies, 1272 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; I2 = 0%; 7 studies, 3126 participants). In absolute terms, this represents an additional two quitters per 100 (95% CI 1 to 3). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that (non-serious) AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.03, 95% CI 0.54 to 1.97; I2 = 38%; 9 studies, 1993 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Polosa R, Casale TB, Tashkin DP. A Close Look at Vaping in Adolescents and Young Adults in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2831-2842. [PMID: 35718259 DOI: 10.1016/j.jaip.2022.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/27/2022] [Accepted: 06/09/2022] [Indexed: 06/15/2023]
Abstract
Vaping by adolescents and young adults is a legitimate concern as there is a risk that some may start smoking and that electronic cigarette (EC) use may have adverse effects in the developing lungs of adolescents. This commentary provides updated information on vaping patterns among adolescents and young adults in the United States, as well as the impact of EC usage on respiratory health. EC use has surged greatly among high school students and young adults over the last decade but fortunately has declined significantly since its peak in 2019. During the same time period, smoking rates have constantly fallen to new low record levels. These trends argue against EC use as a gateway to smoking. Most EC usage is infrequent and unlikely to increase a person's risk of negative health consequences. Furthermore, the majority of EC usage has happened among those who have previously smoked. There is a dearth of data on the long-term health implications of EC usage in adolescents and young adults. We do not know whether short-term or intermittent use of EC in youth can lead to negative health outcomes in adulthood, and long-term high-quality studies in well-defined groups are needed. Although vaping has been linked to respiratory symptoms, they tend to be transient and of uncertain significance. This commentary provides up-to-date information so health care providers can give objective and responsible medical advice on EC usage.
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Affiliation(s)
- Riccardo Polosa
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy; Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), Università di Catania, Catania, Italy; Center for the Prevention and Treatment of Tobacco Addiction (CPCT), Teaching Hospital "Policlinico V. Emanuele," University of Catania, Catania, Italy; ECLAT Srl, Spin-off of the University of Catania, Catania, Italy; Institute of Internal Medicine, AOU "Policlinico V. Emanuele-S. Marco," Catania, Italy.
| | - Thomas B Casale
- Department of Medicine, Division of Allergy/Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Donald P Tashkin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine, UCLA Health Sciences, Los Angeles, Calif
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Miller DV, Watson KE, Wang H, Fyfe-Kirschner B, Heide RSV. Racially Related Risk Factors for Cardiovascular Disease: Society for Cardiovascular Pathology Symposium 2022. Cardiovasc Pathol 2022; 61:107470. [PMID: 36029934 DOI: 10.1016/j.carpath.2022.107470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Dylan V Miller
- Department of Pathology, University of Utah and Intermountain Central Laboratory, Salt Lake City, UT, USA
| | - Karol E Watson
- Department of Medicine (Cardiology), UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - He Wang
- Department of Pathology, Yale University, New Haven, CT, USA
| | - Billie Fyfe-Kirschner
- Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Richard S Vander Heide
- Department of Pathology and Laboratory Medicine, Marshfield Clinic Health System, Marshfield, WI, USA
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13
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Travis N, Knoll M, Cadham CJ, Cook S, Warner KE, Fleischer NL, Douglas CE, Sánchez-Romero LM, Mistry R, Meza R, Hirschtick JL, Levy DT. Health Effects of Electronic Cigarettes: An Umbrella Review and Methodological Considerations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9054. [PMID: 35897421 PMCID: PMC9330875 DOI: 10.3390/ijerph19159054] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Abstract
E-cigarettes are often marketed as a safer alternative to combustible cigarettes. However, their health effects, especially those associated with long-term use, remain largely uncertain. We conducted an umbrella review of the cardiopulmonary and carcinogenic risks of e-cigarette use, distinguishing between short-term and long-term health effects. The search for systematic reviews was conducted across four electronic databases through 25 January 2022. Methodological quality was assessed using the AMSTAR-2 quality appraisal tool. Seventeen systematic reviews, including five meta-analyses, were included in our umbrella review. There was a clear underreporting of e-cigarette devices and e-liquid types, e-cigarette and cigarette exposure, and the health and smoking status of study participants. Overall, the findings suggest that short-term use of e-cigarettes may be associated with acute cardiopulmonary risks, although to a lesser extent than cigarette use. Long-term e-cigarette use may have pulmonary/respiratory benefits in those who switch from chronic cigarette smoking, particularly in individuals with asthma and chronic obstructive pulmonary disease (COPD). Evidence on intermediate and long-term carcinogenic effects is lacking. This umbrella review underscores the urgent need for systematic reviews with better adherence to established reporting guidelines, consistent definitions of duration of e-cigarette use, a focus on newer devices, and accounting for the impacts of former or current smoking.
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Affiliation(s)
- Nargiz Travis
- Lombardi Comprehensive Cancer Center, Georgetown Medical University, Washington, DC 20057, USA; (M.K.); (L.M.S.-R.); (D.T.L.)
| | - Marie Knoll
- Lombardi Comprehensive Cancer Center, Georgetown Medical University, Washington, DC 20057, USA; (M.K.); (L.M.S.-R.); (D.T.L.)
| | - Christopher J. Cadham
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (C.J.C.); (K.E.W.); (C.E.D.)
| | - Steven Cook
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (S.C.); (N.L.F.); (R.M.); (J.L.H.)
| | - Kenneth E. Warner
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (C.J.C.); (K.E.W.); (C.E.D.)
| | - Nancy L. Fleischer
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (S.C.); (N.L.F.); (R.M.); (J.L.H.)
| | - Clifford E. Douglas
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (C.J.C.); (K.E.W.); (C.E.D.)
| | - Luz María Sánchez-Romero
- Lombardi Comprehensive Cancer Center, Georgetown Medical University, Washington, DC 20057, USA; (M.K.); (L.M.S.-R.); (D.T.L.)
| | - Ritesh Mistry
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Rafael Meza
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (S.C.); (N.L.F.); (R.M.); (J.L.H.)
| | - Jana L. Hirschtick
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA; (S.C.); (N.L.F.); (R.M.); (J.L.H.)
| | - David T. Levy
- Lombardi Comprehensive Cancer Center, Georgetown Medical University, Washington, DC 20057, USA; (M.K.); (L.M.S.-R.); (D.T.L.)
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14
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Mendelsohn CP, Wodak A, Hall W, Borland R. A critical analysis of 'Electronic cigarettes and health outcomes: Systematic review of global evidence'. Drug Alcohol Rev 2022; 41:1493-1498. [PMID: 35862283 DOI: 10.1111/dar.13515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/19/2022] [Accepted: 06/25/2022] [Indexed: 11/26/2022]
Affiliation(s)
| | - Alex Wodak
- St Vincent's Hospital Sydney, Alcohol and Drug Service, Sydney, Australia
| | - Wayne Hall
- University of Queensland, Centre for Youth Substance Abuse Research, Brisbane, Australia
| | - Ron Borland
- School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
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Edmiston JS, Webb KM, Wang J, Oliveri D, Liang Q, Sarkar M. Biomarkers of Exposure and Biomarkers of Potential Harm in Adult Smokers Who Switch to e-Vapor Products Relative to Cigarette Smoking in a 24-week, Randomized, Clinical Trial. Nicotine Tob Res 2022; 24:1047-1054. [PMID: 35134961 PMCID: PMC9199942 DOI: 10.1093/ntr/ntac029] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 12/14/2021] [Accepted: 01/02/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Long-term health effects of e-vapor products (EVPs) are not well-established. We compared biomarkers of exposure (BoE) to select harmful and potentially harmful constituents and biomarkers of potential harm (BoPH) in adult smokers who switched to EVPs versus continued smoking for 24 weeks. METHODS Adult smokers (n = 450, >10 cigarettes per day for ≥10 years) were randomly assigned to continue smoking (control) or switch to one of two cartridge-based EVPs (test 1: classic; test 2: menthol, 4% nicotine). BoE and BoPH were measured at baseline and 12 weeks. The results presented here are from a subset of 150 control and EVP subjects (switchers with exhaled carbon monoxide <8 ppm and <10% baseline cigarettes per day) followed for 24 total weeks. RESULTS Total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and carboxyhemoglobin were significantly reduced (p < .0001) in tests 1 and 2 at 24 weeks. Urinary nicotine equivalents were not statistically significantly different between the control and EVP groups. At week 24, statistically significant reductions (p < .05) were observed for white blood cell counts, 11-dehydrothromboxane β2, and sICAM in both test groups, and there were several significant changes in measures of pulmonary function. High-density lipoprotein cholesterol and 8-epi-prostaglandin-F2α were directionally favorable in both EVP groups versus control. CONCLUSIONS We demonstrate that significant reductions of selected harmful and potentially harmful constituents in EVP aerosol results in significant reductions in BoEs and favorable changes in BoPHs after switching to EVPs for 24 weeks. These changes approached those reported for smoking cessation, suggesting that switching to exclusive use of the EVPs may be less harmful than continuing smoking. IMPLICATIONS Cigarette smoking causes serious diseases. Switching from cigarettes to a noncombustible product is a potential harm reduction pathway for adult smokers unable or unwilling to quit. Long-term health effects of e-vapor products (EVPs) compared with continued smoking have not been extensively studied. We present biomarker of exposure evidence on select harmful and potentially harmful constituents and biomarkers of potential harm related to inflammation and oxidative stress in adult smokers switching to two EVPs. This study demonstrates significant reductions in biomarkers of exposure (except for nicotine) accompanied with favorable changes in various biomarkers of potential harm, including pulmonary function. The totality of evidence suggests that exclusive EVP use may present lower health risks compared with smoking cigarettes.
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Affiliation(s)
- Jeffery S Edmiston
- Altria Client Services LLC, Center for Research and Technology, Richmond, VA, USA
| | - Katy M Webb
- Altria Client Services LLC, Center for Research and Technology, Richmond, VA, USA
| | - Jingzhu Wang
- Altria Client Services LLC, Center for Research and Technology, Richmond, VA, USA
| | - Douglas Oliveri
- Employees of Altria Client Services LLC at the time of the study
| | - Qiwei Liang
- Employees of Altria Client Services LLC at the time of the study
| | - Mohamadi Sarkar
- Altria Client Services LLC, Center for Research and Technology, Richmond, VA, USA
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16
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Benowitz NL, Liakoni E. Tobacco use disorder and cardiovascular health. Addiction 2022; 117:1128-1138. [PMID: 34590373 DOI: 10.1111/add.15703] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/01/2021] [Indexed: 12/28/2022]
Abstract
This narrative review examines the impact of cigarette smoking and the use of other tobacco and nicotine products on cardiovascular disease. Smoking increases the incidence of both acute and chronic cardiovascular diseases, and the harmful effects are substantially and relatively quickly reversible after quitting. Recommended cessation treatment includes offering pharmacotherapy, counseling which should emphasize the rapid risk reduction that occurs after quitting and adequate follow-up contacts. Although most research on cardiovascular disease in relation to tobacco use has focused upon cigarette smoking, we also review available data related to other combustible tobacco products, smokeless tobacco, electronic nicotine delivery systems and second-hand smoke. We discuss the implications of smoking on clinical management of patients with heart disease and newer developments with potential relevance to treatment of such patients.
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Affiliation(s)
- Neal L Benowitz
- Clinical Pharmacology Research Program, Division of Cardiology, Department of Medicine, University of California, San Francisco, CA, USA
- Center for Tobacco Control Research and Education, University of California, San Francisco, CA, USA
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Hajat C, Stein E, Shantikumar S, Niaura R, Ferrara P, Polosa R. A scoping review of studies on the health impact of electronic nicotine delivery systems. Intern Emerg Med 2022; 17:241-268. [PMID: 34637075 PMCID: PMC8841326 DOI: 10.1007/s11739-021-02835-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/20/2021] [Indexed: 11/05/2022]
Abstract
We conducted a scoping review of studies on health outcomes from electronic nicotine delivery systems (ENDS). The objective was to identify, narratively synthesize, assess the strength and quality of evidence and critically appraise studies that have reported disease end points associated with the use of ENDS. We included published literature on the health impact of ENDS from 01/01/2015 until 01/02/2020 following the PRISMA guidelines using PubMed, Embase, Scopus and Google Scholar. The database search identified 755 studies, and other sources 265; 37 studies met final eligibility criteria. Levels of evidence included 24(65%) cross-sectional, one (2.7%) case-control and six (16%) case studies, four (11%) cohort studies, one (2.7%) randomized controlled trial (RCT) and one (2.7%) meta-analysis; 27(73%) studies reported only on harms, eight (22%) reported on benefits, two (2%) on benefits and harms. Quality ratings were poor in 20 (54%), fair in 9(24%) and good in 8(22%) of studies. In our review, ENDS was not shown to be causative for harmful cardiovascular disease (CVD) outcomes and shown to be beneficial for hypertensive patients. Switching from cigarettes to e-cigarettes resulted in reduced exacerbations of chronic obstructive pulmonary disease (COPD), with no evidence of long-term deterioration in lung function. Mental Health, cancer and mortality were not adequately studied to form any consensus. Our review has not demonstrated ENDS to be causative of harmful CVD outcomes; furthermore switching from cigarettes to e-cigarettes was associated with improved hypertensive control and reduced exacerbations of COPD, with no evidence of increased asthma risk or long-term respiratory harm. Mental health, cancer and mortality outcomes have not been adequately studied to form a conclusion. Overall, the findings of our review did not provide evidence to counter the consensus held by many that ENDS use is safer than the risks posed from smoking cigarettes.
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Affiliation(s)
- Cother Hajat
- Public Health Institute, UAE University, Al Ain, United Arab Emirates
| | | | | | - Raymond Niaura
- School of Global Public Health, New York University, New York, USA
| | - Pietro Ferrara
- Centre for Public Health Research, University of Milan - Bicocca, Monza, Italy
| | - Riccardo Polosa
- Center of Excellence for the Acceleration of HArm Reduction (CoEHAR), University of Catania, Catania, Italy.
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.
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Quigley JM, Walsh C, Lee C, Long J, Kennelly H, McCarthy A, Kavanagh P. Efficacy and safety of electronic cigarettes as a smoking cessation intervention: A systematic review and network meta-analysis. Tob Prev Cessat 2021; 7:69. [PMID: 34877438 PMCID: PMC8607936 DOI: 10.18332/tpc/143077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/31/2021] [Accepted: 10/14/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION This systematic review of randomized controlled trials (RCTs) evaluated the efficacy and safety of electronic cigarettes (e-cigarettes, ENDS) in helping people who smoke to achieve abstinence compared with electronic non-nicotine delivery systems (ENNDS, no nicotine) or any smoking cessation comparator treatment or combination of treatments at 24–26 weeks and at 52 weeks. METHODS Systematic review techniques involved searches of three databases in February 2020 with update searches run on 14 May 2021, two-person independent screening, two-person independent assessment of bias, formal extraction of data with verification by a second person, a feasibility assessment to decide if meta-analysis was appropriate, and network meta-analysis (NMA) of data at 24–26 weeks. Data at 52 weeks were narratively summarized. RESULTS Ten RCTs met the inclusion criteria, eight for efficacy and ten for safety. Eight of the nine RCTs were assessed as at high risk of bias. The sample sizes of the RCTs were 30–2012. Using nicotine replacement therapy (NRT) as the reference treatment, the incidences of smoking cessation at 24–26 weeks were comparable between ENDS and NRT groups (RR=1.17; 95% CrI: 0.66–1.86). Three sensitivity analyses were carried out indicating the main findings for 24–26 weeks were robust to assumptions. The findings at 52 weeks were inconclusive. CONCLUSIONS This systematic review and NMA indicates that there is no clear evidence of a difference in effect between nicotine containing e-cigarettes and NRT on incidences of smoking cessation at 24–26 weeks, and substantial uncertainty remains.
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Affiliation(s)
- Joan M Quigley
- Health Research Board, Dublin, Ireland.,Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, United Kingdom
| | - Cathal Walsh
- Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland
| | | | - Jean Long
- Health Research Board, Dublin, Ireland
| | | | | | - Paul Kavanagh
- Department of Epidemiology and Public Health, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland.,Health Intelligence Unit, Strategic Planning and Transformation, Health Service Executive, Dublin, Ireland
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Cichońska D, Kusiak A, Piechowicz L, Świetlik D. A pilot investigation into the influence of electronic cigarettes on oral bacteria. Postepy Dermatol Alergol 2021; 38:1092-1098. [PMID: 35126020 PMCID: PMC8802959 DOI: 10.5114/ada.2020.100335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/03/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Electronic cigarettes have already become a popular alternative to traditional smoking. AIM To observe if there were any changes in oral bacteria of electronic cigarette users. MATERIAL AND METHODS The study population included 125 patients (40 - e-cigarette users, 43 - cigarette smokers, 42 - non-smokers). The conducted microbiological tests were aimed at identification of microorganisms with potential pathological influence on the oral cavity. Distributions of the study variables were compared between groups with χ2 test. All calculations were carried out with Statistical 10 software (Stat Soft Inc.; Tulsa, USA) and intergroup differences were considered significant at p ≤ 0.05. RESULTS The differences were statistically significant in relation to Gram-negative bacteria in e-cigarette users (27.5%) compared to smokers of traditional cigarettes (4.6%) (p < 0.05). In relation to Gram-positive bacteria, no statistically significant differences were found between these groups. Co-occurrence of commensal bacteria and potentially pathogenic bacteria from the oral cavity among e-cigarette users was higher than in smokers of traditional cigarettes (32.1% vs. 9.2%; p < 0.05). CONCLUSIONS The use of e-cigarettes caused changes in oral bacteria compared to smokers of traditional cigarettes and non-smokers especially with respect to colonization of potentially pathogenic bacteria. Changes in the oral cavity environment to the disadvantage of commensal flora can affect the course of some pathological processes in the oral cavity.
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Affiliation(s)
- Dominika Cichońska
- Department of Periodontology and Oral Mucosa Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Aida Kusiak
- Department of Periodontology and Oral Mucosa Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Lidia Piechowicz
- Department of Medical Microbiology, Faculty of Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Dariusz Świetlik
- Department of IT and Biostatistics, Medical University of Gdansk, Gdansk, Poland
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Choi S, Lee K, Park SM. Combined Associations of Changes in Noncombustible Nicotine or Tobacco Product and Combustible Cigarette Use Habits With Subsequent Short-Term Cardiovascular Disease Risk Among South Korean Men: A Nationwide Cohort Study. Circulation 2021; 144:1528-1538. [PMID: 34601948 DOI: 10.1161/circulationaha.121.054967] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The associations of changes in noncombustible nicotine or tobacco product (NNTP) and combustible cigarette (CC) use habits with subsequent cardiovascular disease (CVD) risk are still unclear. METHODS The study population consisted of 5 159 538 adult men who underwent health screening examinations during both the first (2014-2015) and second (2018) health screening periods from the Korean National Health Insurance Service database. All participants were divided into continual CC-only smokers, CC and NNTP users, recent (<5 years) CC quitters without NNTP use, recent CC quitters with NNTP use, long-term (≥5 years) CC quitters without NNTP use, long-term CC quitters with NNTP use, and never smokers. Propensity score matching analysis was conducted to further compare CVD risk among CC quitters according to NNTP use. Starting from the second health screening date, participants were followed up until the date of CVD event, death, or December 31, 2019, whichever came earliest. Multivariable Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% CIs for CVD risk according to changes in NNTP and CC smoking habits. RESULTS Compared with continual CC-only smokers, CC and NNTP users (aHR, 0.83 [95% CI, 0.79-0.88]) and initial CC smokers who quit CCs and switched to NNTP use only (recent CC quitters with NNTP use, aHR, 0.81 [95% CI, 0.78-0.84]) had lower risk for CVD. After propensity score matching, recent CC quitters with NNTP use (aHR, 1.31 [95% CI, 1.01-1.70]) had higher risk for CVD than recent CC quitters without NNTP use. Similarly, compared with long-term CC quitters without NNTP use, long-term CC quitters with NNTP use (aHR, 1.70 [95% CI, 1.07-2.72]) had higher CVD risk. CONCLUSIONS Switching to NNTP use among initial CC smokers was associated with lower CVD risk than continued CC smoking. On CC cessation, NNTP use was associated with higher CVD risk than CC quitting without NNTPs. Compared with CC smokers who quit without NNTP use, CC quitters who use NNTPs may be at higher future CVD risk.
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Affiliation(s)
- Seulggie Choi
- Department of Biomedical Sciences (S.C., S.M.P.), Seoul National University College of Medicine, South Korea
| | - Kiheon Lee
- Department of Family Medicine (K.L., S.M.P.), Seoul National University College of Medicine, South Korea
- Department of Family Medicine, Seoul National University Bundang Hospital, South Korea (K.L.)
| | - Sang Min Park
- Department of Biomedical Sciences (S.C., S.M.P.), Seoul National University College of Medicine, South Korea
- Department of Family Medicine (K.L., S.M.P.), Seoul National University College of Medicine, South Korea
- Department of Family Medicine, Seoul National University Hospital, South Korea (S.M.P.)
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21
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Hartmann-Boyce J, McRobbie H, Butler AR, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2021; 9:CD010216. [PMID: 34519354 PMCID: PMC8438601 DOI: 10.1002/14651858.cd010216.pub6] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update conducted as part of a living systematic review. OBJECTIVES To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 May 2021, and reference-checked and contacted study authors. We screened abstracts from the Society for Research on Nicotine and Tobacco (SRNT) 2021 Annual Meeting. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses. MAIN RESULTS We included 61 completed studies, representing 16,759 participants, of which 34 were RCTs. Five of the 61 included studies were new to this review update. Of the included studies, we rated seven (all contributing to our main comparisons) at low risk of bias overall, 42 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.53, 95% confidence interval (CI) 1.21 to 1.93; I2 = 0%; 4 studies, 1924 participants). In absolute terms, this might translate to an additional three quitters per 100 (95% CI 1 to 6). There was low-certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.30, 95% CI 0.89 to 1.90: I2 = 0; 4 studies, 1424 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.06, 95% CI 0.47 to 2.38; I2 = 0; 5 studies, 792 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.61, 95% CI 1.44 to 4.74; I2 = 0%; 6 studies, 2886 participants). In absolute terms this represents an additional six quitters per 100 (95% CI 2 to 15). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that non-serious AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants), and again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.51, 95% CI 0.70 to 3.24; I2 = 0%; 7 studies, 1303 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to NRT and compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect evidence of harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is now a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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22
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Benowitz NL, St.Helen G, Liakoni E. Clinical Pharmacology of Electronic Nicotine Delivery Systems (ENDS): Implications for Benefits and Risks in the Promotion of the Combusted Tobacco Endgame. J Clin Pharmacol 2021; 61 Suppl 2:S18-S36. [PMID: 34396553 PMCID: PMC9239851 DOI: 10.1002/jcph.1915] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/22/2021] [Indexed: 11/11/2022]
Abstract
Electronic nicotine delivery systems (ENDS) such as e-cigarettes and heated tobacco products are novel battery-operated devices that deliver nicotine without combustion of tobacco. Because cigarette smoking is sustained by nicotine addiction and the toxic combustion products are mainly responsible for the harmful effects of smoking, ENDS could be used to promote smoking cessation while exposing users to lower levels of toxicants compared with conventional cigarettes. The currently available evidence from clinical and observational studies indicates a potential role of e-cigarettes as smoking cessation aids, although many continue to use e-cigarettes long after quitting smoking. Nicotine and toxicant delivery vary considerably by device and depend on the characteristics of the e-liquid formulation. Because smokers tend to titrate their nicotine intake to maintain their desired pharmacologic effects, device and liquid characteristics need to be considered when using ENDS as an aid to quit smoking. Factors potentially limiting their use are the currently still unknown long-term safety of these products and concerns regarding widespread use among youth. Implications of clinical pharmacology data on ENDS for the cigarette endgame and regulation by the U.S. Food and Drug administration are discussed.
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Affiliation(s)
- Neal L. Benowitz
- Clinical Pharmacology Research Program, Division of Cardiology, Department of Medicine, University of California, San Francisco
- Center for Tobacco Control Research and Education, University of California, San Francisco
| | - Gideon St.Helen
- Clinical Pharmacology Research Program, Division of Cardiology, Department of Medicine, University of California, San Francisco
- Center for Tobacco Control Research and Education, University of California, San Francisco
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Zakiyah N, Purwadi FV, Insani WN, Abdulah R, Puspitasari IM, Barliana MI, Lesmana R, Amaliya A, Suwantika AA. Effectiveness and Safety Profile of Alternative Tobacco and Nicotine Products for Smoking Reduction and Cessation: A Systematic Review. J Multidiscip Healthc 2021; 14:1955-1975. [PMID: 34326646 PMCID: PMC8315778 DOI: 10.2147/jmdh.s319727] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/02/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Alternative tobacco and nicotine products such as electronic cigarettes (EC), smokeless tobacco, and nicotine replacement therapy (NRT) are currently being assessed as options in tobacco harm reduction due to their potential role in smoking reduction and smoking cessation. OBJECTIVE To provide the current evidence on the effectiveness and safety of various alternative tobacco and nicotine products for smoking reduction and cessation. METHODS A systematic review using databases from MEDLINE (PubMed), EMBASE, and The Cochrane Library was conducted up to December 2020 to identify eligible experimental and observational studies assessing the use of alternative tobacco and nicotine products on smoking reduction and smoking cessation and the safety of these products. The Cochrane Risk of Bias 2 (RoB 2) and ROBINS-I tools were used to assess the risk of bias of the included studies. Results were described through a narrative synthesis of the evidence. RESULTS From 1955 retrieved references, 44 studies (31 randomized controlled trials/RCTs and 13 prospective cohort studies) met the inclusion criteria and were included in the review. Twenty-nine studies were assessing EC, one study evaluated heat-not-burn (HNB) product, five studies were focused on snus, and nine studies assessed NRT in the form of nicotine patch, gum, etc. The overall results suggested that alternative tobacco and nicotine products in the form of EC, snus, and NRT can moderately reduce daily cigarette consumption and has potential to assist smoking cessation attempts, with fewer adverse events. CONCLUSION The findings suggested that alternative tobacco and nicotine products have a potential role in assisting smoking reduction and cessation, highlighting their role in the tobacco harm reduction approach. Further studies should focus on investigating long-term outcomes, safety, and effectiveness of alternative tobacco and nicotine products to better inform smoking reduction/cessation policy. PROSPERO REGISTRATION NUMBER CRD42020205830.
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Affiliation(s)
- Neily Zakiyah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Febby V Purwadi
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Widya N Insani
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Rizky Abdulah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Irma M Puspitasari
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Melisa I Barliana
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Department of Biological Pharmacy, Biotechnology Pharmacy Laboratory, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Ronny Lesmana
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Division of Physiology, Department of Biomedical Science, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Division of Biological Activity, Central Laboratory, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Amaliya Amaliya
- Department of Periodontics, Faculty of Dentistry, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Auliya A Suwantika
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Center for Health Technology Assessment, Universitas Padjadjaran, Bandung, West Java, Indonesia
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Petrella F. Electronic cigarettes, vaping-related lung injury and lung cancer: where do we stand? Eur J Cancer Prev 2021; 30:293-296. [PMID: 34103460 DOI: 10.1097/cej.0000000000000630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Electronic cigarettes have been considered a promising alternative to nicotine replacement products to help heavy tobacco smokers quit smoking. They work thanks to a heating coil causing evaporation of the liquid rapidly followed by cooling, thus creating an aerosol, a completely different mechanism from the combustion of tobacco in traditional cigarettes. The term 'vaping' indicates the use of electronic cigarettes or other devices to inhale heated, aerosolized nicotine, or other substances like cannabidiol, tetrahydrocannabinol, or butane hash oils together with solvents, mainly propylene glycol and vegetable glycerine or their combination. A very fast increase of vaping among adolescents has been observed since electronic cigarettes and other vaping devices first appeared. Although electronic cigarettes have been advocated as a short-term cessation aid for tobacco smokers or as a long-term alternative, there is the concrete risk that they can be perceived by young nonsmokers as a less dangerous alternative to tobacco smoking, thus stimulating nonsmokers to start smoking rather than helping heavy tobacco smokers to quit smoking. Moreover, several cases of exogenous lipoid pneumonia and diffuse alveolar hemorrhage with proven alveolar injury, as well as vaping-associated bronchiolitis obliterans, have been recently reported among electronic cigarette smokers, with severe clinical impact, thus posing the risk of the life-threatening toxic potential of vaping. At the moment, no definitive assessment can be made about the efficacy of electronic cigarettes as a smoking cessation aid, and further studies are required about vaping-related life-threatening acute lung injury.
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Affiliation(s)
- Francesco Petrella
- Department of Thoracic Surgery, IRCCS European Institute of Oncology
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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25
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Fuochi V, Caruso M, Emma R, Stivala A, Polosa R, Distefano A, Furneri PM. Investigation on the Antibacterial Activity of Electronic Cigarette Liquids (ECLs): A Proof of Concept Study. Curr Pharm Biotechnol 2021; 22:983-994. [PMID: 32881666 DOI: 10.2174/1389201021666200903121624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 07/10/2020] [Accepted: 08/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The key ingredients of e-cigarettes liquid are commonly propane-1,2-diol (also called propylene glycol) and propane-1,2,3-triol (vegetal glycerol) and their antimicrobial effects are already established. The nicotine and flavors which are often present in e-liquids can interfere with the growth of some microorganisms. OBJECTIVE The effect of combining these elements in e-liquids is unknown. The aim of the study was to investigate the possible effects of these liquids on bacterial growth in the presence or absence of nicotine and flavors. METHODS Susceptibilities of pathogenic strains (Klebsiella pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, Escherichia coli, Enterococcus faecalis and Sarcina lutea) were studied by means of a multidisciplinary approach. Cell viability and antioxidant assays were also evaluated. RESULTS All e-liquids investigated showed antibacterial activity against at least one pathogenic strain. Higher activity was correlated to the presence of flavors and nicotine. DISCUSSION In most cases, the value of minimal bactericidal concentration is equal to the value of minimal inhibitory concentration showing that these substances have a bactericidal effect. This effect was observed in concentrations up to 6.25% v/v. Antioxidant activity was also correlated to the presence of flavors. Over time, the viability assay in human epithelial lung A549 cells showed a dose-dependent inhibition of cell growth. CONCLUSION Our results have shown that flavors considerably enhance the antibacterial activity of propane-1,2-diol and propane-1,2,3-triol. This study provides important evidence that should be taken into consideration in further investigative approaches, to clarify the different sensitivity of the various bacterial species to e-liquids, including the respiratory microbiota, to highlight the possible role of flavors and nicotine.
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Affiliation(s)
- Virginia Fuochi
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
| | - Massimo Caruso
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
| | - Rosalia Emma
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
| | - Aldo Stivala
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
| | - Riccardo Polosa
- Department of Clinical and Experimental Medicine (MEDCLIN), University of Catania, Catania, Italy
| | - Alfio Distefano
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
| | - Pio M Furneri
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
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26
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Cao Y, Wu D, Ma Y, Ma X, Wang S, Li F, Li M, Zhang T. Toxicity of electronic cigarettes: A general review of the origins, health hazards, and toxicity mechanisms. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 772:145475. [PMID: 33770885 DOI: 10.1016/j.scitotenv.2021.145475] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/24/2021] [Accepted: 01/24/2021] [Indexed: 06/12/2023]
Abstract
Electronic cigarettes (E-cigarette) are an alternative for traditional cigarette smokers to quit smoking. Based on the current understanding, electronic cigarettes have rapidly become popular among existing smokers and former non-smokers. However, increasing research at different levels reveals that e-cigarettes are unsafe. This review provides an overview of the toxicology of e-cigarettes based on existing in vivo and in vitro studies and compares their toxicity with that of traditional cigarettes. Moreover, we describe the associated toxicity components in e-cigarettes, as well as the potential mechanism by which e-cigarettes exert toxic effects. As is known to all, the nicotine in traditional cigarettes and e-cigarettes has certain toxicity. Besides, a few studies have shown that propylene glycol and vegetable glycerin mixture and flavoring agents in e-cigarettes also are the key components causing adverse effects in animals or cells. There is insufficient scientific evidence on the toxicity of e-cigarettes due to the lack of standardized research methods, prompting the need to conduct a comprehensive toxicity assessment of e-cigarette toxicity to elucidate the safety issues of e-cigarettes. Eventually, a basis for decision-making on whether people use e-cigarettes will be obtained.
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Affiliation(s)
- Yuna Cao
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China
| | - Daming Wu
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China
| | - Ying Ma
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China
| | - Xinmo Ma
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China
| | - Shile Wang
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China
| | - Fuxian Li
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China
| | - Menghan Li
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China
| | - Ting Zhang
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China.
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Hartmann-Boyce J, McRobbie H, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Butler AR, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2021; 4:CD010216. [PMID: 33913154 PMCID: PMC8092424 DOI: 10.1002/14651858.cd010216.pub5] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update of a review first published in 2014. OBJECTIVES To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 February 2021, together with reference-checking and contact with study authors. SELECTION CRITERIA We included randomized controlled trials (RCTs) and randomized cross-over trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. To be included, studies had to report abstinence from cigarettes at six months or longer and/or data on adverse events (AEs) or other markers of safety at one week or longer. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included changes in carbon monoxide, blood pressure, heart rate, blood oxygen saturation, lung function, and levels of known carcinogens/toxicants. We used a fixed-effect Mantel-Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data from these studies in meta-analyses. MAIN RESULTS We included 56 completed studies, representing 12,804 participants, of which 29 were RCTs. Six of the 56 included studies were new to this review update. Of the included studies, we rated five (all contributing to our main comparisons) at low risk of bias overall, 41 at high risk overall (including the 25 non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.69, 95% confidence interval (CI) 1.25 to 2.27; I2 = 0%; 3 studies, 1498 participants). In absolute terms, this might translate to an additional four successful quitters per 100 (95% CI 2 to 8). There was low-certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar) (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs occurred rarely, with no evidence that their frequency differed between nicotine EC and NRT, but very serious imprecision led to low certainty in this finding (RR 1.37, 95% CI 0.77 to 2.41: I2 = n/a; 2 studies, 727 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.70, 95% CI 1.03 to 2.81; I2 = 0%; 4 studies, 1057 participants). In absolute terms, this might again lead to an additional four successful quitters per 100 (95% CI 0 to 11). These trials mainly used older EC with relatively low nicotine delivery. There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 0.60, 95% CI 0.15 to 2.44; I2 = n/a; 4 studies, 494 participants). Compared to behavioral support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.70, 95% CI 1.39 to 5.26; I2 = 0%; 5 studies, 2561 participants). In absolute terms this represents an increase of seven per 100 (95% CI 2 to 17). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was no evidence that the rate of SAEs differed, but some evidence that non-serious AEs were more common in people randomized to nicotine EC (AEs: RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants; SAEs: RR 1.17, 95% CI 0.33 to 4.09; I2 = 5%; 6 studies, 1011 participants, very low certainty). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued use. Very few studies reported data on other outcomes or comparisons and hence evidence for these is limited, with confidence intervals often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to ECs without nicotine and compared to NRT. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the size of effect, particularly when using modern EC products. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, though evidence indicated no difference in AEs between nicotine and non-nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect any clear evidence of harm from nicotine EC, but longest follow-up was two years and the overall number of studies was small. The evidence is limited mainly by imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information, this review is now a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Krysinski A, Russo C, John S, Belsey JD, Campagna D, Caponnetto P, Vudu L, Lim CW, Purrello F, Di Mauro M, Iqbal F, Fluck D, Franek E, Polosa R, Sharma P. International randomised controlled trial evaluating metabolic syndrome in type 2 diabetic cigarette smokers following switching to combustion-free nicotine delivery systems: the DIASMOKE protocol. BMJ Open 2021; 11:e045396. [PMID: 33906842 PMCID: PMC8088261 DOI: 10.1136/bmjopen-2020-045396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Reducing exposure to cigarette smoke is an imperative for public health and for patients with diabetes. Increasingly, combustion-free nicotine delivery systems (C-F NDS) such as e-cigarettes and heated tobacco products are substituting conventional cigarettes and accelerating the downward trends in smoking prevalence. However, there is limited information about the long-term health impact in patients with diabetes who use C-F NDS. This randomised trial of type 2 diabetic cigarette smokers will test the hypothesis that following a switch from conventional cigarettes to C-F NDS a measurable improvement in metabolic syndrome (MetS) factors will be shown over the course of 2 years. METHODS AND ANALYSIS The study is multicentre and thus will take place in five locations in four countries in an ambulatory setting. A total of 576 patients with diabetes will be randomised (1:2 ratio) to either a control arm (Study Arm A), in which they will be offered referral to smoking cessation programmes or to an intervention arm (Study Arm B) assigned to C-F NDS use. Participants will be at least 23 years old and of any gender. Patient recruitment will start in February 2021 and is expected to be completed by December 2021. Primary outcome measures include fasting plasma glucose, blood pressure, triglycerides, high-density lipoprotein and waist circumference, while secondary feature absolute change in the sum of the individual factors of MetS and change in each individual factor of MetS measured at each study time point. ETHICS AND DISSEMINATION The approval of research ethics committee (REC) regarding the trial protocol, informed consent forms and other relevant documents is required to commence the study. Substantial amendments to the study protocol cannot be implemented until the REC grants a favourable opinion. The results of the study are intended to be published as articles in high quality peer-reviewed journals and disseminated through conference papers. TRIAL REGISTRATION NUMBER NCT04231838. Pre-results stage.
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Affiliation(s)
- Arkadiusz Krysinski
- Polish Academy of Sciences, Mossakowski Medical Research Centre Polish Academy of Sciences, Warsaw, Poland
- Department of Internal Diseases, Endocrinology and Diabetology, CK MSW, Warszawa, Poland
| | - Cristina Russo
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, Surrey, UK
| | - Sarah John
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | | | - Davide Campagna
- U O C. MCAU, University Teaching Hospital 'Policlinico-Vittorio Emanuele', University of Catania, Catania, Italy
| | - Pasquale Caponnetto
- Centro per la Prevenzione e Cura del Tabagismo (CPCT), Universita degli Studi di Catania Scuola di Facolta di Medicina, Catania, Italy
- Center of Excellence for the Acceleration of HArm Reduction (CoEHAR), University of Catania, Catania, Sicilia, Italy
| | - Lorina Vudu
- Endocrinology, Nicolae Testemitanu State Medical and Pharmaceutical University, Chisinau, The Republic of Moldova
| | - Chong Wei Lim
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, Surrey, UK
| | - Francesco Purrello
- Center of Excellence for the Acceleration of HArm Reduction (CoEHAR), University of Catania, Catania, Sicilia, Italy
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Sicilia, Italy
| | - Maurizio Di Mauro
- Center of Excellence for the Acceleration of HArm Reduction (CoEHAR), University of Catania, Catania, Sicilia, Italy
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Sicilia, Italy
| | - Farrukh Iqbal
- The University of Lahore University College of Medicine and Dentistry, Lahore, Pakistan
| | - David Fluck
- Cardiology, Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, Surrey, UK
| | - Edward Franek
- Department of Internal Diseases, Endocrinology and Diabetology, CK MSW, Warszawa, Poland
- Mossakowski Medical Research Centre, Polska Akademia Nauk, Warszawa, Poland
| | - Riccardo Polosa
- Center of Excellence for the Acceleration of HArm Reduction (CoEHAR), University of Catania, Catania, Sicilia, Italy
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Sicilia, Italy
| | - Pankaj Sharma
- Ashford and Saint Peter's Hospitals NHS Trust, Chertsey, Surrey, UK
- Institute of Cardiovascular Research, Royal Holloway University of London, Egham, Surrey, UK
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O’Leary R, Polosa R, Li Volti G. Critical appraisal of the European Union Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) Preliminary Opinion on electronic cigarettes. Harm Reduct J 2021; 18:31. [PMID: 33691708 PMCID: PMC7945356 DOI: 10.1186/s12954-021-00476-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/22/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In preparation for the 2021 revision of the European Union Tobacco Products Directive, the Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) has posted its Preliminary Opinion on Electronic Cigarettes. They concluded that e-cigarettes only achieve a sub-optimal level of protection of human health. In this paper, we provide evidence that the Opinion's conclusions are not adequately backed up by scientific evidence and did not discuss the potential health benefits of using alternative combustion-free nicotine-containing products as substitute for tobacco cigarettes. METHODS Searches for articles were conducted in PubMed and by citation chasing in Google Scholar. Articles were also retrieved with a review of references in major publications. Primary data from World Health Organization surveys, the conclusions of reviews, and peer-reviewed non-industry studies were cited to address errors and omissions identified in the Opinion. RESULTS The Opinion omitted reporting on the individual and population health benefits of the substitution of e-cigarettes (ENDS) for cigarette smoking. Alternative hypotheses to the gateway theory were not evaluated. Its assessment of cardiovascular risk is contradicted by numerous reviews. It cites ever-use data that do not represent current patterns of use. It did not report non-nicotine use. It presented erroneous statements on trends in ENDS prevalence. It over-emphasized the role of flavours in youth ENDS initiation. It did not discuss cessation in sufficient length. CONCLUSIONS For the delivery of a robust and comprehensive final report, the members of the Working Group of the Scientific Committee on Health, Environmental and Emerging Risks will need to consider (1) the potential health benefits of ENDS substitution for cigarette smoking, (2) alternative hypotheses and contradictory studies on the gateway effect, (3) its assessment of cardiovascular risk, (4) the measurements of frequency of use, (5) non-nicotine use, (6) the role of flavours, and (7) a fulsome discussion of cessation.
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Affiliation(s)
- Renée O’Leary
- Center of Excellence for the Acceleration of Harm Reduction, Via S. Sofia, 89, 95123 Catania, Italy
| | - Riccardo Polosa
- Center of Excellence for the Acceleration of Harm Reduction, Via S. Sofia, 89, 95123 Catania, Italy
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Miller CR, Shi H, Li D, Goniewicz ML. Cross-Sectional Associations of Smoking and E-cigarette Use with Self-Reported Diagnosed Hypertension: Findings from Wave 3 of the Population Assessment of Tobacco and Health Study. TOXICS 2021; 9:toxics9030052. [PMID: 33803457 PMCID: PMC7999635 DOI: 10.3390/toxics9030052] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 11/16/2022]
Abstract
Following their introduction a decade ago, electronic cigarettes (e-cigarettes) have grown in popularity. Given their novelty, knowledge of the health consequences of e-cigarette use remains limited. Epidemiologic studies have not comprehensively explored associations between e-cigarette use and hypertension, a highly prevalent health condition and major contributor to cardiovascular disease burden. In this study, cross-sectional associations of cigarette smoking and e-cigarette use (vaping) with self-reported diagnosed hypertension were evaluated among 19,147 18-55 year old respondents in Wave 3 (2015-2016) of the Population Assessment of Tobacco and Health Study. Multivariable analyses first modeled smoking and vaping as separate 2-category variables, then as a 6-category composite variable accounting for former smoking. After adjusting for potential confounders, current vaping (aOR = 1.31; 95%CI: 1.05-1.63) and current smoking (aOR = 1.27; 95%CI: 1.10-1.47) were both associated with higher odds of hypertension. In analyses modeling smoking and vaping compositely, respondents who were concurrently smoking and vaping had the highest odds of hypertension (aOR = 1.77; 95%CI: 1.32-2.39 [referent: never smokers]). These results differ somewhat from prior epidemiologic studies of vaping and respiratory outcomes, which consistently report smaller point estimates for current vaping than for current smoking. Our findings reinforce the uncertainty surrounding long-term health consequences of vaping, as well as highlight important distinctions between respiratory and cardiovascular outcomes when considering the harm reduction potential of e-cigarettes.
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Affiliation(s)
- Connor R. Miller
- Roswell Park Comprehensive Cancer Center, Department of Health Behavior, Buffalo, NY 14263, USA;
- Correspondence:
| | - Hangchuan Shi
- Department of Clinical & Translational Research, University of Rochester Medical Center, Rochester, NY 14627, USA; (H.S.); (D.L.)
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14627, USA
| | - Dongmei Li
- Department of Clinical & Translational Research, University of Rochester Medical Center, Rochester, NY 14627, USA; (H.S.); (D.L.)
| | - Maciej L. Goniewicz
- Roswell Park Comprehensive Cancer Center, Department of Health Behavior, Buffalo, NY 14263, USA;
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Navas-Acien A, Martinez-Morata I, Hilpert M, Rule A, Shimbo D, LoIacono NJ. Early Cardiovascular Risk in E-cigarette Users: the Potential Role of Metals. Curr Environ Health Rep 2020; 7:353-361. [PMID: 33242201 DOI: 10.1007/s40572-020-00297-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW Electronic cigarettes (e-cigs) are a source of metals. Epidemiologic and experimental evidence support that metals are toxic to the cardiovascular system. Little is known, however, about the role that e-cig metals may play as toxicants for the possible cardiovascular effects of e-cig use. The goal of this narrative review is to summarize the evidence on e-cig use and metal exposure and on e-cig use and cardiovascular toxicity and discuss the research needs. RECENT FINDINGS In vitro studies show cytotoxicity and increased oxidative stress in myocardial cells and vascular endothelial cells exposed to e-liquids and e-cig aerosols, with effects partially reversed with antioxidant treatment. There is some evidence that the heating coil plays a role in cell toxicity. Mice exposed to e-cigs for several weeks showed higher levels of oxidative stress, inflammation, platelet activation, and thrombogenesis. Cross-over clinical experiments show e-cig use alters nitric oxide-mediated flow-mediated dilation, endothelial progenitor cells, and arterial stiffness. Cross-sectional evidence from large nationally representative samples in the USA support that e-cig use is associated with self-reported myocardial infarction. Smaller studies found associations of e-cig use with higher oxidized low-density protein and heart variability compared to healthy controls. Numerous studies have measured elevated levels of toxic metals in e-cig aerosols including lead, nickel, chromium, and manganese. Arsenic has been measured in some e-liquids. Several of these metals are well known to be cardiotoxic. Numerous studies show that e-cigs are a source of cardiotoxic metals. Experimental studies (in vitro, in vivo, and clinical studies) show acute toxicity of e-cigs to the vascular system. Studies of long-term toxicity in animals and humans are missing. Longitudinal studies with repeated measures of metal exposure and subclinical cardiovascular outcomes (e.g., coronary artery calcification) could contribute to determine the long-term cardiovascular effects of e-cigs and the potential role of metals in those effects.
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Affiliation(s)
- Ana Navas-Acien
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA
| | - Irene Martinez-Morata
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA
| | - Markus Hilpert
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA
| | - Ana Rule
- Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Daichi Shimbo
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Nancy J LoIacono
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY, 10032, USA.
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Benowitz NL, St Helen G, Nardone N, Addo N, Zhang JJ, Harvanko AM, Calfee CS, Jacob P. Twenty-Four-Hour Cardiovascular Effects of Electronic Cigarettes Compared With Cigarette Smoking in Dual Users. J Am Heart Assoc 2020; 9:e017317. [PMID: 33208019 PMCID: PMC7763797 DOI: 10.1161/jaha.120.017317] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiovascular safety is an important consideration regarding the benefits versus risks of electronic cigarette use (EC) for public health. The single‐use cardiovascular effects of EC have been well studied but may not reflect effects of ad libitum use throughout the day. We aimed to compare the circadian hemodynamic effects as well as 24‐hour biomarkers of oxidative stress, and platelet aggregation and inflammation, with ad libitum cigarette smoking (CS) versus EC versus no tobacco product use. Methods and Results Thirty‐six healthy dual CS and EC users participated in a crossover study in a confined research setting. Circadian heart rate, blood pressure and plasma nicotine levels, 24‐hour urinary catecholamines, 8‐isoprostane and 11‐dehydro‐thromboxane B2, and plasma interleukin‐6 and interleukin‐8 were compared in CS, EC, and no nicotine conditions. Over 24 hours, and during daytime, heart rate and blood pressure were higher in CS and EC compared with no tobacco product conditions (P<0.01). Heart rate on average was higher with CS versus EC. Urinary catecholamines, 8‐isoprostane, and 11‐dehydro‐thromboxane B2 were not significantly different, but plasma IL‐6 and IL‐8 were higher with both CS and EC compared with no tobacco product (P<0.01). Conclusions CS and EC had similar 24‐hour patterns of hemodynamic effects compared with no tobacco product, with a higher average heart rate with CS versus EC, and similar effects on biomarkers of inflammation. EC may pose some cardiovascular risk, particularly to smokers with underlying cardiovascular disease, but may also provide a harm reduction opportunity for smokers willing to switch entirely to EC. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02470754.
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Affiliation(s)
- Neal L Benowitz
- Clinical Pharmacology Research Program Division of Cardiology Department of Medicine University of California San Francisco CA.,Center for Tobacco Control Research and Education University of California San Francisco CA.,Tobacco Center of Regulatory Science University of California San Francisco CA
| | - Gideon St Helen
- Clinical Pharmacology Research Program Division of Cardiology Department of Medicine University of California San Francisco CA.,Center for Tobacco Control Research and Education University of California San Francisco CA.,Tobacco Center of Regulatory Science University of California San Francisco CA
| | - Natalie Nardone
- Clinical Pharmacology Research Program Division of Cardiology Department of Medicine University of California San Francisco CA
| | - Newton Addo
- Clinical Pharmacology Research Program Division of Cardiology Department of Medicine University of California San Francisco CA
| | - Junfeng Jim Zhang
- Global Health Institute & Nicholas School of the Environment Duke University Durham NC.,Duke Cancer Institute Duke University Durham NC
| | - Arit M Harvanko
- Clinical Pharmacology Research Program Division of Cardiology Department of Medicine University of California San Francisco CA.,Center for Tobacco Control Research and Education University of California San Francisco CA.,Tobacco Center of Regulatory Science University of California San Francisco CA
| | - Carolyn S Calfee
- Division of Pulmonary Critical Care Allergy and Sleep Medicine Department of Medicine University of California San Francisco CA.,Department of Anaesthesia University of California San Francisco CA
| | - Peyton Jacob
- Clinical Pharmacology Research Program Division of Cardiology Department of Medicine University of California San Francisco CA.,Center for Tobacco Control Research and Education University of California San Francisco CA.,Tobacco Center of Regulatory Science University of California San Francisco CA.,Department of Psychiatry University of California San Francisco CA
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Electronic Cigarette Use and Metabolic Syndrome Development: A Critical Review. TOXICS 2020; 8:toxics8040105. [PMID: 33212878 PMCID: PMC7711672 DOI: 10.3390/toxics8040105] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023]
Abstract
The metabolic syndrome is a combination of several metabolic disorders, such as cardiovascular disease, atherosclerosis, and type 2 diabetes. Lifestyle modifications, including quitting smoking, are recommended to reduce the risk of metabolic syndrome and its associated complications. Not much research has been conducted in the field of e-cigarettes and the risk of metabolic syndrome. Furthermore, taking into account the influence of e-cigarettes vaping on the individual components of metabolic syndrome, i.e, abdominal obesity, insulin resistance, dyslipidemia and elevated arterial blood pressure, the results are also ambiguous. This article is a review and summary of existing reports on the impact of e-cigarettes on the development of metabolic syndrome as well as its individual components. A critical review for English language articles published until 30 June 2020 was made, using a PubMed (including MEDLINE), Cochrane, CINAHL Plus, and Web of Science data. The current research indicated that e-cigarettes use does not affect the development of insulin resistance, but could influence the level of glucose and pre-diabetic state development. The lipid of profile an increase in the TG level was reported, while the influence on the level of concentration of total cholesterol, LDL fraction, and HDL fraction differed. In most cases, e-cigarettes use increased the risk of developing abdominal obesity or higher arterial blood pressure. Further research is required to provide more evidence on this topic.
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Hartmann-Boyce J, McRobbie H, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Butler AR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database Syst Rev 2020; 10:CD010216. [PMID: 33052602 PMCID: PMC8094228 DOI: 10.1002/14651858.cd010216.pub4] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. People who smoke report using ECs to stop or reduce smoking, but some organisations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This review is an update of a review first published in 2014. OBJECTIVES To evaluate the effect and safety of using electronic cigarettes (ECs) to help people who smoke achieve long-term smoking abstinence. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO for relevant records to January 2020, together with reference-checking and contact with study authors. SELECTION CRITERIA We included randomized controlled trials (RCTs) and randomized cross-over trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. To be included, studies had to report abstinence from cigarettes at six months or longer and/or data on adverse events (AEs) or other markers of safety at one week or longer. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, AEs, and serious adverse events (SAEs). Secondary outcomes included changes in carbon monoxide, blood pressure, heart rate, blood oxygen saturation, lung function, and levels of known carcinogens/toxicants. We used a fixed-effect Mantel-Haenszel model to calculate the risk ratio (RR) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data from these studies in meta-analyses. MAIN RESULTS We include 50 completed studies, representing 12,430 participants, of which 26 are RCTs. Thirty-five of the 50 included studies are new to this review update. Of the included studies, we rated four (all which contribute to our main comparisons) at low risk of bias overall, 37 at high risk overall (including the 24 non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.69, 95% confidence interval (CI) 1.25 to 2.27; I2 = 0%; 3 studies, 1498 participants). In absolute terms, this might translate to an additional four successful quitters per 100 (95% CI 2 to 8). There was low-certainty evidence (limited by very serious imprecision) of no difference in the rate of adverse events (AEs) (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs occurred rarely, with no evidence that their frequency differed between nicotine EC and NRT, but very serious imprecision led to low certainty in this finding (RR 1.37, 95% CI 0.77 to 2.41: I2 = n/a; 2 studies, 727 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.71, 95% CI 1.00 to 2.92; I2 = 0%; 3 studies, 802 participants). In absolute terms, this might again lead to an additional four successful quitters per 100 (95% CI 0 to 12). These trials used EC with relatively low nicotine delivery. There was low-certainty evidence, limited by very serious imprecision, that there was no difference in the rate of AEs between these groups (RR 1.00, 95% CI 0.73 to 1.36; I2 = 0%; 2 studies, 346 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 0.25, 95% CI 0.03 to 2.19; I2 = n/a; 4 studies, 494 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.50, 95% CI 1.24 to 5.04; I2 = 0%; 4 studies, 2312 participants). In absolute terms this represents an increase of six per 100 (95% CI 1 to 14). However, this finding was very low-certainty, due to issues with imprecision and risk of bias. There was no evidence that the rate of SAEs varied, but some evidence that non-serious AEs were more common in people randomized to nicotine EC (AEs: RR 1.17, 95% CI 1.04 to 1.31; I2 = 28%; 3 studies, 516 participants; SAEs: RR 1.33, 95% CI 0.25 to 6.96; I2 = 17%; 5 studies, 842 participants). Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate over time with continued use. Very few studies reported data on other outcomes or comparisons and hence evidence for these is limited, with confidence intervals often encompassing clinically significant harm and benefit. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to ECs without nicotine and compared to NRT. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the degree of effect, particularly when using modern EC products. Confidence intervals were wide for data on AEs, SAEs and other safety markers. Overall incidence of SAEs was low across all study arms. We did not detect any clear evidence of harm from nicotine EC, but longest follow-up was two years and the overall number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information for decision-makers, this review is now a living systematic review. We will run searches monthly from December 2020, with the review updated as relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Rachna Begh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Caitlin Notley
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tari Turner
- Cochrane Australia, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hajek
- Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Polosa R, Morjaria JB, Prosperini U, Busà B, Pennisi A, Malerba M, Maglia M, Caponnetto P. COPD smokers who switched to e-cigarettes: health outcomes at 5-year follow up. Ther Adv Chronic Dis 2020; 11:2040622320961617. [PMID: 33101622 PMCID: PMC7549158 DOI: 10.1177/2040622320961617] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 09/04/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND AIMS The long-term health effects of the use of electronic cigarettes (ECs) in patients with chronic obstructive pulmonary disease (COPD) are largely unexplored. We present findings from a 5-year prospective assessment of respiratory parameters in a cohort of COPD patients who substantially reduced conventional smoking or achieved abstinence by switching to ECs. METHODS Patients were evaluated prospectively for their measurements of respiratory exacerbations, spirometric indices, quality of life using the COPD assessment tool (CAT), 6-min walk distance (6MWD), as well as conventional cigarette consumption. Baseline measurements prior to switching to EC use were compared with follow-up visits at 12-, 24-, 48- and 60-months. Age- and sex-matched COPD patients reporting to be regular smokers (not using ECs) were the reference group for the analysis. RESULTS Complete data were available from 39 patients. Those in the EC user group achieved a marked decline in cigarette smoking or abstinence. COPD EC users had a significant diminution in COPD exacerbations; with the mean (±SD) exacerbation rate falling from 2.3 (±0.9) at baseline to 1.1 (±1.0) at 5 years (p < 0.001), whereas no significant changes were observed in the control group.Significant and constant improvements in lung function, CAT scores and 6MWD were reported in the EC user group over the 5-year observation period compared with the reference group (p < 0.05). CONCLUSION The present study suggests that EC use may ameliorate objective and subjective COPD outcomes, and that the benefits gained appear to persist long term. EC use for abstinence and smoking reduction may ameliorate some of the harm resulting from tobacco smoking in COPD patients.
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Affiliation(s)
- Ricardo Polosa
- Department of Clinical and Experimental
Medicine, University of Catania, Catania, Italy
- Centre for the Prevention and Treatment of
Tobacco Addiction (CPCT), Teaching Hospital ‘Policlinico – V. Emanuele’,
University of Catania, Catania, Italy
- Center of Excellence for the Acceleration of
Harm Reduction (CoEHAR), Università di Catania, Catania, Italy
| | - Jaymin B Morjaria
- Department of Respiratory Medicine, Royal
Brompton and Harefield Hospital Foundation Trust, Harefield Hospital, Hill
End Road, Harefield UB9 6JH, UK
| | | | - Barbara Busà
- UOC Farmacia Ospedaliera, Hospital ARNAS
Garibaldi, Catania, Italy
| | - Alfio Pennisi
- Department of Respiratory Medicine, Hospital
Clinics ‘Musumeci-Gecas’, Catania, Italy
| | - Mario Malerba
- Center of Excellence for the Acceleration of
Harm Reduction (CoEHAR), Università di Catania, Catania, Italy
- Department of Translational Medicine, University
of Piemonte Orientale, Novara, Italy
| | - Marilena Maglia
- Department of Clinical and Experimental
Medicine, University of Catania, Catania, Italy
- Centre for the Prevention and Treatment of
Tobacco Addiction (CPCT), Teaching Hospital ‘Policlinico – V. Emanuele’,
University of Catania, Catania, Italy
| | - Pasquale Caponnetto
- Department of Clinical and Experimental
Medicine, University of Catania, Catania, Italy
- Centre for the Prevention and Treatment of
Tobacco Addiction (CPCT), Teaching Hospital ‘Policlinico – V. Emanuele’,
University of Catania, Catania, Italy
- Center of Excellence for the Acceleration of
Harm Reduction (CoEHAR), Università di Catania, Catania, Italy
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36
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Rodrigo G, Jaccard G, Tafin Djoko D, Korneliou A, Esposito M, Belushkin M. Cancer potencies and margin of exposure used for comparative risk assessment of heated tobacco products and electronic cigarettes aerosols with cigarette smoke. Arch Toxicol 2020; 95:283-298. [PMID: 33025067 PMCID: PMC7811518 DOI: 10.1007/s00204-020-02924-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 09/29/2020] [Indexed: 12/31/2022]
Abstract
Health risk associated with the use of combustible cigarettes is well characterized and numerous epidemiological studies have been published for many years. Since more than a decade, innovative non-combusted tobacco products have emerged like heated tobacco products (HTP) or electronic cigarettes (EC). Long-term effects of these new products on health remain, however, unknown and there is a need to characterize associated potential health risks. The time dedicated to epidemiological data generation (at least 20 to 40 years for cancer endpoint), though, is not compatible with innovative development. Surrogates need, therefore, to be developed. In this work, non-cancer and cancer risks were estimated in a range of HTP and commercial combustible cigarettes based upon their harmful and potentially harmful constituent yields in aerosols and smoke, respectively. It appears that mean lifetime cancer risk values were decreased by more than one order of magnitude when comparing HTPs and commercial cigarettes, and significantly higher margin of exposure for non-cancer risk was observed for HTPs when compared to commercial cigarettes. The same approach was applied to two commercial ECs. Similar results were also found for this category of products. Despite uncertainties related to the factors used for the calculations and methodological limitations, this approach is valuable to estimate health risks associated to the use of innovative products. Moreover, it acts as predictive tool in absence of long-term epidemiological data. Furthermore, both cancer and non-cancer risks estimated for HTPs and ECs highlight the potential of reduced risk for non-combusted products when compared to cigarette smoking.
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Affiliation(s)
- Gregory Rodrigo
- PMI R&D, Philip Morris Products S.A., Rue des Usines 56, 2000, Neuchâtel, Switzerland
| | - Guy Jaccard
- PMI R&D, Philip Morris Products S.A., Rue des Usines 56, 2000, Neuchâtel, Switzerland.
| | - Donatien Tafin Djoko
- PMI R&D, Philip Morris Products S.A., Rue des Usines 56, 2000, Neuchâtel, Switzerland
| | - Alexandra Korneliou
- PMI R&D, Philip Morris Products S.A., Rue des Usines 56, 2000, Neuchâtel, Switzerland
| | - Marco Esposito
- PMI R&D, Philip Morris Products S.A., Rue des Usines 56, 2000, Neuchâtel, Switzerland
| | - Maxim Belushkin
- PMI R&D, Philip Morris Products S.A., Rue des Usines 56, 2000, Neuchâtel, Switzerland
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37
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Buchanan ND, Grimmer JA, Tanwar V, Schwieterman N, Mohler PJ, Wold LE. Cardiovascular risk of electronic cigarettes: a review of preclinical and clinical studies. Cardiovasc Res 2020; 116:40-50. [PMID: 31696222 DOI: 10.1093/cvr/cvz256] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/08/2019] [Accepted: 10/04/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Nicholas D Buchanan
- Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, 473 W. 12th Avenue, Columbus, OH 43210, USA.,College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Jacob A Grimmer
- Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, 473 W. 12th Avenue, Columbus, OH 43210, USA.,College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Vineeta Tanwar
- Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, 473 W. 12th Avenue, Columbus, OH 43210, USA.,College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Neill Schwieterman
- Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, 473 W. 12th Avenue, Columbus, OH 43210, USA.,College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Peter J Mohler
- Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, 473 W. 12th Avenue, Columbus, OH 43210, USA.,Department of Physiology and Cell Biology, The Ohio State University College of Medicine and Wexner Medical Center, Columbus, OH, USA
| | - Loren E Wold
- Dorothy M. Davis Heart and Lung Research Institute, College of Medicine, The Ohio State University, 473 W. 12th Avenue, Columbus, OH 43210, USA.,College of Nursing, The Ohio State University, Columbus, OH, USA.,Department of Physiology and Cell Biology, The Ohio State University College of Medicine and Wexner Medical Center, Columbus, OH, USA
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38
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Lai L, Qiu H. Biological Toxicity of the Compositions in Electronic-Cigarette on Cardiovascular System. J Cardiovasc Transl Res 2020; 14:371-376. [PMID: 32748205 DOI: 10.1007/s12265-020-10060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/15/2020] [Indexed: 11/24/2022]
Abstract
Using electronic cigarette (e-cig) among youth is becoming a critical public health crisis in the USA. However, the biological impacts of the e-cig on multiple organ systems, especially in the cardiovascular system, are largely unknown. Unlike conventional tobacco, e-cig combines various chemical ingredients including nicotine and other add-on non-nicotine chemicals, such as the solvents (propylene glycol and/or vegetable glycerin) and flavoring chemicals, which dramatically increases the diversity of the potential implications. The recent outbreak of e-cig vaping-related tragic deaths in youth and multiple hospitalized patients raised a question on the safety of e-cig use and led to an urgent need for the knowledge of the health risk of the e-cig compositions. Therefore, in the review, we summarized the latest findings from both human and animal studies on the potential cardiovascular toxicological effects of e-cig on the cardiovascular system in terms of the systemic physiological implications and the cellular and molecular mechanisms involved.
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Affiliation(s)
- Lo Lai
- Center of Molecular and Translational Medicine, Petit Research Center, Institution of Biomedical Science, Georgia State University, Room 588, 100 Piedmont Ave, Atlanta, GA, 30303, USA.
| | - Hongyu Qiu
- Center of Molecular and Translational Medicine, Petit Research Center, Institution of Biomedical Science, Georgia State University, Room 588, 100 Piedmont Ave, Atlanta, GA, 30303, USA
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39
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Oh SS, Jang JE, Lee DW, Park EC, Jang SI. Cigarette type or smoking history: Which has a greater impact on the metabolic syndrome and its components? Sci Rep 2020; 10:10467. [PMID: 32591636 PMCID: PMC7319978 DOI: 10.1038/s41598-020-67524-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/22/2020] [Indexed: 12/21/2022] Open
Abstract
Few studies have researched the gender-specific effects of electronic nicotine delivery systems on the metabolic syndrome (MetS) and/or its risk factors (central obesity, raised triglycerides, decreased HDL cholesterol, raised blood pressure, raised fasting plasma glucose). Thus, this study investigated the association between smoking behavior (cigarette type, smoking history) and MetS in a nationally representative sample of Korean men and women. Our study employed data for 5,462 cases of MetS and 12,194 controls from the Korea National Health and Nutritional Examination Survey (KNHANES) for the years 2014 to 2017. Logistic regression analysis was employed to determine the association between type of cigarette (non-smoker, ex-smoker, and current smoker-conventional only, current smoker-conventional and electronic) and the prevalence of metabolic syndrome and its risk factors. Smoking history was clinically quantified by pack-year. No association between cigarette type and MetS was found for men. For women, relative to non-smokers, smokers of conventional cigarettes (OR 1.80, 95% CI 1.02-3.18) and both conventional and electronic cigarettes (OR 4.02, 95% CI 1.48-10.93) had increased odds of MetS. While there was no association between smoking history and MetS for women, for men, conventional smoking history was associated with MetS for individuals with a smoking history of > 25 pack-years (> 25 to ≤ 37.5 OR 1.45, 95% CI 1.04-2.02; > 37.5 to ≤ 50 OR 1.53, 95% CI 1.08-2.18; > 50 OR 1.56, 95% CI 1.07-2.27). Sex differences were found in the association between smoking behavior and MetS. Such findings reveal sociodemographic differences that should be considered for interventions regarding conventional and/or e-cigarette users at risk of metabolic complications.
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Affiliation(s)
- Sarah Soyeon Oh
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Public Health, Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji-Eun Jang
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Public Health, Graduate School, Ajou University College of Medicine, Seoul, Republic of Korea
| | - Doo-Woong Lee
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Public Health, Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-In Jang
- Institute of Health Services Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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40
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Lemay F, Baker P, McRobbie H. Electronic cigarettes: A narrative review of the implications for the pediatric anesthesiologist. Paediatr Anaesth 2020; 30:653-659. [PMID: 32304606 DOI: 10.1111/pan.13885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Francois Lemay
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Paul Baker
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Hayden McRobbie
- National Drug and Alcohol Centre, The University of New South Wales, Sydney, New South Wales, Australia
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41
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Caponnetto P, Polosa R, Robson D, Bauld L. Tobacco smoking, related harm and motivation to quit smoking in people with schizophrenia spectrum disorders. Health Psychol Res 2020; 8:9042. [PMID: 32510003 PMCID: PMC7267811 DOI: 10.4081/hpr.2020.9042] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
This narrative review focuses on the topic of tobacco smoking amongst people with schizophrenia spectrum disorders. We searched PubMed, PsycInfo and Scopus databases for schizophrenia spectrum disorders and smoking and included articles about the epidemiology of tobacco smoking in people with schizophrenia spectrum disorders, examining the relationship between smoking and mental health. This narrative review describes that a higher prevalence, frequency and impact of both high nicotine dependence and its harmful effects in patients with schizophrenia spectrum disorders compared with those in the general population. Despite several existent theories, the reasons for high smoking rates, the high dependence on nicotine and severity of nicotine withdrawal symptoms are not fully understood. The main aim of this paper is to inform mental health personnel and particularly clinical and health psychologists about the impact and role of tobacco smoking for smokers with schizophrenia spectrum disorders.
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Affiliation(s)
| | | | | | - Linda Bauld
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- UK Centre for Tobacco & Alcohol Studies, Nottingham, UK
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42
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Abstract
E‑cigarettes are increasingly used to replace tobacco cigarettes and to stop smoking, but mainly in the sense of dual use. There is lively debate about the assessment of the health risks of e‑cigarettes, but so far there are no comprehensive data for direct comparison with tobacco cigarettes. Other points of controversy include the potential for smoking cessation and the risk of moving from e‑cigarettes to tobacco cigarettes (gateway hypothesis). The present overview comes to the conclusion that, in accordance with the health policy already largely implemented in Great Britain, e‑cigarettes represent a greatly reduced health risk compared with tobacco cigarettes and are certainly suitable for giving up smoking.
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43
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Jakschitz T, Fischnaller M, Noel JC, Gstir R, Rainer D, Rutzinger P, Bonn G, Rode BM. Electronic cigarettes – an important progress or just another risk for health? PURE APPL CHEM 2020. [DOI: 10.1515/pac-2019-0206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Liquids for electronic cigarettes and the vapor generated from them were examined by chemical and biological methods in order to reveal potential risk factors and their acceptability for consumers. Although the majority of the liquids on the market appear to be safe, some aroma compositions have been identified as possibly toxic for human vein epithelial cells, similar to tobacco smoke, thus indicating potential health risks and suggesting suitable test procedures before marketing the liquids.
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Affiliation(s)
- Thomas Jakschitz
- Austrian Drug Screening Institute (ADSI) and Institute for Analytical and Radiochemistry , University of Innsbruck , Innrain 80-82 , A-6020 Innsbruck , Austria
| | - Martin Fischnaller
- Austrian Drug Screening Institute (ADSI) and Institute for Analytical and Radiochemistry , University of Innsbruck , Innrain 80-82 , A-6020 Innsbruck , Austria
| | - Jean-Christophe Noel
- Austrian Drug Screening Institute (ADSI) and Institute for Analytical and Radiochemistry , University of Innsbruck , Innrain 80-82 , A-6020 Innsbruck , Austria
| | - Ronald Gstir
- Austrian Drug Screening Institute (ADSI) and Institute for Analytical and Radiochemistry , University of Innsbruck , Innrain 80-82 , A-6020 Innsbruck , Austria
| | - Daniela Rainer
- Austrian Drug Screening Institute (ADSI) and Institute for Analytical and Radiochemistry , University of Innsbruck , Innrain 80-82 , A-6020 Innsbruck , Austria
| | - Peter Rutzinger
- Austrian Drug Screening Institute (ADSI) and Institute for Analytical and Radiochemistry , University of Innsbruck , Innrain 80-82 , A-6020 Innsbruck , Austria
| | - Günther Bonn
- Austrian Drug Screening Institute (ADSI) and Institute for Analytical and Radiochemistry , University of Innsbruck , Innrain 80-82 , A-6020 Innsbruck , Austria
| | - Bernd Michael Rode
- Austrian Drug Screening Institute (ADSI) and Institute for Analytical and Radiochemistry , University of Innsbruck , Innrain 80-82 , A-6020 Innsbruck , Austria
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44
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Garcia PD, Gornbein JA, Middlekauff HR. Cardiovascular autonomic effects of electronic cigarette use: a systematic review. Clin Auton Res 2020; 30:507-519. [PMID: 32219640 PMCID: PMC7704447 DOI: 10.1007/s10286-020-00683-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/17/2020] [Indexed: 12/17/2022]
Abstract
Purpose Electronic cigarettes (ECs) are the fastest growing tobacco product in the USA, and ECs, like tobacco cigarettes (TCs), have effects on the cardiovascular autonomic nervous system, with clinical implications. The purpose of this review was to collect and synthesize available studies that have investigated the autonomic cardiovascular effects of EC use in humans. Special attention is paid to the acute and chronic effects of ECs, the relative contributions of the nicotine versus non-nicotine constituents in EC emissions and the relative effects of ECs compared to TCs. Methods Using the methodology described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, we conducted a literature search of the Ovid PubMed and Embase databases on 6 December 2019 using keywords in titles and abstracts of published literature. Acute (minutes to hours) and chronic (days or longer) changes in heart rate variability (HRV), heart rate (HR) and blood pressure (BP) were used as estimates of cardiovascular autonomic effects. Results Nineteen studies were included in this systematic review, all of which used earlier generation EC devices. Acute EC vaping increased HR and BP less than acute TC smoking. Nicotine but not non-nicotine constituents in EC aerosol were responsible for the sympathoexcitatory effects. The results of chronic EC vaping studies were consistent with a chronic sympathoexcitatory effect as estimated by HRV, but this did not translate into chronic increases in HR or BP. Conclusions Electronic cigarettes are sympathoexcitatory. Cardiac sympathoexcitatory effects are less when vaping using the earlier generation ECs than when smoking TCs. Additional studies of the latest pod-like EC devices, which deliver nicotine similarly to a TC, are necessary. Electronic supplementary material The online version of this article (10.1007/s10286-020-00683-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Phoebe D Garcia
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jeffrey A Gornbein
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Computational Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Holly R Middlekauff
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, A2-237 CHS, 650 Charles Young Drive South, Los Angeles, CA, 90025, USA.
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45
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Camacho OM, Hedge A, Lowe F, Newland N, Gale N, McEwan M, Proctor C. Statistical analysis plan for "A randomised, controlled study to evaluate the effects of switching from cigarette smoking to using a tobacco heating product on health effect indicators in healthy subjects". Contemp Clin Trials Commun 2020; 17:100535. [PMID: 32072070 PMCID: PMC7013164 DOI: 10.1016/j.conctc.2020.100535] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/10/2020] [Accepted: 01/26/2020] [Indexed: 02/06/2023] Open
Abstract
Tobacco harm reduction strategies aim to substitute smoking with potentially reduced risk products (PRRPs) such as e-cigarettes and tobacco-heating products (THPs). The health benefits of switching from smoking to PRRPs is unknown. A randomised controlled trial is being conducted to increase understanding of the health effects of switching from smoking to a THP in a 12-month long ambulatory study (ISRCTN81075760). Here we describe the study endpoints and the statistical analysis plan. Endpoints are divided into biomarkers of exposure (BoE) to tobacco smoke constituents and health effect indicators related to risk of lung cancer, cardiovascular and obstructive lung disease. These have been selected on the basis of extensive literature evidence. Three primary endpoints, augmentation index (risk factor for cardiovascular disease), total NNAL (linked to lung cancer) and 8-Epi-PGF2α type III (indicator of oxidative stress linked to various diseases), and multiple secondary endpoints will be analysed at 90, 180, and 360 days. Changes from baseline will be compared between study arms by specific contrasts in mixed models. Study wise multiple comparisons adjustments will be performed to account for multiplicity of timepoints and comparisons within timepoints. Generalisability of outcomes will be tested by a sensitivity analysis adjusting for age and gender. Importantly, an ancillary analysis will be performed to assess product compliance during the study based on plasma levels of CEVal, a surrogate marker for acrylonitrile exposure. The rationale underlying the selection of BoEs and health effect indicators, coupled with the statistical analysis plan will be central to understanding the potential health effects of replacing smoking with THP use for one year.
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Affiliation(s)
- Oscar M. Camacho
- British American Tobacco Investments Ltd, Regents Park Road, Southampton, Hampshire, SO15 8TL, UK
| | - Andrew Hedge
- Covance Clinical Research Unit Ltd, Springfield House, Hyde Street, Leeds, Yorkshire, LS2 9LH, UK
| | - Frazer Lowe
- British American Tobacco Investments Ltd, Regents Park Road, Southampton, Hampshire, SO15 8TL, UK
| | - Nik Newland
- British American Tobacco Investments Ltd, Regents Park Road, Southampton, Hampshire, SO15 8TL, UK
| | - Nathan Gale
- British American Tobacco Investments Ltd, Regents Park Road, Southampton, Hampshire, SO15 8TL, UK
| | - Mike McEwan
- British American Tobacco Investments Ltd, Regents Park Road, Southampton, Hampshire, SO15 8TL, UK
| | - Christopher Proctor
- British American Tobacco Investments Ltd, Regents Park Road, Southampton, Hampshire, SO15 8TL, UK
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Verhaegen A, Van Gaal L. Vaping and Cardiovascular Health: the Case for Health Policy Action. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0634-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Signes-Costa J, de Granda-Orive JI, Ramos Pinedo Á, Camarasa Escrig A, de Higes Martínez E, Rábade Castedo C, Cabrera César E, Jiménez-Ruiz CA. Declaración Oficial de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR) sobre cigarrillos electrónicos e IQOS®. Arch Bronconeumol 2019; 55:581-586. [DOI: 10.1016/j.arbres.2019.04.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/22/2019] [Accepted: 04/29/2019] [Indexed: 12/25/2022]
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Kennedy CD, van Schalkwyk MCI, McKee M, Pisinger C. The cardiovascular effects of electronic cigarettes: A systematic review of experimental studies. Prev Med 2019; 127:105770. [PMID: 31344384 DOI: 10.1016/j.ypmed.2019.105770] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/18/2019] [Accepted: 07/12/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Smoking is responsible for substantial cardiovascular morbidity and mortality. Electronic cigarettes have been advocated as a means to reduce this disease burden; by reducing exposure to harmful substances in smokers who are unable to quit. Concerns have been raised however, about cardiovascular effects of their use, with inhalants containing carbonyls and fine particulate matter. We systematically reviewed experimental studies of in vitro, animal, and human cardiovascular effects associated with electronic cigarette use. METHODS A literature search was conducted using Ovid MEDLINE & Embase databases, identifying experimental studies investigating cardiovascular effects of electronic cigarette use. Subsequently, Cochrane Risk of Bias tools were used to assess study quality. Any differences in outcomes by conflict of interest and risk of bias status were sought. RESULTS 38 studies were included, investigating animals (n=6), humans (n=24) and human cardiovascular cells in vitro (n=8). 74.3% of studies found potentially harmful effects. Increased sympathetic nerve activity was observed in human studies, whilst platelet haemostatic processes, reactive oxygen species production and endothelial dysfunction were reported across all study types. Studies with conflicts of interest or median-high risk of bias were less likely to identify potentially harmful effects (p=0.0007, p=0.04 respectively). DISCUSSION Most studies suggest potential for cardiovascular harm from electronic cigarette use, through mechanisms that increase risk of thrombosis and atherosclerosis. Notably, studies with conflicts of interest are significantly less likely to identify concerning cardiovascular effects. Included studies examine healthy, adult participants, limiting generalisation to potential high-risk groups including individuals with established cardiovascular disease or young, non-smokers.
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Affiliation(s)
- Ciaran D Kennedy
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - May C I van Schalkwyk
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin McKee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Charlotta Pisinger
- Center for Clinical Research and Prevention, Bispebjerg-Frederiksberg University Hospital, Capital Region of Denmark, Denmark; Danish Heart Foundation, Copenhagen, Denmark; University of Copenhagen, Faculty of Health and Medical Science, Denmark.
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Warner KE. How to Think-Not Feel-about Tobacco Harm Reduction. Nicotine Tob Res 2019; 21:1299-1309. [PMID: 29718475 DOI: 10.1093/ntr/nty084] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 04/27/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The debate over tobacco harm reduction (THR) has divided the tobacco control community into two camps, one expressing serious reservations about THR whereas the other believes that reduced-risk products like e-cigarettes will disrupt the cigarette market. The often emotional debate would benefit from dispassionate data-based evaluation of evidence. METHODS After briefly discussing harm reduction in public health and specifically in tobacco control, this paper identifies major issues concerning e-cigarettes and reviews relevant evidence. Issues include: e-cigarettes' risks compared to cigarette smoking; the effect of vaping on youth smoking; vaping's impact on adult smoking cessation; the net long-term public health implications of vaping; and differences in views on policy issues. The intent is to provide a broad overview of issues and evidence, directing readers to more detailed reviews of specific issues. FINDINGS Principal findings include the following: (1) while longitudinal studies suggest that vaping increases never-smoking young people's odds of trying smoking, national survey data indicate that adolescents' 30-day smoking prevalence decreased at an unprecedented rate precisely whereas vaping increased. Use of all other tobacco products also declined. (2) Recent population-level studies add evidence that vaping is increasing adult smoking cessation. (3) Vaping is likely to make a positive contribution to public health. CONCLUSIONS THR can be a complement to, not a substitute for, evidenced-based tobacco control interventions. Tobacco control professionals need to focus on objective assessment of and discussion about the potential costs and benefits of THR. IMPLICATIONS Participants on both sides of the divisive THR debate need to examine the complicated issues and evidence more objectively. This entails considering both the potential benefits and costs associated with reduced-risk products like e-cigarettes. Furthermore, it requires examining different kinds of evidence when considering specific issues. For example, those concerned by longitudinal study findings that vaping increases students' trial of cigarettes should consider US national survey evidence that youth smoking has decreased at an unprecedented rate. A review of the major issues suggests that the potential of vaping to assist adult smokers to quit outweighs the potential negatives.
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Affiliation(s)
- Kenneth E Warner
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
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Price LR, Martinez J. Biological effects of nicotine exposure: A narrative review of the scientific literature. F1000Res 2019; 8:1586. [PMID: 32595938 PMCID: PMC7308884 DOI: 10.12688/f1000research.20062.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 09/07/2023] Open
Abstract
The emergence of new tobacco heating products and electronic nicotine delivery systems (ENDS) is changing the way humans are exposed to nicotine. The purpose of this narrative review is to provide a broad overview of published scientific literature with respect to the effects of nicotine on three key health-related areas: 1) cardiovascular risk, 2) carcinogenesis and 3) reproductive outcomes. These areas are known to be particularly vulnerable to the effects of cigarette smoke, and in addition, nicotine has been hypothesized to play a role in disease pathogenesis. Acute toxicity will also be discussed. The literature to February 2019 suggests that there is no increased cardiovascular risk of nicotine exposure in consumers who have no underlying cardiovascular pathology. There is scientific consensus that nicotine is not a direct or complete carcinogen, however, it remains to be established whether it plays some role in human cancer propagation and metastasis. These cancer progression pathways have been proposed in models in vitro and in transgenic rodent lines in vivo but have not been demonstrated in cases of human cancer. Further studies are needed to determine whether nicotine is linked to decreased fertility in humans. The results from animal studies indicate that nicotine has the potential to act across many mechanisms during fetal development. More studies are needed to address questions regarding nicotine exposure in humans, and this may lead to additional guidance concerning new ENDS entering the market.
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Affiliation(s)
- Leonie R. Price
- Scientific and Regulatory Affairs, Japan Tobacco International, Genève, Genève, 1202, Switzerland
| | - Javier Martinez
- Scientific and Regulatory Affairs, Japan Tobacco International, Genève, Genève, 1202, Switzerland
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