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Yacoub MI, Aslanoğlu A, Khraim F, Alsharawneh A, Abdelkader R, Almagharbeh WT, Alhejaili AA, Alshahrani BD, Sobeh DE, Eltayeb MM, Elshatarat RA, Saleh ZT. Comparing E-Cigarettes and Traditional Cigarettes in Relation to Myocardial Infarction, Arrhythmias, and Sudden Cardiac Death: A Systematic Review and Meta-Analysis. Biol Res Nurs 2024:10998004241287782. [PMID: 39317411 DOI: 10.1177/10998004241287782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
BACKGROUND The use of electronic cigarettes (e-cigarettes) as a perceived safer alternative to traditional cigarettes has grown rapidly. However, the cardiovascular risks associated with e-cigarettes compared to regular cigarettes remain unclear. OBJECTIVE To systematically review and compare the cardiovascular outcomes of e-cigarette use versus traditional cigarette use, focusing on the risks of myocardial infarction, arrhythmias, and sudden death. METHODS A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Peer-reviewed studies published in English were included if they reported cardiovascular outcomes related to e-cigarette or traditional cigarette use. A total of 20 studies were included, covering observational and interventional studies focusing on heart rate variability, myocardial infarction, arrhythmias, and sudden cardiac events. The quality of the evidence was assessed using the GRADE criteria, and data were extracted and analyzed based on the PICOS (Population, Interventions, Comparisons, Outcomes, and Study designs) framework. RESULTS The systematic review found that both e-cigarettes and traditional cigarettes pose significant cardiovascular risks, with traditional cigarettes linked to a higher incidence of myocardial infarction, arrhythmias, and sudden cardiac death. E-cigarette users also face increased risks of arrhythmias and myocardial infarction compared to non-smokers, primarily due to the constituents of aerosolized e-liquid, including nicotine and flavorings, which contribute to adverse cardiac effects. Regular e-cigarette use, particularly in combination with traditional cigarette use, was associated with a heightened risk of myocardial infarction. Studies also reported heart function abnormalities, such as systolic and diastolic dysfunction, and reduced ejection fractions. Additionally, changes in heart rate variability, heart rate, and blood pressure were observed, indicating both acute and chronic effects of e-cigarettes on cardiovascular autonomic regulation. CONCLUSIONS While e-cigarettes may present a lower cardiovascular risk compared to traditional cigarettes, they are not without harm. Both products are linked to increased risks of myocardial infarction and arrhythmias, though traditional cigarettes pose a higher overall threat. Given the limitations in the current evidence base, particularly concerning the long-term effects of e-cigarette use, further research is needed to clarify these cardiovascular risks and inform public health guidelines.
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Affiliation(s)
- Mohammed I Yacoub
- Department of Clinical Nursing, School of Nursing, The University of Jordan, Amman, Jordan
| | - Aziz Aslanoğlu
- Department of Nursing, School of Health Sciences, Cyprus International University, Lefkoşa, Cyprus
- Department of Nursing, Vision College, Riyadh, Saudi Arabia
| | - Fadi Khraim
- College of Nursing, Qatar University, Doha, Qatar
| | - Anas Alsharawneh
- Department of Adult Health Nursing, Faculty of Nursing, The Hashemite University, Zarqa, Jordan
| | - Raghad Abdelkader
- Nursing Department, Faculty of Nursing, Applied Science Private University, Amman, Jordan
| | - Wesam T Almagharbeh
- Medical Surgical Nursing Department, Faculty of Nursing, University of Tabuk, Tabuk, Saudi Arabia
| | - Asim Abdullah Alhejaili
- Department of Medical and Surgical Nursing, College of Nursing, Taibah University, Madinah, Saudi Arabia
| | - Bassam Dhafer Alshahrani
- Department of Medical and Surgical Nursing, College of Nursing, Taibah University, Madinah, Saudi Arabia
- Honorary Fellow, School of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Dena Eltabey Sobeh
- Department of Medical Surgical Nursing, College of Nursing, Prince Sattam Bin Abdulaziz University, AlKharj, Saudi Arabia
| | - Mudathir M Eltayeb
- Department of Medical Surgical Nursing, College of Nursing, Prince Sattam Bin Abdulaziz University, AlKharj, Saudi Arabia
| | - Rami A Elshatarat
- Department of Medical and Surgical Nursing, College of Nursing, Taibah University, Madinah, Saudi Arabia
| | - Zyad T Saleh
- Department of Clinical Nursing, School of Nursing, The University of Jordan, Amman, Jordan
- Department of Nursing, Vision College, Riyadh, Saudi Arabia
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Velayutham M, Mills A, Khramtsov VV, Olfert IM. An electron paramagnetic resonance time-course study of oxidative stress in the plasma of electronic cigarette exposed rats. Exp Physiol 2024; 109:1420-1425. [PMID: 39090831 PMCID: PMC11363090 DOI: 10.1113/ep092064] [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: 05/24/2024] [Accepted: 07/09/2024] [Indexed: 08/04/2024]
Abstract
The long-term consequences of electronic cigarette (Ecig) use in humans are not yet known, but it is known that Ecig aerosols contain many toxic compounds of concern. We have recently shown that Ecig exposure impairs middle cerebral artery (MCA) endothelial function and that it takes 3 days for MCA reactivity to return to normal. However, the sources contributing to impairment of the endothelium were not investigated. We hypothesized that the increased levels of oxidative stress markers in the blood are correlated with impaired MCA reactivity. We used electron paramagnetic resonance (EPR) spectroscopy to examine plasma from 4-month-old male Sprague-Dawley rats that were exposed to either air (n = 5) or 1 h Ecig exposure, after which blood samples were collected at varying times after exposure (i.e., 1-4, 24, 48 and 72 h postexposure, n = 4 or 5 in each time group). The EPR analyses were performed using the redox-sensitive hydroxylamine spin probe 1-hydroxy-3-carboxymethyl-2,2,5,5-tetramethyl-pyrrolidine (CMH) to measure the level of reactive oxidant species in the plasma samples. We found that EPR signal intensity from the CM• radical was significantly increased in plasma at 1-4, 24 and 48 h (P < 0.05, respectively) and returned to control (air) levels by 72 h. When evaluating the EPR results with MCA reactivity, we found a significant negative correlation (Pearson's P = 0.0027). These data indicate that impaired cerebrovascular reactivity resulting from vaping is associated with the oxidative stress level (measured by EPR from plasma) and indicate that a single 1 h vaping session can negatively influence vascular health for up to 3 days after vaping. HIGHLIGHTS: What is the central question of this study? Does the time course of oxidative stress triggered by electronic cigarette exposure follow the cerebral vascular dysfunction? What is the main finding and its importance? Electron paramagnetic resonance analysis shows that the oxidative stress induced after a single 1 h exposure to electronic cigarette aerosol takes ≤72 h to return to normal, which mirrors the time course for vascular dysfunction in the middle cerebral artery that we have reported previously.
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Affiliation(s)
- Murugesan Velayutham
- In vivo Multifunctional Magnetic Resonance CenterWest Virginia University School of MedicineMorgantownWest VirginiaUSA
- Center for Inhalation ToxicologyWest Virginia University School of MedicineMorgantownWest VirginiaUSA
- Department of Biochemistry and Molecular MedicineWest Virginia University School of MedicineMorgantownWest VirginiaUSA
| | - Amber Mills
- Department of Physiology, Pharmacology & ToxicologyWest Virginia University School of MedicineMorgantownWest VirginiaUSA
| | - Valery V. Khramtsov
- In vivo Multifunctional Magnetic Resonance CenterWest Virginia University School of MedicineMorgantownWest VirginiaUSA
- Department of Biochemistry and Molecular MedicineWest Virginia University School of MedicineMorgantownWest VirginiaUSA
| | - I. Mark Olfert
- Center for Inhalation ToxicologyWest Virginia University School of MedicineMorgantownWest VirginiaUSA
- Department of Physiology, Pharmacology & ToxicologyWest Virginia University School of MedicineMorgantownWest VirginiaUSA
- Department of Human Performance, Division of Exercise PhysiologyWest Virginia University School of MedicineMorgantownWest VirginiaUSA
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Feli M, Azimi I, Sarhaddi F, Sharifi-Heris Z, Niela-Vilen H, Liljeberg P, Axelin A, Rahmani AM. Preterm birth risk stratification through longitudinal heart rate and HRV monitoring in daily life. Sci Rep 2024; 14:19896. [PMID: 39191907 DOI: 10.1038/s41598-024-70773-0] [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: 02/12/2024] [Accepted: 08/21/2024] [Indexed: 08/29/2024] Open
Abstract
Preterm birth (PTB) remains a global health concern, impacting neonatal mortality and lifelong health consequences. Traditional methods for estimating PTB rely on electronic health records or biomedical signals, limited to short-term assessments in clinical settings. Recent studies have leveraged wearable technologies for in-home maternal health monitoring, offering continuous assessment of maternal autonomic nervous system (ANS) activity and facilitating the exploration of PTB risk. In this paper, we conduct a longitudinal study to assess the risk of PTB by examining maternal ANS activity through heart rate (HR) and heart rate variability (HRV). To achieve this, we collect long-term raw photoplethysmogram (PPG) signals from 58 pregnant women (including seven preterm cases) from gestational weeks 12-15 to three months post-delivery using smartwatches in daily life settings. We employ a PPG processing pipeline to accurately extract HR and HRV, and an autoencoder machine learning model with SHAP analysis to generate explainable abnormality scores indicative of PTB risk. Our results reveal distinctive patterns in PTB abnormality scores during the second pregnancy trimester, indicating the potential for early PTB risk estimation. Moreover, we find that HR, average of interbeat intervals (AVNN), SD1SD2 ratio, and standard deviation of interbeat intervals (SDNN) emerge as significant PTB indicators.
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Affiliation(s)
- Mohammad Feli
- Department of Computing, University of Turku, Turku, Finland.
| | - Iman Azimi
- Department of Computer Science, University of California, Irvine, USA
| | | | | | | | - Pasi Liljeberg
- Department of Computing, University of Turku, Turku, Finland
| | - Anna Axelin
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Amir M Rahmani
- Department of Computer Science, University of California, Irvine, USA
- School of Nursing, University of California, Irvine, USA
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Wu HH, Du JM, Liu P, Meng FL, Li YY, Li WJ, Wang SX, Du NL, Zheng Y, Zhang L, Wang HY, Liu YR, Song CH, Ni X, Li Y, Su GH. LDHA contributes to nicotine induced cardiac fibrosis through autophagy flux impairment. Int Immunopharmacol 2024; 136:112338. [PMID: 38850787 DOI: 10.1016/j.intimp.2024.112338] [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: 01/23/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 06/10/2024]
Abstract
Cardiac fibrosis is a typical feature of cardiac pathological remodeling, which is associated with adverse clinical outcomes and has no effective therapy. Nicotine is an important risk factor for cardiac fibrosis, yet its underlying molecular mechanism remains poorly understood. This study aimed to identify its potential molecular mechanism in nicotine-induced cardiac fibrosis. Our results showed nicotine exposure led to the proliferation and transformation of cardiac fibroblasts (CFs) into myofibroblasts (MFs) by impairing autophagy flux. Through the use of drug affinity responsive target stability (DARTS) assay, cellular thermal shift assay (CETSA), and surface plasmon resonance (SPR) technology, it was discovered that nicotine directly increased the stability and protein levels of lactate dehydrogenase A (LDHA) by binding to it. Nicotine treatment impaired autophagy flux by regulating the AMPK/mTOR signaling pathway, impeding the nuclear translocation of transcription factor EB (TFEB), and reducing the activity of cathepsin B (CTSB). In vivo, nicotine treatment exacerbated cardiac fibrosis induced in spontaneously hypertensive rats (SHR) and worsened cardiac function. Interestingly, the absence of LDHA reversed these effects both in vitro and in vivo. Our study identified LDHA as a novel nicotine-binding protein that plays a crucial role in mediating cardiac fibrosis by blocking autophagy flux. The findings suggest that LDHA could potentially serve as a promising target for the treatment of cardiac fibrosis.
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Affiliation(s)
- Hui-Hui Wu
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China
| | - Jia-Min Du
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China
| | - Peng Liu
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Fan-Liang Meng
- Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yue-Yan Li
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China
| | - Wen-Jing Li
- Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shuang-Xi Wang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, China
| | - Nai-Li Du
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yan Zheng
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Liang Zhang
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Hui-Yun Wang
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yi-Ran Liu
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chun-Hong Song
- Department of Laboratory Animal Center, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xi Ni
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China.
| | - Ying Li
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China.
| | - Guo-Hai Su
- Department of Cardiology, Jinan Central Hospital, Shandong University, Jinan, China; Research Center for Translational Medicine, Central Hospital Affiliated to Shandong First Medical University, Jinan, China.
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Cordery S, Thompson K, Stevenson M, Simms L, Chapman F, Grandolfo E, Malt L, Weaver S, Fearon IM, Nahde T. The Product Science of Electrically Heated Tobacco Products: An Updated Narrative Review of the Scientific Literature. Cureus 2024; 16:e61223. [PMID: 38939262 PMCID: PMC11209752 DOI: 10.7759/cureus.61223] [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] [Accepted: 05/28/2024] [Indexed: 06/29/2024] Open
Abstract
Heated tobacco products represent a novel category of tobacco products in which a tobacco consumable is heated to a temperature that releases nicotine from the tobacco leaf but not to a temperature sufficient to cause combustion. Heated tobacco products may therefore have the potential to be a less harmful alternative for adult smokers who would otherwise continue to smoke cigarettes, as their use should result in exposure to substantially fewer and lower levels of toxicants. This update represents a two-year extension to our previous narrative review, which covered peer-reviewed journal articles published up to August 31, 2021. The scientific evidence published between 2021 and 2023 continues to indicate that aerosols produced from heated tobacco products contain fewer and substantially lower levels of harmful and potentially harmful constituents and that these observed reductions consistently translate to reduced biological effects in both in vitro and in vivo toxicological studies. Biomarker and clinical data from studies in which product use is controlled within a clinical setting continue to suggest changes in levels of biomarkers of exposure, biomarkers of potential harm, and clinical endpoints indicating the potential for reduced harm with switching to exclusive use of heated tobacco products in adult smokers. Overall, the available peer-reviewed scientific evidence continues to indicate that heated tobacco products offer promise as a potentially less harmful alternative to cigarettes, and as such, the conclusions of our original narrative review remain valid.
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Affiliation(s)
- Sarah Cordery
- Group Science and Regulatory Affairs, Imperial Brands Plc., Bristol, GBR
| | - Keith Thompson
- Independent Scientific Consultant, Elucid8 Holdings Ltd., Coleraine, GBR
| | - Matthew Stevenson
- Group Science and Regulatory Affairs, Imperial Brands Plc., Bristol, GBR
| | - Liam Simms
- Group Science and Regulatory Affairs, Imperial Brands Plc., Bristol, GBR
| | - Fiona Chapman
- Group Science and Regulatory Affairs, Imperial Brands Plc., Bristol, GBR
| | - Erika Grandolfo
- Group Science and Regulatory Affairs, Imperial Brands Plc., Bristol, GBR
| | - Layla Malt
- Group Science and Regulatory Affairs, Imperial Brands Plc., Bristol, GBR
| | - Sarah Weaver
- Group Science and Regulatory Affairs, Imperial Brands Plc., Bristol, GBR
| | - Ian M Fearon
- Scientific Research, whatIF? Consulting Ltd., Harwell, GBR
| | - Thomas Nahde
- Group Science and Regulatory Affairs, Imperial Brands Reemtsma, Hamburg, DEU
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6
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Kucera C, Ramalingam A, Srivastava S, Bhatnagar A, Carll AP. Nicotine Formulation Influences the Autonomic and Arrhythmogenic Effects of Electronic Cigarettes. Nicotine Tob Res 2024; 26:536-544. [PMID: 38011908 PMCID: PMC11033561 DOI: 10.1093/ntr/ntad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/09/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Evidence is mounting that electronic cigarette (e-cig) use induces cardiac sympathetic dominance and electrical dysfunction conducive to arrhythmias and dependent upon nicotine. A variety of nicotine types and concentrations are available in e-cigs, but their relative cardiovascular effects remain unclear. Here we examine how different nicotine forms (racemic, free base, and salt) and concentrations influence e-cig-evoked cardiac dysfunction and arrhythmogenesis and provide a mechanism for nicotine-salt-induced autonomic imbalance. METHODS ECG-telemetered C57BL/6J mice were exposed to filtered air (FA) or e-cig aerosols from propylene glycol and vegetable glycerin solvents either without nicotine (vehicle) or with increasing nicotine concentrations (1%, 2.5%, and 5%) for three 9-minute puff sessions per concentration. Spontaneous ventricular premature beat (VPB) incidence rates, heart rate, and heart rate variability (HRV) were compared between treatments. Subsequently, to test the role of β1-adrenergic activation in e-cig-induced cardiac effects, mice were pretreated with atenolol and exposed to either FA or 2.5% nicotine salt. RESULTS During puffing and washout phases, ≥2.5% racemic nicotine reduced heart rate and increased HRV relative to FA and vehicle controls, indicating parasympathetic dominance. Relative to both controls, 5% nicotine salt elevated heart rate and decreased HRV during washout, suggesting sympathetic dominance, and also increased VPB frequency. Atenolol abolished e-cig-induced elevations in heart rate and declines in HRV during washout, indicating e-cig-evoked sympathetic dominance is mediated by β1-adrenergic stimulation. CONCLUSIONS Our findings suggest that inhalation of e-cig aerosols from nicotine-salt-containing e-liquids could increase the cardiovascular risks of vaping by inducing sympathetic dominance and cardiac arrhythmias. IMPLICATIONS Exposure to e-cig aerosols containing commercially relevant concentrations of nicotine salts may increase nicotine delivery and impair cardiac function by eliciting β1-adrenoceptor-mediated sympathoexcitation and provoking ventricular arrhythmias. If confirmed in humans, our work suggests that regulatory targeting of nicotine salts through minimum pH standards or limits on acid additives in e-liquids may mitigate the public health risks of vaping.
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Affiliation(s)
- Cory Kucera
- Department of Physiology, University of Louisville School of Medicine (ULSOM), Louisville, KY, USA
- Christina Lee Brown Envirome Institute, ULSOM, Louisville, KY, USA
- American Heart Association Tobacco Regulation and Addiction Center 2.0 (A-TRAC 2.0), ULSOM, Louisville, KY, USA
- Center for Cardiometabolic Science, ULSOM, Louisville, KY, USA
| | - Anand Ramalingam
- Christina Lee Brown Envirome Institute, ULSOM, Louisville, KY, USA
- American Heart Association Tobacco Regulation and Addiction Center 2.0 (A-TRAC 2.0), ULSOM, Louisville, KY, USA
- Center for Cardiometabolic Science, ULSOM, Louisville, KY, USA
| | - Shweta Srivastava
- Christina Lee Brown Envirome Institute, ULSOM, Louisville, KY, USA
- American Heart Association Tobacco Regulation and Addiction Center 2.0 (A-TRAC 2.0), ULSOM, Louisville, KY, USA
- Center for Cardiometabolic Science, ULSOM, Louisville, KY, USA
| | - Aruni Bhatnagar
- Christina Lee Brown Envirome Institute, ULSOM, Louisville, KY, USA
- American Heart Association Tobacco Regulation and Addiction Center 2.0 (A-TRAC 2.0), ULSOM, Louisville, KY, USA
- Center for Cardiometabolic Science, ULSOM, Louisville, KY, USA
- Division of Environmental Medicine, ULSOM, Louisville, KY, USA
- Center for Integrative Environmental Health Sciences, ULSOM, Louisville, KY, USA
| | - Alex P Carll
- Department of Physiology, University of Louisville School of Medicine (ULSOM), Louisville, KY, USA
- Christina Lee Brown Envirome Institute, ULSOM, Louisville, KY, USA
- American Heart Association Tobacco Regulation and Addiction Center 2.0 (A-TRAC 2.0), ULSOM, Louisville, KY, USA
- Center for Cardiometabolic Science, ULSOM, Louisville, KY, USA
- Division of Environmental Medicine, ULSOM, Louisville, KY, USA
- Center for Integrative Environmental Health Sciences, ULSOM, Louisville, KY, USA
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Glantz SA, Nguyen N, Oliveira da Silva AL. Population-Based Disease Odds for E-Cigarettes and Dual Use versus Cigarettes. NEJM EVIDENCE 2024; 3:EVIDoa2300229. [PMID: 38411454 DOI: 10.1056/evidoa2300229] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND: E-cigarettes are promoted as less harmful than cigarettes. There has not been a direct comparison of health effects of e-cigarettes or dual use (concurrently using e-cigarettes and cigarettes) with those of cigarettes in the general population. METHODS: Studies in PubMed, EMBASE, Web of Science, and PsychINFO published through October 1, 2023, were pooled in a random-effects meta-analysis if five or more studies were identified with a disease outcome. We assessed risk of bias with Risk Of Bias In Non-randomized Studies of Exposure and certainty with Grading of Recommendations, Assessment, Development, and Evaluations. Outcomes with fewer studies were summarized but not pooled. RESULTS: We identified 124 odds ratios (94 cross-sectional and 30 longitudinal) from 107 studies. Pooled odds ratios for current e-cigarette versus cigarette use were not different for cardiovascular disease (odds ratio, 0.81; 95% confidence interval, 0.58 to 1.14), stroke (0.73; 0.47 to 1.13), or metabolic dysfunction (0.99; 0.91 to 1.09) but were lower for asthma (0.84; 0.74 to 0.95), chronic obstructive pulmonary disease (0.53; 0.38 to 0.74), and oral disease (0.87; 0.76 to 1.00). Pooled odds ratios for dual use versus cigarettes were increased for all outcomes (range, 1.20 to 1.41). Pooled odds ratios for e-cigarettes and dual use compared with nonuse of either product were increased (e-cigarette range, 1.24 to 1.47; dual use, 1.49 to 3.29). All included studies were assessed as having a low risk of bias. Results were generally not sensitive to study characteristics. Limited studies of other outcomes suggest that e-cigarette use is associated with additional diseases. CONCLUSIONS: There is a need to reassess the assumption that e-cigarette use provides substantial harm reduction across all cigarette-caused diseases, particularly accounting for dual use.
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Affiliation(s)
| | - Nhung Nguyen
- Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco
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Gwon SH, Thongpriwan V, Mobarki A, Eyadat A, Noonan D. Experiences and Perceptions of E-Cigarette Cessation for Young Adults in Rural Communities. Nurs Res 2024; 73:46-53. [PMID: 37768961 DOI: 10.1097/nnr.0000000000000692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND Electronic nicotine delivery systems (ENDS), also known as e-cigarettes, are the most commonly used tobacco products among young adults in the United States. Young adults in rural areas have a higher prevalence of ENDS use compared to their urban counterparts, yet there is limited evidence regarding the in-depth understanding of experiences and perspectives directly from young adults. OBJECTIVES The aim of this study was to explore individual experiences and perspectives about use and cessation of ENDS from young adults in rural areas. METHODS This was a qualitative study using interpretive description for analysis. Young adults (18-24 years) who used ENDS every day but not other tobacco products (cigarettes, smokeless, etc.) in the past month and had an address in a rural county of Wisconsin were eligible; there were nine participants interviewed using Zoom. Interview questions focused on initial use, maintenance of use, experiences of quitting, and social and rural environmental contexts regarding ENDS. RESULTS Three themes emerged with eight categories: (a) addiction to ENDS and health, (b) cessation and resources, and (c) rural environment and culture in ENDS addiction. DISCUSSION Findings have implications for ENDS cessation interventions targeting young adults in rural areas.
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Sharifi-Heris Z, Yang Z, Rahmani AM, Fortier MA, Sharifiheris H, Bender M. Phenotyping the autonomic nervous system in pregnancy using remote sensors: potential for complication prediction. Front Physiol 2023; 14:1293946. [PMID: 38074317 PMCID: PMC10702512 DOI: 10.3389/fphys.2023.1293946] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/23/2023] [Indexed: 10/16/2024] Open
Abstract
Objectives: The autonomic nervous system (ANS) plays a central role in dynamic adaptation during pregnancy in accordance with the pregnancy demands which otherwise can lead to various pregnancy complications. Despite the importance of understanding the ANS function during pregnancy, the literature lacks sufficiency in the ANS assessment. In this study, we aimed to identify the heart rate variability (HRV) function during the second and third trimesters of pregnancy and 1 week after childbirth and its relevant predictors in healthy pregnant Latina individuals in Orange County, CA. Materials and methods: N = 16 participants were enrolled into the study from which N = 14 (N = 13 healthy and n = 1 complicated) participants proceeded to the analysis phase. For the analysis, we conducted supervised machine learning modeling including the hierarchical linear model to understand the association between time and HRV and random forest regression to investigate the factors that may affect HRV during pregnancy. A t-test was used for exploratory analysis to compare the complicated case with healthy pregnancies. Results: The results of hierarchical linear model analysis showed a significant positive relationship between time (day) and average HRV (estimated effect = 0.06; p < 0.0001), regardless of being healthy or complicated, indicating that HRV increases during pregnancy significantly. Random forest regression results identified some lifestyle and sociodemographic factors such as activity, sleep, diet, and mental stress as important predictors for HRV changes in addition to time. The findings of the t-test indicated that the average weekly HRV of healthy and non-healthy subjects differed significantly (p < 0.05) during the 17 weeks of the study. Conclusion: It is imperative to focus our attention on potential autonomic changes, particularly the possibility of increased parasympathetic activity as pregnancy advances. This observation may challenge the existing literature that often suggests a decline in parasympathetic activity toward the end of pregnancy. Moreover, our findings indicated the complexity of HRV prediction, involving various factors beyond the mere passage of time. To gain a more comprehensive understanding of this dynamic state, future investigations should delve into the intricate relationship between autonomic activity, considering diverse parasympathetic and sympathetic metrics, and the progression of pregnancy.
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Affiliation(s)
- Zahra Sharifi-Heris
- Sue and Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States
| | - Zhongqi Yang
- Department of Computer Science, University of California, Irvine, Irvine, CA, United States
| | - Amir M. Rahmani
- Sue and Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States
- Department of Computer Science, University of California, Irvine, Irvine, CA, United States
| | - Michelle A. Fortier
- Sue and Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States
- Center on Stress and Health, University of California, Irvine, Irvine, CA, United States
| | | | - Miriam Bender
- Sue and Bill Gross School of Nursing, University of California, Irvine, Irvine, CA, United States
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Deshmukh T, Kovoor JG, Byth K, Chow CK, Zaman S, Chong JJH, Figtree GA, Thiagalingam A, Kovoor P. Influence of standard modifiable risk factors on ventricular tachycardia after myocardial infarction. Front Cardiovasc Med 2023; 10:1283382. [PMID: 37942068 PMCID: PMC10628449 DOI: 10.3389/fcvm.2023.1283382] [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: 08/25/2023] [Accepted: 09/27/2023] [Indexed: 11/10/2023] Open
Abstract
Background Inducible ventricular tachycardia (VT) at electrophysiology study (EPS) predicts sudden cardiac death because of ventricular tachyarrhythmia, the single greatest cause of death within 2 years after myocardial infarction (MI). Objectives We aimed to assess the association between standard modifiable risk factors (SMuRFs) and inducible VT at EPS early after MI. Methods Consecutive patients with left ventricle ejection fraction ≤40% on days 3-5 after ST elevation MI (STEMI) who underwent EPS were prospectively recruited. Positive EPS was defined as induced sustained monomorphic VT cycle length ≥200 ms for ≥10 s or shorter if hemodynamically compromised. The primary outcome was inducibility of VT at EPS, and the secondary outcome was all-cause mortality on follow-up. Results In 410 eligible patients undergoing EPS soon (median of 9 days) after STEMI, 126 had inducible VT. Ex-smokers experienced an increased risk of inducible VT [multivariable logistic regression adjusted odds ratio (OR) 2.0, p = 0.033] compared with current or never-smokers, with comparable risk. The presence of any SMuRFs apart from being a current smoker conferred an increased risk of inducible VT (adjusted OR 1.9, p = 0.043). Neither the number of SMuRFs nor the presence of any SMuRFs was associated with mortality at a median follow-up of 5.4 years. Conclusions In patients with recent STEMI and impaired left ventricular function, the presence of any SMuRFs, apart from being a current smoker, conferred an increased risk of inducible VT at EPS. These results highlight the need to modify SMuRFs in this high-risk subset of patients.
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Affiliation(s)
- Tejas Deshmukh
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Centre for Heart Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, NSW, Australia
| | - Joshua G. Kovoor
- University of Adelaide, The Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
| | - Clara K. Chow
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
| | - Sarah Zaman
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
| | - James J. H. Chong
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Centre for Heart Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, NSW, Australia
| | - Gemma A. Figtree
- Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - Aravinda Thiagalingam
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
| | - Pramesh Kovoor
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, NSW, Australia
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Jones CA, Wallace MJ, Bandaru P, Woodbury ED, Mohler PJ, Wold LE. E-cigarettes and arrhythmogenesis: a comprehensive review of pre-clinical studies and their clinical implications. Cardiovasc Res 2023; 119:2157-2164. [PMID: 37517059 PMCID: PMC10578912 DOI: 10.1093/cvr/cvad113] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Electronic cigarette use has grown exponentially in recent years, and while their popularity has increased, the long-term effects on the heart are yet to be fully studied and understood. Originally designed as devices to assist with those trying to quit traditional combustible cigarette use, their popularity has attracted use by teens and adolescents who traditionally have not smoked combustible cigarettes. Acute effects on the heart have been shown to be similar to traditional combustible cigarettes, including increased heart rate and blood pressure. The main components of electronic cigarettes that contribute to these arrhythmic effects are found in the e-liquid that is aerosolized and inhaled, comprised of nicotine, flavourings, and a combination of vegetable glycerin (VG) and propylene glycol (PG). Nicotine can potentially induce both ventricular and atrial arrhythmogenesis, with both the atrial and ventricular effects resulting from the interactions of nicotine and the catecholamines they release via potassium channels. Atrial arrhythmogenesis, more specifically atrial fibrillation, can also occur due to structural alterations, which happens because of nicotine downregulating microRNAs 133 and 590, both post-transcriptional growth factor repressors. Liquid flavourings and the combination of PG and VG can possibly lead to arrhythmic events by exposing users to acrolein, an aldehyde that stimulates TRPA1 that in turn causes a change towards sympathetic activation and autonomic imbalance. The design of these electronic delivery devices is constantly changing; therefore, it has proven extremely difficult to study the long-term effects on the heart caused by electronic cigarettes but will be important to understand given their rising popularity. The arrhythmic effects of electronic cigarettes appear similar to traditional cigarettes as well; however, a comprehensive review has not been compiled and is the focus of this article.
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Affiliation(s)
- Carson A Jones
- Dorothy M. Davis Heart and Lung Research Institute, Wexner Medical Center, The Ohio State University, 473 W 12th Avenue, Columbus, OH 43210, USA
| | - Michael J Wallace
- Dorothy M. Davis Heart and Lung Research Institute, Wexner Medical Center, The Ohio State University, 473 W 12th Avenue, Columbus, OH 43210, USA
| | - Priya Bandaru
- Dorothy M. Davis Heart and Lung Research Institute, Wexner Medical Center, The Ohio State University, 473 W 12th Avenue, Columbus, OH 43210, USA
| | - Emerson D Woodbury
- Dorothy M. Davis Heart and Lung Research Institute, Wexner Medical Center, The Ohio State University, 473 W 12th Avenue, Columbus, OH 43210, USA
| | - Peter J Mohler
- Dorothy M. Davis Heart and Lung Research Institute, Wexner Medical Center, The Ohio State University, 473 W 12th Avenue, Columbus, OH 43210, USA
- Department of Internal Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Loren E Wold
- Dorothy M. Davis Heart and Lung Research Institute, Wexner Medical Center, The Ohio State University, 473 W 12th Avenue, Columbus, OH 43210, USA
- Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, 473 W 12th Avenue, Room 603, Columbus, OH 43210, USA
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12
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Mohamed AAR, Moustafa GG, El Bohy KM, Saber TM, Metwally MMM, El Desoukey Mohammed H, El-Far AH, Alotaibi BS, Alosaimi M, Abuzahrah SS, Alqahtani LS. Exploring cardiac impact of oral nicotine exposure in a transplantable Neoplasm Mice Model: Insights from biochemical analysis, morphometry, and molecular docking: Chlorella vulgaris green algae support. Toxicology 2023; 497-498:153629. [PMID: 37704175 DOI: 10.1016/j.tox.2023.153629] [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: 07/24/2023] [Revised: 09/02/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Abstract
Nicotine-induced cardiac tissue damage is a concern for cancer patients, but the exact pathogenesis from nicotine oral exposure is unclear. This study was designed to investigate the impact of nicotine and Chlorella vulgaris (Ch. V) on cardiac glutathione homeostasis, inflammatory response, cardiac damage markers, apoptotic proteins and histopathological findings in an experimentally transplantable neoplasm mouse model (Ehrlich ascites carcinoma; EAC). In the in-vivo experiment, the female Swiss mice were divided into four groups: control, Ch.V (100 mg/kg), Nicotine (100 µg/ml/kg), and a combination group ( Nocotine+ Ch.V) for 40 days. Furthermore, in this study,the effects of C. vulgaris components on caspase-3, TNF-α, and IL-1β activity were explored using Molecular Operating Environment (MOE) docking software to ensure its ability to counteract the toxic effects of nicotine. The results indicated that nicotine has induced significant (P < 0.001) cardiopathic alterations in EAC-bearing mice with changes in cardiac tissue enzymes. C. Vulgaris attenuated the nicotine-induced cardiac glutathione inhibition, suppressed the inflammatory response, exerted antiapoptotic effects, mitigated myocardial injury biomarkers, and repaired cellular and tissue damage. Moreover, the molecular docking results revealed the ability of C. vulgaris to bind with interleukin-1 receptor type 1 (IL1R1) and tumor necrosis factor receptor superfamily member 1 A (TNFRSF1A) in the mice tissues, ameliorating apoptosis and inflammatory processes associated with nicotine-induced cardiotoxicity. This study provides a model for understanding nicotine-induced myocardial injury during experimentally transplantable neoplasm. It highlights C. vulgaris as a beneficial food supplement for cancer patients exposed to nicotine orally.
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Affiliation(s)
- Amany Abdel-Rahman Mohamed
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Gihan G Moustafa
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Khlood M El Bohy
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Taghred M Saber
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Mohamed M M Metwally
- Department of pathology and clinical pathology, faculty of veterinary medicine, King Salman international University, Ras sudr، Egypt; Department of Pathology, Faculty of Veterinary Medicine, Zagazig University, Zagazig 44511, Egypt
| | - Heba El Desoukey Mohammed
- Specialist of Forensic Medicine and Toxicology, Veterinary Services, El Senbellawein, Dakahlia Governorate, Egypt
| | - Ali H El-Far
- Department of Biochemistry, Faculty of Veterinary Medicine, Damanhour University, Damanhour 22511, Egypt
| | - Badriyah S Alotaibi
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia.
| | - Manal Alosaimi
- Department of Basic Health Sciences, College of Medicine, Princess Nourah bint Abdulrahman University, P.O Box 84428, Riyadh 11671, Saudi Arabia
| | - Samah S Abuzahrah
- Department of Biological Sciences, College of Science, University of Jeddah, 21959, Saudi Arabia
| | - Leena S Alqahtani
- Department of Biochemistry, College of Science, University of Jeddah, Jeddah 23445, Saudi Arabia
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13
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Hamann SL, Kungskulniti N, Charoenca N, Kasemsup V, Ruangkanchanasetr S, Jongkhajornpong P. Electronic Cigarette Harms: Aggregate Evidence Shows Damage to Biological Systems. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6808. [PMID: 37835078 PMCID: PMC10572885 DOI: 10.3390/ijerph20196808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/25/2023] [Accepted: 09/15/2023] [Indexed: 10/15/2023]
Abstract
Evidence of the harms of e-cigarettes has been unfolding slowly and has been documented in many reviews and reports worldwide. A narrative review of new evidence is presented since, as research has continued, newly aggregated evidence of the dangers of electronic cigarettes on the brain, heart, and lungs is vital to inform decisions on restricting the use of e-cigarettes. Several biomedical research databases were searched for electronic cigarette health effects, emphasizing reviews, systematic reviews, and meta-analyses. Over 50 review studies, primarily in 2022 and 2023, illustrate some of the latest information on e-cigarette harms. Results show studies of respiratory, neurological, and cardiovascular effects. Researchers call for expanding studies through new methods to elaborate on initial findings of multiple harms emerging in clinical investigations. Since the use of electronic cigarettes for adult cessation is not sanctioned in most countries, it is clear that health authorities see significant costs to the health of the general population if the promotion and use of electronic cigarettes occur worldwide. Regulatory action to control electronic cigarettes should consider the substantial evidence of electronic cigarette harm.
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Affiliation(s)
- Stephen L. Hamann
- Tobacco Control Research and Knowledge Management Center, Bangkok 10400, Thailand; (S.L.H.); (V.K.); (S.R.); (P.J.)
| | - Nipapun Kungskulniti
- Faculty of Public Health, Mahidol University, Bangkok 10400, Thailand;
- Thailand Health Promotion Institute, Bangkok 10330, Thailand
| | - Naowarut Charoenca
- Faculty of Public Health, Mahidol University, Bangkok 10400, Thailand;
- Thailand Health Promotion Institute, Bangkok 10330, Thailand
| | - Vijj Kasemsup
- Tobacco Control Research and Knowledge Management Center, Bangkok 10400, Thailand; (S.L.H.); (V.K.); (S.R.); (P.J.)
| | - Suwanna Ruangkanchanasetr
- Tobacco Control Research and Knowledge Management Center, Bangkok 10400, Thailand; (S.L.H.); (V.K.); (S.R.); (P.J.)
| | - Passara Jongkhajornpong
- Tobacco Control Research and Knowledge Management Center, Bangkok 10400, Thailand; (S.L.H.); (V.K.); (S.R.); (P.J.)
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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14
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Fountoulakis P, Theofilis P, Tsalamandris S, Antonopoulos AS, Tsioufis P, Toutouzas K, Oikonomou E, Tsioufis K, Tousoulis D. The cardiovascular consequences of electronic cigarette smoking: a narrative review. Expert Rev Cardiovasc Ther 2023; 21:651-661. [PMID: 37755116 DOI: 10.1080/14779072.2023.2264179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/25/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION E-cigarettes have emerged as a popular alternative to traditional tobacco smoking in recent years. Despite their growing popularity, concerns have arisen regarding the cardiovascular implications of e-cigarette use. AREAS COVERED This narrative review aims to highlight the latest evidence on the impact of e-cigarettes on cardiovascular health. EXPERT OPINION Numerous studies have demonstrated that e-cigarette use can lead to acute adverse cardiovascular effects. Inhalation of e-cigarette aerosols exposes users to a wide range of potentially harmful substances that have been implicated in critical pathophysiologic pathways of cardiovascular disease, namely endothelial dysfunction, oxidative stress, inflammation, sympathetic overdrive, and arterial stiffness. While long-term epidemiological studies specifically focusing on the cardiovascular effects of e-cigarettes are still relatively scarce, early evidence suggests a potential association between e-cigarette use and an increased risk of adverse cardiovascular events. However, it is essential to recognize that e-cigarettes are relatively new products, and the full extent of their long-term cardiovascular impact has not been fully elucidated. In the meantime, promoting tobacco cessation strategies that are evidence-based and regulated, along with rigorous monitoring of e-cigarette use patterns and associated health outcomes, are essential steps in safeguarding cardiovascular health in the face of this emerging public health challenge.
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Affiliation(s)
- Petros Fountoulakis
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
| | - Panagiotis Theofilis
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
| | - Sotiris Tsalamandris
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
| | - Panagiotis Tsioufis
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
| | - Konstantinos Toutouzas
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
| | - Evangelos Oikonomou
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
- Cardiology Department, Sotiria Chest Diseases Hospital, University of Athens Medical School, Athens, Greece
| | - Konstantinos Tsioufis
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- Cardiology Department, Hippokration General Hospital, University of Athens Medical School, Athens, Greece
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