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Taylor E, Simonavičius E, McNeill A, Brose LS, East K, Marczylo T, Robson D. Exposure to Tobacco-Specific Nitrosamines Among People Who Vape, Smoke, or do Neither: A Systematic Review and Meta-Analysis. Nicotine Tob Res 2024; 26:257-269. [PMID: 37619211 PMCID: PMC10882431 DOI: 10.1093/ntr/ntad156] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Smoking exposes people to high levels of Tobacco-Specific Nitrosamines (TSNAs), which include potent carcinogens. We systematically reviewed TSNA exposure between people smoking, vaping, and doing neither. AIMS AND METHODS Databases were searched between August 2017-March 2022, using vaping-related terms. Peer-reviewed articles reporting TSNA metabolites (NNAL, NNN, NAB, and NAT) levels in bio-samples among adults exclusively vaping, exclusively smoking, or doing neither were included. Where possible, meta-analyses were conducted. RESULTS Of 12 781 identified studies, 22 were included. TSNA levels fell substantially when people who smoke switched to vaping in longitudinal studies and were lower among people who vaped compared to smoked in cross-sectional studies. Levels of TSNAs were similar when comparing people who switched from smoking to vaping, to those who switched to no use of nicotine products, in longitudinal studies. Levels were higher among people who vaped compared to people who neither vaped nor smoked in cross-sectional studies.When comparing people who vaped to smoked: pooled urinary NNAL was 79% lower across three randomized controlled trials and 96% lower across three cross-sectional studies; pooled NAB was 87% lower and NAT 94% lower in two cross-sectional studies. When comparing people who neither vaped nor smoked to people who vaped, pooled urinary NNAL was 80%, NAB 26%, and NAT 27% lower in two cross-sectional studies. Other longitudinal data, and NNN levels could not be pooled. CONCLUSIONS Exposure to all TSNAs was lower among people who vaped compared to people who smoked. Levels were higher among people who vaped compared to people who neither vaped nor smoked. IMPLICATIONS As well as TSNAs, there are many other toxicant exposures from smoking and vaping that can increase the risk of disease. However, it is likely that the reduced exposure to TSNAs from vaping relative to smoking reduces the risk to health of those who use vaping products to quit smoking. Future high-quality research, with robust definitions of exclusive vaping and smoking, and accounting for TSNAs half-lives, is needed to fully assess exposure to TSNAs among people who vape.
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Affiliation(s)
- Eve Taylor
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College, London, UK
- NIHR HPRU Environmental Exposures and Health, London, UK
| | - Erikas Simonavičius
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College, London, UK
| | - Ann McNeill
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College, London, UK
- NIHR HPRU Environmental Exposures and Health, London, UK
- SPECTRUM Consortium, London, UK
- NIHR ARC SouthLondon, Oxford, UK
| | - Leonie S Brose
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College, London, UK
- SPECTRUM Consortium, London, UK
| | - Katherine East
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College, London, UK
| | - Tim Marczylo
- NIHR HPRU Environmental Exposures and Health, London, UK
- Radiation, Chemical and Environmental Hazards, UK Health Security Agency (UKHSA)
| | - Debbie Robson
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College, London, UK
- NIHR HPRU Environmental Exposures and Health, London, UK
- SPECTRUM Consortium, London, UK
- NIHR ARC SouthLondon, Oxford, UK
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Mallock N, Schulz T, Malke S, Dreiack N, Laux P, Luch A. Levels of nicotine and tobacco-specific nitrosamines in oral nicotine pouches. Tob Control 2024; 33:193-199. [PMID: 38378209 DOI: 10.1136/tc-2022-057280] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 07/15/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Nicotine pouches without tobacco are new products that deliver nicotine into the body via the oral mucosa. There is a lack of independent research on the chemical composition and product characteristics of these products, contributing to uncertainties regarding product regulation. This study sought to address knowledge gaps by assessing levels of nicotine and screening for tobacco-specific nitrosamines (TSNAs) in a sample of these products. METHODS Nicotine pouches (n=44) and nicotine-free pouches (n=2) from 20 different manufacturers were analysed regarding their contents of nicotine and TSNAs by gas chromatography with flame ionisation and liquid chromatography-tandem mass spectrometry, respectively. Product labelling and pH values of aqueous extracts were determined. RESULTS Nicotine contents of products ranged from 1.79 to 47.5 mg/pouch; median product weight, pH, and proportion of free-base nicotine were 0.643 g, 8.8, and 86%, respectively. A clear labelling of the nicotine content was missing on 29 products and nicotine strength descriptions were ambiguous. TSNAs were detected in 26 products, with a maximum of 13 ng N-nitrosonornicotine/pouch. CONCLUSION Although nicotine pouches may potentially be a reduced risk alternative for cigarette smokers or users of some other oral tobacco products, nicotine contents of some pouches were alarmingly high. Presence of carcinogenic TSNAs in the nicotine pouches is of serious concern. Better manufacturing processes and quality control standards should be implemented. Labels of nicotine strength on most products are misleading. A strict regulation regarding nicotine contents and its labelling would be advisable.
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Affiliation(s)
- Nadja Mallock
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Thomas Schulz
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Sebastian Malke
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Nadine Dreiack
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Peter Laux
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Andreas Luch
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
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Gallagher KPD, Vargas PA, Santos-Silva AR. The use of E-cigarettes as a risk factor for oral potentially malignant disorders and oral cancer: a rapid review of clinical evidence. Med Oral Patol Oral Cir Bucal 2024; 29:e18-e26. [PMID: 37992145 PMCID: PMC10765326 DOI: 10.4317/medoral.26042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 09/25/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND The popularity of e-cigarettes has increased rapidly in the last decade, particularly among teens and young adults, being advertised as a less harmful alternative to conventional tobacco products. However, in vitro and in vivo studies have evidenced a variable quantity of potentially harmful components and some recognized carcinogens which may cause DNA damage in oral cells. Additionally, evidence suggests that e-cigarettes may play active roles in the pathogenesis of other malignancies, such as lung and bladder cancers. Therefore, this rapid review aimed to assess the available clinical evidence about using e-cigarettes as a risk factor for oral potentially malignant disorders (OPMD) and oral cancer. MATERIAL AND METHODS A systematic search for English language articles published was performed in PubMed (MEDLINE), Embase, Scopus, and Web of Science. After the study selection process, the authors included twelve clinical studies about OPMD and oral cancer risk in e-cigarette users. RESULTS The main findings showed the presence of carcinogenic compounds in saliva and morphologic changes, DNA damage, and molecular pathways related to carcinogenesis in the oral cells of e-cigarette users. However, results were inconsistent compared to tobacco smokers and control groups. CONCLUSIONS the current clinical evidence on this topic is limited and insufficient to support using e-cigarettes as a risk factor for OPMD and oral cancer. Nevertheless, dental care professionals should advise patients responsibly about the potentially harmful effects of e-cigarettes on the oral mucosa cells. Future long-term and well-designed clinical studies are needed.
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Affiliation(s)
- K-P-D Gallagher
- School of Dentistry, National University of Asunción (UNA), Paraguay
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Foster JA. Consideration of vaping products as an alternative to adult smoking: a narrative review. Subst Abuse Treat Prev Policy 2023; 18:67. [PMID: 37974269 PMCID: PMC10655401 DOI: 10.1186/s13011-023-00571-w] [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: 03/07/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023] Open
Abstract
Tobacco harm reduction is a public health approach to reduce the impact of cigarette smoking on individuals. Non-combustible alternatives to cigarettes, such as electronic cigarettes (e-cigarettes), deliver nicotine to the user in the absence of combustion. The absence of combustion in e-cigarettes reduces the level of harmful or potentially harmful chemicals in the aerosol generated. This narrative review examines the published literature that studied the chemistry of e-cigarette aerosols, the related toxicology in cell culture and animal models, as well as clinical studies that investigated short- and long-term changes in biomarkers of smoke exposure after switching to e-cigarettes. In the context of the literature reviewed, the evidence supports the harm reduction potential for adult smokers who switch to e-cigarettes.
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Affiliation(s)
- Jane A Foster
- Department of Psychiatry & Behavioural Neurosciences, St. Joseph's Healthcare, 50 Charlton Ave. E., Hamilton, ON, L8N 4A6, Canada.
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Auschwitz E, Almeda J, Andl CD. Mechanisms of E-Cigarette Vape-Induced Epithelial Cell Damage. Cells 2023; 12:2552. [PMID: 37947630 PMCID: PMC10650279 DOI: 10.3390/cells12212552] [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: 07/25/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023] Open
Abstract
E-cigarette use has been reported to affect cell viability, induce DNA damage, and modulate an inflammatory response resulting in negative health consequences. Most studies focus on oral and lung disease associated with e-cigarette use. However, tissue damage can be found in the cardio-vascular system and even the bladder. While the levels of carcinogenic compounds found in e-cigarette aerosols are lower than those in conventional cigarette smoke, the toxicants generated by the heat of the vaping device may include probable human carcinogens. Furthermore, nicotine, although not a carcinogen, can be metabolized to nitrosamines. Nitrosamines are known carcinogens and have been shown to be present in the saliva of e-cig users, demonstrating the health risk of e-cigarette vaping. E-cig vape can induce DNA adducts, promoting oxidative stress and DNA damage and NF-kB-driven inflammation. Together, these processes increase the transcription of pro-inflammatory cytokines. This creates a microenvironment thought to play a key role in tumorigenesis, although it is too early to know the long-term effects of vaping. This review considers different aspects of e-cigarette-induced cellular changes, including the generation of reactive oxygen species, DNA damage, DNA repair, inflammation, and the possible tumorigenic effects.
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Affiliation(s)
| | | | - Claudia D. Andl
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, FL 32816, USA
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Guo J, Hecht SS. DNA damage in human oral cells induced by use of e-cigarettes. Drug Test Anal 2023; 15:1189-1197. [PMID: 36169810 PMCID: PMC10043052 DOI: 10.1002/dta.3375] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/09/2022]
Abstract
The use of electronic cigarettes (e-cigarettes) has increased rapidly in the United States, especially among high school students. e-Cigarettes contain some recognized carcinogens and may induce DNA damage in oral cells. The aim of this review is to summarize studies reporting DNA adducts or other types of DNA damage in oral cells in vitro or in vivo upon exposure to e-cigarette vapor and to evaluate the possible connections between e-cigarette exposure and oral cancer. Three databases including PubMed, Scopus, and EMBASE and gray literature were searched for articles published up to April 24, 2022. After screening 321 articles, we extracted 27 for further investigation. Based on the inclusion criteria, 22 articles were eligible for this review. The in vitro studies demonstrate that e-cigarette liquid or vapor can induce DNA damage, oxidative stress, DNA double-stranded breaks, apoptosis, cytotoxicity, and genotoxicity in different types of oral cells. The clinical studies showed that e-cigarette users have significantly higher levels of N'-nitrosonornicotine, acrolein DNA adducts, metanuclear anomalies, gene regulation, and lactate dehydrogenase enzyme expression and significantly lower levels of apurinic/apyrimidinic sites than non-users. Comparison of micronuclei levels between e-cigarette users and non-users gave inconsistent results. e-Cigarettes are implicated in DNA damage to oral cells, but publications to date present limited evidence. Future studies with larger sample sizes are required to investigate the long-term consequences of e-cigarette use.
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Affiliation(s)
- Jiehong Guo
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Stephen S Hecht
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
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Sala M, Gotti C. Electronic nicotine delivery systems (ENDS): A convenient means of smoking? Pharmacol Res 2023; 195:106885. [PMID: 37634554 DOI: 10.1016/j.phrs.2023.106885] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/05/2023] [Accepted: 08/08/2023] [Indexed: 08/29/2023]
Abstract
Electronic nicotine delivery systems (ENDS), which are becoming increasingly popular in many parts of the world, have recently become more sophisticated in terms of their more active content and better controlled vaporisation. This review begins by describing how cigarette smoking led to the development of ENDS as a means of combatting nicotine addiction. ENDS are usually categorised as belonging to one of only three main generations, but a fourth has been added in order to differentiate the latest, most powerful, most advanced and innovative that have improved heating efficiency. Descriptions of the principal substances contained in ENDS are followed by considerations concerning the risk of toxicity due to the presence of albeit low concentrations of such a variety of compounds inhaled over a long time, and the increasingly widespread use of ENDS as a means of smoking illicit drugs. We also review the most widely used pharmacotherapeutic approaches to smoking cessation, and recent epidemiological data showing that ENDS can help some people to stop smoking. However, in order to ensure their appropriate regulation, there is a need for higher-quality evidence concerning the health effects and safety of ENDS, and their effectiveness in discouraging tobacco smoking.
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Affiliation(s)
- Mariaelvina Sala
- Institute of Neuroscience, CNR-Milan Unit, c/o Bldg. U28, University of Milano-Bicocca, Via Follereau 3, 20854 Vedano al Lambro, MB, Italy; NeuroMi Milan Center for Neuroscience University of Milano Bicocca,Italy.
| | - Cecilia Gotti
- Institute of Neuroscience, CNR-Milan Unit, c/o Bldg. U28, University of Milano-Bicocca, Via Follereau 3, 20854 Vedano al Lambro, MB, Italy; NeuroMi Milan Center for Neuroscience University of Milano Bicocca,Italy
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Pang Y, Li M, Li F, Lei J, Zhang T. Preliminary study on the E-liquid and aerosol on the neurobehavior of C. elegans. ENVIRONMENT INTERNATIONAL 2023; 179:108180. [PMID: 37690220 DOI: 10.1016/j.envint.2023.108180] [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: 05/19/2023] [Revised: 07/27/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023]
Abstract
E-cigarettes, also known as electronic nicotine delivery systems (ENDS), are mainly used among adolescents and young adults. Similar to traditional cigarettes, different concentrations of nicotine are also added to E-cigarette's liquid (E-liquid), but due to the supplementation of chemicals such as propylene glycol (PG), vegetable glycerin (VG) and flavors, it is difficult to determine the risk after using E-cigarettes. And given to the specificity of the aerosol particle composition and atomization process of E-cigarettes, it is necessary to assess the neurotoxic effects of long-term E-cigarettes use. In this study, two commercial nicotine-containing (5%) and nicotine-free E-liquids were diluted to investigate the neurobehavioral changes and addictive tendencies of developing C. elegans after sub-chronic exposure to E-liquid. The results showed that sub-chronic exposure of E-liquid could lead to impaired growth and development of nematodes, abnormal general neuromotor behavior and advanced learning and memory behavior, and nicotine-containing E-liquid could also lead to increased addiction tendency of nematodes. Although the damage effect of nicotine free E-liquid is smaller than that of the nicotine-containing group, its toxic effect cannot be ignored. Further analysis of the neurotoxicity mechanism found that redox imbalance-mediated mitochondrial stress and aging may be important causes of E-liquid-induced biological damage. The biosafety of e-cigarette aerosols was also included in the assessment. The study found that the heated atomization process did not alter the E-liquid components, and E-cigarette aerosols still have the effect of interfering with the growth and development of nematodes and neurobehavior, and its addictive nature is also of concern. This study can provide new ideas for future studies on the neurotoxic effects and safety assessment of the E-cigarettes, and provide theoretical reference for the study on the injury mechanism of E-cigarettes.
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Affiliation(s)
- Yanting Pang
- 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
| | - Fuxian Li
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing 210009, China
| | - Jialin Lei
- 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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Thiem DGE, Donkiewicz P, Rejaey R, Wiesmann-Imilowski N, Deschner J, Al-Nawas B, Kämmerer PW. The impact of electronic and conventional cigarettes on periodontal health-a systematic review and meta-analysis. Clin Oral Investig 2023; 27:4911-4928. [PMID: 37526741 PMCID: PMC10492702 DOI: 10.1007/s00784-023-05162-4] [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] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVES This systematic review and meta-analysis examined the effects of electronic cigarettes on periodontal health compared to conventional cigarette smoke and a non-smoking population. MATERIALS AND METHODS MEDLINE, Embase, Web of Science, CENTRAL, and ClinicalTrials.gov were screened for literature. Eligibility criteria included clinical studies published between 2006 and 2022 that compare e-cigarettes and conventional cigarettes on periodontal health (bleeding on probing (BoP), plaque index (PI), probing depth (PD), attachment loss (AL), marginal bone loss (MBL), tooth loss, molecular inflammation markers, salivary flow rate). Meta-regression analysis was used to examine the influence of moderator variables. RESULTS Sixteen studies were found to be eligible for qualitative synthesis. Individual analyses showed that cigarette smokers had significantly higher PI, PD, AL, and MBL and increased concentrations of proinflammatory mediators than e-cigarette users and non-smokers. Meta-analysis revealed a 0.33-fold lower chance for BoP in e-cigarette users compared to smokers (p = 0.03), whereby meta-regression failed to detect any effects regarding the age of users and frequency of smoking. A 0.01-fold decreased chance for positive BoP in e-cigarette users compared with non-smokers was seen (p < 0.01). CONCLUSIONS The current findings suggest that that e-cigarette use might be considered a healthier alternative to cigarette smoking concerning periodontal health. Even so, harmful effects of electronic nicotine delivery system (ENDS) usage on periodontal health were seen as well. However, a definitive decision on this research question remains elusive due to the absence of randomized controlled trials. CLINICAL RELEVANCE Electronic cigarettes, marketed as a safer alternative to traditional cigarettes, are becoming increasingly popular. Evidence on the use of electronic cigarettes as a cessation aid and its beneficial impact compared to cigarette smoke remains inconclusive, so the analysis conducted in this review addresses a recent question of high clinical relevance.
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Affiliation(s)
- Daniel G. E. Thiem
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Phil Donkiewicz
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
- Department of Periodontology and Operative Dentistry, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
- BioHorizons Camlog, Maybachstr. 5, 71299 Wimsheim, Germany
| | - Raha Rejaey
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Nadine Wiesmann-Imilowski
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - James Deschner
- Department of Periodontology and Operative Dentistry, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Peer W. Kämmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Center Mainz, Augustusplatz 2, 55131 Mainz, Germany
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Rodriguez J, Liang D, Tchen R, Yang I. Saliva and Exhaled Breath Condensate Correlate With Serum in 4-12-Year-Olds Exposed to Secondhand Electronic Cigarette Vapors: A Pilot Study. Biol Res Nurs 2023; 25:417-425. [PMID: 36637872 PMCID: PMC10404906 DOI: 10.1177/10998004221149959] [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] [Indexed: 01/14/2023]
Abstract
Electronic cigarette use is highest among adults of child-bearing age. Many parents that use electronic cigarettes believe that secondhand exposure of electronic cigarette vapors for their children is not dangerous and is less harmful than secondhand exposure to traditional cigarette smoke. These beliefs may prompt excessive secondhand exposure to electronic cigarette vapors for their children. Little research has been done to document exposure in children. The traditional biological method of exposure detection is through a blood draw, which is difficult and undesirable in children. The purpose of this study was to assess the feasibility of using saliva and exhaled breath condensate as non-invasive biomatrices for detecting secondhand electronic cigarette vapor exposure in children. In this cross-sectionally designed study, we recruited 22 children exposed to electronic cigarette vapors and 26 non-exposed between the ages of 4-12 years. We compared metabolic features across three biomatrices, blood, saliva, and exhaled breath condensate. We noted moderate to strong pairwise, sample-specific, and feature-specific adjusted correlations. Annotated features associated with direct and secondhand electronic cigarette exposure were noted. These results demonstrate that less invasive biomatrices may be used to detect features associated with secondhand electronic cigarette vapor exposure in children.
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Affiliation(s)
| | - Donghai Liang
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rachel Tchen
- Oak Ridge Institute for Science and Education and Agency for Toxic Substances and Disease Registry, Oak Ridge, TN, USA
| | - Irene Yang
- School of Nursing, Emory University, Atlanta, GA, USA
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Melero-Ollonarte JL, Lidón-Moyano C, Perez-Ortuño R, Fu M, Ballbè M, Martín-Sánchez JC, González-Marrón A, Cartanyà-Hueso À, Pascual JA, Fernández E, Martínez-Sánchez JM. Specific biomarker comparison in current smokers, e-cigarette users, and non-smokers. Addict Behav 2023; 140:107616. [PMID: 36680837 DOI: 10.1016/j.addbeh.2023.107616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/19/2022] [Accepted: 01/06/2023] [Indexed: 01/09/2023]
Abstract
INTRODUCTION This study aims to address the existing gap in the literature, while adding evidence, by comparing tobacco-specific biomarkers (cotinine and nitrosamines: NNK, NNAL, NNN), and other biomarkers of e-cigarette use (humectants: glycerol, 1,2-PD, 1,3-PD) according to five study groups. METHODS A pooling analysis including two different studies was conducted. In both analyses, we took saliva samples from smokers (n = 409) and non-smokers (n = 154), dual tobacco and e-cig users (n = 92), exclusive e-cig user with nicotine (n = 158), and exclusive e-cig users without nicotine (n = 38). We analyzed and compared the geometric means (GM) and geometric standard deviations (GSD) of the concentration of tobacco-specific biomarkers, and e-cigarette biomarkers among groups. We used log-linear models adjusted for sex and age to model the change percentage and their 95% confidence intervals. RESULTS Cotinine was significantly higher in nicotine consumers and in e-cigarette users without nicotine when compared to non-smokers. TSNAs were generally significantly lower in non-smokers and higher in nicotine consumers. NNN and NNAL were lower in e-cigarette users with nicotine comparted to smokers, and NNN was higher in e-cigarette users without nicotine when compared to non-smokers. No differences were found in humectant biomarkers between e-cigarette groups. CONCLUSIONS Although there was a reduction in TSNAs in e-cigarette exclusive users compared to smokers, and a reduction of cotinine concentrations in e-cigarette exclusive users without nicotine compared to smokers, there are still high levels of these biomarkers when compared to non-smokers, which may be a clue towards the harmful effect of e-cigarettes.
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Affiliation(s)
- Juan Luis Melero-Ollonarte
- Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain
| | - Cristina Lidón-Moyano
- Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain.
| | - Raúl Perez-Ortuño
- Group of Integrative Pharmacology and Systems Neuroscience, Neurosciences Programme, IMIM (Hospital del Mar Medical Research Institute), Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain
| | - Marcela Fu
- Tobacco Control Unit, Cancer Prevention and Control Program, Institut Català d'Oncologia, l'Hospitalet de Llobregat, Barcelona, Spain; Tobacco Control Research Group, Epidemiology, Public Health, Cancer Prevention and Palliative Care Programme, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, l'Hospitalet de Llobregat, Barcelona, Spain; Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Medicine and Health Sciences - Bellvitge Campus, Universitat de Barcelona, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Montse Ballbè
- Tobacco Control Unit, Cancer Prevention and Control Program, Institut Català d'Oncologia, l'Hospitalet de Llobregat, Barcelona, Spain; Tobacco Control Research Group, Epidemiology, Public Health, Cancer Prevention and Palliative Care Programme, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, l'Hospitalet de Llobregat, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Addictions Unit, Institute of Neurosciences, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Juan Carlos Martín-Sánchez
- Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain
| | - Adrián González-Marrón
- Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain
| | - Àurea Cartanyà-Hueso
- Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain; Group of Perinatal Epidemiology, Environmental Health, and Clinical Research, Department of Medicine, School of Health Sciences, Universitat Jaume I, Av. Vicent Sos Baynat, s/n 12071 Castelló de la Plana, Spain
| | - José A Pascual
- Group of Integrative Pharmacology and Systems Neuroscience, Neurosciences Programme, IMIM (Hospital del Mar Medical Research Institute), Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain; Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain
| | - Esteve Fernández
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences - Bellvitge Campus, Universitat de Barcelona, Barcelona, Spain; Tobacco Control Research Group, Epidemiology, Public Health, Cancer Prevention and Palliative Care Programme, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, l'Hospitalet de Llobregat, Barcelona, Spain; Department of Public Health, Mental Health, and Maternal and Child Health Nursing, Faculty of Medicine and Health Sciences - Bellvitge Campus, Universitat de Barcelona, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Jose M Martínez-Sánchez
- Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain; Tobacco Control Unit, Cancer Prevention and Control Program, Institut Català d'Oncologia, l'Hospitalet de Llobregat, Barcelona, Spain; Tobacco Control Research Group, Epidemiology, Public Health, Cancer Prevention and Palliative Care Programme, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, l'Hospitalet de Llobregat, Barcelona, Spain
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12
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Maan M, Abuzayeda M, Kaklamanos EG, Jamal M, Dutta M, Moharamzadeh K. Molecular insights into the role of electronic cigarettes in oral carcinogenesis. Crit Rev Toxicol 2023; 53:1-14. [PMID: 37051806 DOI: 10.1080/10408444.2023.2190764] [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: 04/14/2023]
Abstract
Electronic cigarette (EC) usage or vaping has seen a significant rise in recent years across various parts of the world. They have been publicized as a safe alternative to smoking; however, this is not supported strongly by robust research evidence. Toxicological analysis of EC liquid and aerosol has revealed presence of several toxicants with known carcinogenicity. Oral cavity is the primary site of exposure of both cigarette smoke and EC aerosol. Role of EC in oral cancer is not as well-researched as that of traditional smoking. However, several recent studies have shown that it can lead to a wide range of potentially carcinogenic molecular events in oral cells. This review delineates the oral carcinogenesis potential of ECs at the molecular level, providing a summary of the effects of EC usage on cancer therapy resistance, cancer stem cells (CSCs), immune evasion, and microbiome dysbiosis, all of which may lead to increased tumor malignancy and poorer patient prognosis. This review of literature indicates that ECs may not be as safe as they are perceived to be, however further research is needed to definitively determine their oncogenic potential.
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Affiliation(s)
- Meenu Maan
- Hamdan Bin Mohammed College of Dental Medicine (HBMCDM), Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, UAE
| | - Moosa Abuzayeda
- Hamdan Bin Mohammed College of Dental Medicine (HBMCDM), Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, UAE
| | - Eleftherios G Kaklamanos
- Hamdan Bin Mohammed College of Dental Medicine (HBMCDM), Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, UAE
- School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece
- School of Dentistry, European University Cyprus, Nicosia, Cyprus
| | - Mohamed Jamal
- Hamdan Bin Mohammed College of Dental Medicine (HBMCDM), Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, UAE
| | - Mainak Dutta
- Department of Biotechnology, BITS Pilani, Dubai Campus, Academic City, Dubai, UAE
| | - Keyvan Moharamzadeh
- Hamdan Bin Mohammed College of Dental Medicine (HBMCDM), Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, UAE
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
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13
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Soo J, Easwaran M, Erickson‐DiRenzo E. Impact of Electronic Cigarettes on the Upper Aerodigestive Tract: A Comprehensive Review for Otolaryngology Providers. OTO Open 2023; 7:e25. [PMID: 36998560 PMCID: PMC10046796 DOI: 10.1002/oto2.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/18/2022] [Accepted: 12/02/2022] [Indexed: 02/19/2023] Open
Abstract
Objective The use and effects of electronic (e)-cigarettes (e-cigs) are particularly relevant for otolaryngology providers as tobacco plays a major role in benign and malignant diseases of the upper aerodigestive tract. This review aims to (1) summarize the recent policies regarding e-cigs and important patterns of use and (2) serve as a comprehensive resource for clinical providers on the known biologic and clinical effects of e-cigs on the upper aerodigestive tract. Data Sources PubMed/MEDLINE. Review Methods We conducted a narrative review on (1) general information on e-cig use and informative findings in the lower respiratory system and a comprehensive review on (2) the effects of e-cigs on cell and animal models and the clinical implications of these products on human health as is relevant to otolaryngology. Conclusions Although e-cigs are likely less harmful than conventional cigarettes, preliminary research on e-cigs suggest several deleterious effects including in the upper aerodigestive tract. Due to this, there has been increased interest in restricting e-cig usage, particularly among the adolescent population, and caution in recommending e-cigs to current smokers. Implications for Practice Chronic e-cig use is likely to have clinical implications. It is critical for otolaryngology providers to be aware of the rapidly changing regulations and use patterns regarding e-cigs and how e-cigs influence human health, particularly with regards to the upper aerodigestive tract, to accurately council patients regarding potential risks and benefits of use.
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Affiliation(s)
- Joanne Soo
- Department of Otolaryngology–Head & Neck Surgery Stanford University School of Medicine Stanford California USA
| | - Meena Easwaran
- Department of Otolaryngology–Head & Neck Surgery Stanford University School of Medicine Stanford California USA
| | - Elizabeth Erickson‐DiRenzo
- Department of Otolaryngology–Head & Neck Surgery Stanford University School of Medicine Stanford California USA
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14
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Herbst RS, Hatsukami D, Acton D, Giuliani M, Moushey A, Phillips J, Sherwood S, Toll BA, Viswanath K, Warren NJH, Warren GW, Alberg AJ. Electronic Nicotine Delivery Systems: An Updated Policy Statement From the American Association for Cancer Research and the American Society of Clinical Oncology. J Clin Oncol 2022; 40:4144-4155. [PMID: 36287017 DOI: 10.1200/jco.22.01749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Combustible tobacco use has reached historic lows, demonstrating the importance of proven strategies to reduce smoking since publication of the 1964 Surgeon General's report. In contrast, the use of electronic nicotine delivery systems (ENDS), specifically e-cigarettes, has grown to alarming rates and threatens to hinder progress against tobacco use. A major concern is ENDS use by youth and adults who never previously used tobacco. While ENDS emit fewer carcinogens than combustible tobacco, preliminary evidence links ENDS use to DNA damage and inflammation, key steps in cancer development. Furthermore, high levels of nicotine can also increase addiction, raise blood pressure, interfere with brain development, and suppress the immune system. The magnitude of long-term health risks will remain unknown until longitudinal studies are completed. ENDS have been billed as a promising tool for combustible tobacco cessation, but further evidence is needed to assess their potential efficacy for adults who smoke. Of concern, epidemiological studies estimate that approximately 15%-42% of adults who use ENDS have never used another tobacco product, and another 36%-54% dual use both ENDS and combustible tobacco. This policy statement details advances in science related to ENDS and calls for urgent action to end predatory practices of the tobacco industry and protect public health. Importantly, we call for an immediate ban on all non-tobacco-flavored ENDS products that contain natural or synthetic nicotine to reduce ENDS use by youth and adults who never previously used tobacco. Concurrently, evidence-based treatments to promote smoking cessation and prevent smoking relapse to reduce cancer incidence and improve public health remain top priorities for our organizations. We also recognize there is an urgent need for research to understand the relationship between ENDS and tobacco-related disparities.
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Affiliation(s)
- Roy S Herbst
- Yale Comprehensive Cancer Center, Yale School of Medicine, New Haven, CT
| | | | - Dana Acton
- American Association for Cancer Research, Washington, DC
| | | | - Allyn Moushey
- American Society of Clinical Oncology, Alexandria, VA
| | | | | | | | | | | | | | - Anthony J Alberg
- Arnold School of Public Health, University of South Carolina, Columbia, SC
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15
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Herbst RS, Hatsukami D, Acton D, Giuliani M, Moushey A, Phillips J, Sherwood S, Toll BA, Viswanath K, Warren NJH, Warren GW, Alberg AJ. Electronic Nicotine Delivery Systems: An Updated Policy Statement from the American Association for Cancer Research and the American Society of Clinical Oncology. Clin Cancer Res 2022; 28:4861-4870. [PMID: 36287033 DOI: 10.1158/1078-0432.ccr-22-2429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/01/2022] [Indexed: 01/24/2023]
Abstract
Combustible tobacco use has reached historic lows, demonstrating the importance of proven strategies to reduce smoking since publication of the 1964 Surgeon General's report. In contrast, the use of electronic nicotine delivery systems (ENDS), specifically e-cigarettes, has grown to alarming rates and threatens to hinder progress against tobacco use. A major concern is ENDS use by youth and adults who never previously used tobacco. While ENDS emit fewer carcinogens than combustible tobacco, preliminary evidence links ENDS use to DNA damage and inflammation, key steps in cancer development. Furthermore, high levels of nicotine can also increase addiction, raise blood pressure, interfere with brain development, and suppress the immune system. The magnitude of long-term health risks will remain unknown until longitudinal studies are completed. ENDS have been billed as a promising tool for combustible tobacco cessation, but further evidence is needed to assess their potential efficacy for adults who smoke. Of concern, epidemiological studies estimate that approximately 15% to 42% of adults who use ENDS have never used another tobacco product, and another 36% to 54% "dual use" both ENDS and combustible tobacco. This policy statement details advances in science related to ENDS and calls for urgent action to end predatory practices of the tobacco industry and protect public health. Importantly, we call for an immediate ban on all non-tobacco-flavored ENDS products that contain natural or synthetic nicotine to reduce ENDS use by youth and adults who never previously used tobacco. Concurrently, evidence-based treatments to promote smoking cessation and prevent smoking relapse to reduce cancer incidence and improve public health remain top priorities for our organizations. We also recognize there is an urgent need for research to understand the relationship between ENDS and tobacco-related disparities.
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Affiliation(s)
- Roy S Herbst
- Yale Comprehensive Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | | | - Dana Acton
- American Association for Cancer Research, Washington, D.C
| | | | - Allyn Moushey
- American Society of Clinical Oncology, Alexandria, Virginia
| | | | | | - Benjamin A Toll
- Medical University of South Carolina, Charleston, South Carolina
| | | | | | - Graham W Warren
- Medical University of South Carolina, Charleston, South Carolina
| | - Anthony J Alberg
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
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16
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Research progress of N-nitrosamine detection methods: a review. Bioanalysis 2022; 14:1123-1135. [PMID: 36125029 DOI: 10.4155/bio-2022-0091] [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: 11/17/2022] Open
Abstract
N-Nitrosamines (nitrosamines) are attracting increased attention because of their high toxicity and wide distribution. They have been strictly restricted by regulations in many fields. Researchers around the world have conducted substantial work on nitrosamine detection. This paper reviews the progress of research on nitrosamine detection methods with emphasis on biological-matrix samples. After introducing the category, toxicity, regulatory limit and source of nitrosamines, the paper discusses the most commonly used sample-preparation techniques and instrumental-detection techniques for nitrosamine detection, including some typical application cases.
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17
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Asfar T, Jebai R, Li W, Oluwole OJ, Ferdous T, Gautam P, Schmidt M, Noar SM, Lindblom EN, Eissenberg T, Bursac Z, Vallone D, Maziak W. Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies. Tob Control 2022:tobaccocontrol-2022-057495. [PMID: 36252567 PMCID: PMC10043882 DOI: 10.1136/tc-2022-057495] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/30/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES This umbrella review aims to summarise the evidence about electronic nicotine delivery systems' (ENDS) risk and safety health profile to inform ENDS health communication strategies. DATA SOURCES AND STUDY SELECTION Six databases were searched for systematic reviews presenting evidence on ENDS-related health effects. Ninety reviews divided into five categories were included: toxicity=20, health effects=40, role in smoking cessation=24, role in transition to combustible cigarettes (CCs)=13 and industry marketing claims=4. DATA EXTRACTION Findings were synthesised in narrative summaries. Meta-analyses were conducted by study type when appropriate. Quality assessment was conducted using the Measurement Tool to Assess Systematic Reviews. The Institute of Medicine's Levels of Evidence Framework was used to classify the evidence into high-level, moderate, limited-suggestive and limited-not-conclusive. DATA SYNTHESIS We found high-level evidence that ENDS exposes users to toxic substances; increases the risk of respiratory disease; leads to nicotine dependence; causes serious injuries due to explosion or poisoning; increases smoking cessation in clinical trials but not in observational studies; increases CC initiation; and exposure to ENDS marketing increases its use/intention to use. Evidence was moderate for ENDS association with mental health and substance use, limited-suggestive for cardiovascular, and limited-not-conclusive for cancer, ear, ocular and oral diseases, and pregnancy outcomes. CONCLUSIONS As evidence is accumulating, ENDS communication can focus on high-level evidence on ENDS association with toxicity, nicotine addiction, respiratory disease, ENDS-specific harm (explosion, poisoning) and anti-ENDS industry sentiment. Direct comparison between the harm of CCs and ENDS should be avoided. PROSPERO REGISTRATION NUMBER CRD42021241630.
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Affiliation(s)
- Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rime Jebai
- Robert Stempel College of Public Health and Social Work, Department of Epidemiology, Florida International University, Miami, FL, USA
| | - Wei Li
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Olusanya Joshua Oluwole
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tarana Ferdous
- Robert Stempel College of Public Health and Social Work, Department of Epidemiology, Florida International University, Miami, FL, USA
| | - Prem Gautam
- Robert Stempel College of Public Health and Social Work, Department of Epidemiology, Florida International University, Miami, FL, USA
| | - Michael Schmidt
- Department of Art, The University of Memphis, Memphis, TN, USA
| | - Seth M Noar
- Hussman School of Journalism and Media, University of North Carolina System, Chapel Hill, NC, USA
| | - Eric N Lindblom
- O'Neill Institute for National & Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Thomas Eissenberg
- Psychology and Institute for Drug/Alcohol Studies, Virginia Commonwealth University, Richmond, VA, USA
| | - Zoran Bursac
- Biostatistics, Florida International University, Robert Stempel College of Public Health and Social Work, Miami, FL, USA
| | - Donna Vallone
- Schroeder Institute, Truth Initiative, Washington, DC, USA
- Truth Initiative Schroeder Institute, New York University College of Global Public Health, New York, NY, USA
| | - Wasim Maziak
- Epidemiology, Florida International University, Robert Stempel College of Public Health and Social Work, Miami, FL, USA
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18
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Li Y, Hecht SS. Mass Spectrometric Quantitation of N'-Nitrosonornicotine-1 N-oxide in the Urine of Cigarette Smokers and Smokeless Tobacco Users. Chem Res Toxicol 2022; 35:1579-1588. [PMID: 36006857 DOI: 10.1021/acs.chemrestox.2c00195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
N'-Nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), which always occur together and are present exclusively in tobacco products, are classified as "carcinogenic to humans" (Group 1) by the International Agency for Research on Cancer. While 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) serves as an excellent biomarker for NNK exposure, the currently available biomarker for NNN exposure is urinary "total NNN" (free NNN plus its N-glucuronide). Quantitation of urinary NNN requires extensive precautions to prevent artifactual formation of NNN resulting from nitrosation of nornicotine during analysis. NNN itself can also be formed endogenously by the same nitrosation reaction, which may sometimes cause an overestimation of exposure to preformed NNN. It is thus important to develop an alternative biomarker to specifically reflect NNN metabolic fate and facilitate relevant cancer etiology studies. In this study, we report the first detection of N'-nitrosonornicotine-1N-oxide (NNN-N-oxide) in human urine. Using a highly specific and sensitive MS3 transition-based method, NNN-N-oxide was quantified with a mean level of 8.40 ± 6.04 fmol/mL in the urine of 10 out of 32 cigarette smokers. It occurred in a substantially higher level in the urine of 13 out of 14 smokeless tobacco users, amounting to a mean concentration of 85.2 ± 96.3 fmol/mL urine. No NNN-N-oxide was detected in any of the nonsmoker urine samples analyzed (n = 20). The possible artifactual formation of NNN-N-oxide during sample preparation steps was excluded by experiments using added ammonium sulfamate. The low levels of NNN-N-oxide in the urine of tobacco users indicate that the pyridine N-oxidation pathway represents a minor detoxification pathway of NNN, which further supports the importance of the α-hydroxylation pathway of NNN metabolic activation in humans.
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Affiliation(s)
- Yupeng Li
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota 55455, United States.,Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Stephen S Hecht
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota 55455, United States
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19
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Li Y, Hecht SS. Metabolism and DNA Adduct Formation of Tobacco-Specific N-Nitrosamines. Int J Mol Sci 2022; 23:5109. [PMID: 35563500 PMCID: PMC9104174 DOI: 10.3390/ijms23095109] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 01/06/2023] Open
Abstract
The tobacco-specific N-nitrosamines 4-(N-nitrosomethylamino)-1-(3-pyridyl)-1-butanone (NNK) and N'-nitrosonornicotine (NNN) always occur together and exclusively in tobacco products or in environments contaminated by tobacco smoke. They have been classified as "carcinogenic to humans" by the International Agency for Research on Cancer. In 1998, we published a review of the biochemistry, biology and carcinogenicity of tobacco-specific nitrosamines. Over the past 20 years, considerable progress has been made in our understanding of the mechanisms of metabolism and DNA adduct formation by these two important carcinogens, along with progress on their carcinogenicity and mutagenicity. In this review, we aim to provide an update on the carcinogenicity and mechanisms of the metabolism and DNA interactions of NNK and NNN.
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Affiliation(s)
- Yupeng Li
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA;
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA
| | - Stephen S. Hecht
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA;
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20
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Catala-Valentin A, Bernard JN, Caldwell M, Maxson J, Moore SD, Andl CD. E-Cigarette Aerosol Exposure Favors the Growth and Colonization of Oral Streptococcus mutans Compared to Commensal Streptococci. Microbiol Spectr 2022; 10:e0242121. [PMID: 35377225 PMCID: PMC9045065 DOI: 10.1128/spectrum.02421-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/02/2022] [Indexed: 11/20/2022] Open
Abstract
E-cigarettes (e-cigs) have drastically increased in popularity during the last decade, especially among teenagers. While recent studies have started to explore the effect of e-cigs in the oral cavity, little is known about their effects on the oral microbiota and how they could affect oral health and potentially lead to disease, including periodontitis and head and neck cancers. To explore the impact of e-cigs on oral bacteria, we selected members of the genus Streptococcus, which are abundant in the oral cavity. We exposed the commensals Streptococcus sanguinis and Streptococcus gordonii and the opportunistic pathogen Streptococcus mutans, best known for causing dental caries, to e-liquids and e-cig aerosols with and without nicotine and with and without menthol flavoring and measured changes in growth patterns and biofilm formation. Our results demonstrate that e-cig aerosols hindered the growth of S. sanguinis and S. gordonii, while they did not affect the growth of S. mutans. We also show that e-cig aerosols significantly increased biofilm formation by S. mutans but did not affect the biofilm formation of the two commensals. We found that S. mutans exhibits higher hydrophobicity and coaggregation abilities along with higher attachment to OKF6 cells than S. sanguinis and S. gordonii. Therefore, our data suggest that e-cig aerosols have the potential to dysregulate oral bacterial homeostasis by suppressing the growth of commensals while enhancing the biofilm formation of the opportunistic pathogen S. mutans. This study highlights the importance of understanding the consequences of e-cig aerosol exposure on selected commensals and pathogenic species. Future studies modeling more complex communities will provide more insight into how e-cig aerosols and vaping affect the oral microbiota. IMPORTANCE Our study shows that e-cigarette aerosol exposure of selected bacteria known to be residents of the oral cavity hinders the growth of two streptococcal commensals while enhancing biofilm formation, hydrophobicity, and attachment for the pathogen S. mutans. These results indicate that e-cigarette vaping could open a niche for opportunistic bacteria such as S. mutans to colonize the oral cavity and affect oral health.
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Affiliation(s)
- Alma Catala-Valentin
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Joshua N. Bernard
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Matthew Caldwell
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Jessica Maxson
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Sean D. Moore
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Claudia D. Andl
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
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21
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Scherer G, Scherer M, Mütze J, Hauke T, Pluym N. Assessment of the Exposure to Tobacco-Specific Nitrosamines and Minor Tobacco Alkaloids in Users of Various Tobacco/Nicotine Products. Chem Res Toxicol 2022; 35:684-693. [PMID: 35298128 DOI: 10.1021/acs.chemrestox.2c00020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Tobacco-specific nitrosamines (TSNAs), in particular, the human carcinogens 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N'-nitrosonornicotine (NNN), are important toxicants in tobacco and also (as contaminants) in nicotine products. In a clinical study comprising a period of 74 h under confinement, we investigated the exposure to NNK, NNN, N'-nitrosoanabasine (NAB), and N'-nitrosoanatabine (NAT) as well as to the minor tobacco alkaloids anabasine (AB) and anatabine (AT) by measuring suitable biomarkers in habitual users of combustible cigarettes (CCs), electronic cigarettes (ECs), heated tobacco products (HTPs), oral tobacco (OT), and nicotine replacement therapy products (NRTs). Non-users (NU) of any tobacco/nicotine products served as the (negative) control group. Smokers exhibited the highest levels for all biomarkers measured, except for AB in urine, which was found to be highest in OT users. Somewhat elevated levels compared to NU, EC, and NRT groups were also observed in the users of HTPs. In the users of tobacco-containing products (CC, HTP, and OT), most frequently the biomarkers significantly correlated with the dose markers such as daily consumption, urinary nicotine equivalents (Nequ), and plasma cotinine (CotP). In conclusion, except for smokers (CC) and OT users, exposure of users of ECs, HTPs, and NRTs to TSNAs as well as the minor tobacco alkaloids AB and AT is marginal and statistically not distinguishable from that of NU. Finally, our results for NNN in the saliva provide preliminary evidence for the formation of NNN from the precursor nornicotine in the presence of thiocyanate as a catalyst. The latter hypothesis requires experimental verification.
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Affiliation(s)
- Gerhard Scherer
- ABF, Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstraße 5, 82152 Planegg, Germany
| | - Max Scherer
- ABF, Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstraße 5, 82152 Planegg, Germany
| | - Janina Mütze
- ABF, Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstraße 5, 82152 Planegg, Germany
| | - Tobias Hauke
- ABF, Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstraße 5, 82152 Planegg, Germany
| | - Nikola Pluym
- ABF, Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstraße 5, 82152 Planegg, Germany
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22
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Pluym N, Scherer G, Edmiston JS, Jin XC, Sarkar M, Scherer M. Assessment of the Exposure to NNN in the Plasma of Smokeless Tobacco Users. Chem Res Toxicol 2022; 35:663-669. [PMID: 35298127 PMCID: PMC9019808 DOI: 10.1021/acs.chemrestox.1c00431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Indexed: 01/10/2023]
Abstract
N-Nitrosonornicotine (NNN) is a human carcinogen present in cigarette smoke and smokeless tobacco. Urinary NNN is usually measured in order to assess the exposure to this toxicant for tobacco users. NNN excretion in urine can be highly biased due to the formation of NNN by nitrosation of nornicotine under acidic conditions, both endogenously and exogenously. Hence, urinary NNN levels may not necessarily correctly reflect the product-specific exposure. Measurement of plasma NNN may be less prone to endogenous formation due to the stable pH (7.4) of blood. We developed an LC-MS/MS method for the quantification of NNN using 1 mL of human plasma. Validation according to FDA guidelines proved that the method is selective and highly sensitive with an LLOQ of 0.3 pg/mL. Accuracy and precision averaged to 98.7 and 7.5% (CV), respectively. The assay was applied to plasma samples collected from 10 experienced moist smokeless tobacco users during and after a single use of 2 g of the product for 40 min under controlled use conditions. Blood was drawn at 15 time points over a 6 h time course. The maximum NNN concentration (Cmax) ranged from 3.5 to 10 pg/mL (mean: 7.1 pg/mL) at a tmax of 32 min. Plasma NNN and nicotine were found to have similar time courses. In conclusion, the determination of NNN in plasma may be fit-for-purpose to evaluate the product-use-specific exposure to this carcinogen.
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Affiliation(s)
- Nikola Pluym
- ABF,
Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstraße 5, 82152 Planegg, Germany
| | - Gerhard Scherer
- ABF,
Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstraße 5, 82152 Planegg, Germany
| | - Jeffery S. Edmiston
- Altria
Client Services LLC. Center for Research and Technology, 601 East Jackson Street, Richmond, Virginia 23219, United States
| | - Xiaohong C. Jin
- Altria
Client Services LLC. Center for Research and Technology, 601 East Jackson Street, Richmond, Virginia 23219, United States
| | - Mohamadi Sarkar
- Altria
Client Services LLC. Center for Research and Technology, 601 East Jackson Street, Richmond, Virginia 23219, United States
| | - Max Scherer
- ABF,
Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstraße 5, 82152 Planegg, Germany
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23
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Chang YJ, Muthukumaran RB, Chen JL, Chang HY, Hung YC, Hu CW, Chao MR. Simultaneous determination of areca nut- and tobacco-specific alkaloids in saliva by LC-MS/MS: Distribution and transformation of alkaloids in oral cavity. JOURNAL OF HAZARDOUS MATERIALS 2022; 426:128116. [PMID: 34968842 DOI: 10.1016/j.jhazmat.2021.128116] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 06/14/2023]
Abstract
Areca nut and tobacco are frequently used in combination. Cigarette smoking and betel quid (BQ) chewing habits impose greater oral cancer risk than either habit alone. Saliva is a better noninvasive diagnostic material as it is in direct contact with oral mucosa and cancerous lesions. This study describes the application of isotope-dilution LC-MS/MS for simultaneous quantitation of five areca nut-specific alkaloids (ASAs) and three tobacco-specific alkaloids (TSAs) in human saliva. With this method, we demonstrate that the distribution of ASAs vary significantly in smokers who chew BQ habitually, due to the hydrolysis of ASAs and metabolic activity in the oral cavity. The alkaline condition formed due to slaked lime in BQ, plays an important role in the distribution of ASAs and TSAs, by catalyzing the hydrolysis of ester forms of ASAs to their respective carboxylic acid forms besides facilitating the TSA (i.e., nicotine) absorption in the oral cavity. Moreover, our results reveal that oral mucosa rather than saliva contributes to the metabolism of ASAs at oral cavity. Less than 2.1% of ASAs were metabolized by saliva, as determined by in vitro test. Our findings may provide a better insight into the pathobiology of oral carcinogenesis due to BQ chewing.
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Affiliation(s)
- Yuan-Jhe Chang
- Department of Occupational Safety and Health, Chung Shan Medical University, Taichung 402, Taiwan; Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | | | - Jian-Lian Chen
- School of Pharmacy, China Medical University, Taichung 404, Taiwan
| | - Hsin-Yi Chang
- Department of Public Health, Chung Shan Medical University, Taichung 402, Taiwan
| | - Yu-Cheng Hung
- Department of Public Health, Chung Shan Medical University, Taichung 402, Taiwan
| | - Chiung-Wen Hu
- Department of Public Health, Chung Shan Medical University, Taichung 402, Taiwan.
| | - Mu-Rong Chao
- Department of Occupational Safety and Health, Chung Shan Medical University, Taichung 402, Taiwan; Department of Occupational Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan.
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24
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Vaping-Associated Lung Injury: A Review. Medicina (B Aires) 2022; 58:medicina58030412. [PMID: 35334588 PMCID: PMC8949983 DOI: 10.3390/medicina58030412] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/01/2022] [Accepted: 03/07/2022] [Indexed: 11/16/2022] Open
Abstract
Since commercial development in 2003, the usage of modern electronic cigarette (e-cigarette) continues to increase amongst people who have never smoked, ex-smokers who have switched to e-cigarettes, and dual-users of both conventional cigarettes and e-cigarettes. With such an increase in use, knowledge of the irritative, toxic and potential carcinogenic effects on the lungs is increasing. This review article will discuss the background of e-cigarettes, vaping devices and explore their popularity. We will further summarise the available literature describing the mechanism of lung injury caused by e-cigarette or vaping use.
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25
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E-Cigarette Aerosols Promote Oral S. aureus Colonization by Delaying an Immune Response and Bacterial Clearing. Cells 2022; 11:cells11050773. [PMID: 35269394 PMCID: PMC8909134 DOI: 10.3390/cells11050773] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 12/13/2022] Open
Abstract
E-cigarette (e-cig) vapor has been shown to play a pathological role in oral health and alter the oral microbiota, providing growth advantages for opportunistic pathogens. Enrichment of Staphylococcus aureus, a commensal resident in the oral cavity, correlates with the progression of periodontal disease, suggesting a role as an opportunistic pathogen. Environmental conditions, such as cigarette smoke, are known to increase S. aureus virulence, yet the role of S. aureus in periodontitis and oral preneoplasia is unknown. We exposed oral epithelial cells to e-cig aerosols and showed a dose-dependent cell viability reduction, regardless of nicotine content, in a possible attempt to repair DNA damage, as measured by pH2AX. S. aureus attachment to oral epithelial cells and bacterial biofilm formation were enhanced upon e-cig exposure, indicating an increased capacity for oral colonization. Mechanistically, e-cig aerosol exposure resulted in an immunosuppression, as determined by a reduction in IL8, IL6, and IL1β secretion by oral epithelial cells during co-culture with S. aureus. Consistent with this, e-cig vape reduced the oral epithelial cell clearance of S. aureus. Furthermore, we observed an increased expression of the inflammatory regulator COX2. This work suggests that e-cigs promote S. aureus colonization and modulate the oral inflammatory response, possibly promoting oral periodontitis and preneoplasia.
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26
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Besaratinia A. From Tobacco Cigarettes to Electronic Cigarettes: The Two Sides of a Nicotine Coin. FRONTIERS IN ORAL HEALTH 2022; 2:790634. [PMID: 35048076 PMCID: PMC8757837 DOI: 10.3389/froh.2021.790634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/04/2021] [Indexed: 01/31/2023] Open
Abstract
Tobacco smoking-related diseases, including cardiovascular disease, pulmonary disease, stroke, and cancer in multiple organ sites, are the leading causes of preventable death, worldwide. Youth electronic cigarette use (vaping) is an evolving public health problem in the United States and around the world. Many of the same toxicants and carcinogens present in tobacco smoke are also found in electronic cigarette vapor, although mostly at substantially lower levels. The reduced concentrations of these chemicals in electronic cigarette vapor may imply lower health risk; however, they cannot equate to no risk. To date, the long-term health consequences of vaping are largely unknown. This “Perspective” provides a concise chronology of events leading up to an unprecedented global challenge, namely the convergence of global tobacco epidemic and youth vaping epidemic. Current state of knowledge, outstanding questions in the field, present challenges, and future directions in research are highlighted. The existing data show a continued and dynamic evolution of the converged epidemics. The goal should be to prevent youth vaping while improving smoking cessation strategies. In smokers who are unable or unwilling to quit smoking, the objective should be to provide “provably” safe or less-harmful alternatives, which should “completely” or “substantially” substitute tobacco cigarettes.
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Affiliation(s)
- Ahmad Besaratinia
- Department of Population and Public Health Sciences, USC Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
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27
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Tang MS, Lee HW, Weng MW, Wang HT, Hu Y, Chen LC, Park SH, Chan HW, Xu J, Wu XR, Wang H, Yang R, Galdane K, Jackson K, Chu A, Halzack E. DNA damage, DNA repair and carcinogenicity: Tobacco smoke versus electronic cigarette aerosol. MUTATION RESEARCH. REVIEWS IN MUTATION RESEARCH 2022; 789:108409. [PMID: 35690412 PMCID: PMC9208310 DOI: 10.1016/j.mrrev.2021.108409] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/06/2021] [Accepted: 12/13/2021] [Indexed: 01/03/2023]
Abstract
The allure of tobacco smoking is linked to the instant gratification provided by inhaled nicotine. Unfortunately, tobacco curing and burning generates many mutagens including more than 70 carcinogens. There are two types of mutagens and carcinogens in tobacco smoke (TS): direct DNA damaging carcinogens and procarcinogens, which require metabolic activation to become DNA damaging. Recent studies provide three new insights on TS-induced DNA damage. First, two major types of TS DNA damage are induced by direct carcinogen aldehydes, cyclic-1,N2-hydroxy-deoxyguanosine (γ-OH-PdG) and α-methyl-1, N2-γ-OH-PdG, rather than by the procarcinogens, polycyclic aromatic hydrocarbons and aromatic amines. Second, TS reduces DNA repair proteins and activity levels. TS aldehydes also prevent procarcinogen activation. Based on these findings, we propose that aldehydes are major sources of TS induce DNA damage and a driving force for carcinogenesis. E-cigarettes (E-cigs) are designed to deliver nicotine in an aerosol state, without burning tobacco. E-cigarette aerosols (ECAs) contain nicotine, propylene glycol and vegetable glycerin. ECAs induce O6-methyl-deoxyguanosines (O6-medG) and cyclic γ-hydroxy-1,N2--propano-dG (γ-OH-PdG) in mouse lung, heart and bladder tissues and causes a reduction of DNA repair proteins and activity in lungs. Nicotine and nicotine-derived nitrosamine ketone (NNK) induce the same types of DNA adducts and cause DNA repair inhibition in human cells. After long-term exposure, ECAs induce lung adenocarcinoma and bladder urothelial hyperplasia in mice. We propose that E-cig nicotine can be nitrosated in mouse and human cells becoming nitrosamines, thereby causing two carcinogenic effects, induction of DNA damage and inhibition of DNA repair, and that ECA is carcinogenic in mice. Thus, this article reviews the newest literature on DNA adducts and DNA repair inhibition induced by nicotine and ECAs in mice and cultured human cells, and provides insights into ECA carcinogenicity in mice.
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Affiliation(s)
- Moon-Shong Tang
- Department of Environmental Medicine, Pathology and Medicine, United States.
| | - Hyun-Wook Lee
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Mao-Wen Weng
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Hsiang-Tsui Wang
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Yu Hu
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Lung-Chi Chen
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Sung-Hyun Park
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Huei-Wei Chan
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Jiheng Xu
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Xue-Ru Wu
- Departmemt of Urology, New York University School of Medicine, New York, NY10016, United States
| | - He Wang
- Department of Pathology and Laboratory Medicine, Robert Wood Johnson MedicalSchool, Rutgers University, Piscataway, NJ 08854, United States
| | - Rui Yang
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Karen Galdane
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Kathryn Jackson
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Annie Chu
- Department of Environmental Medicine, Pathology and Medicine, United States
| | - Elizabeth Halzack
- Department of Environmental Medicine, Pathology and Medicine, United States
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28
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Nikam SS, Gurjar M, Singhavi H, Patil A, Singh A, Villalta P, Chaturvedi P, Khariwala SS, Gota V, Stepanov I. Simultaneous analysis of urinary total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol, N'-nitrosonornicotine, and cotinine by liquid chromatography-tandem mass-spectrometry. Sci Rep 2021; 11:20007. [PMID: 34625573 PMCID: PMC8501032 DOI: 10.1038/s41598-021-99259-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/14/2021] [Indexed: 11/11/2022] Open
Abstract
Biomarkers of exposure to harmful tobacco constituents are key tools for identifying individuals at risk and developing interventions and tobacco control measures. However, tobacco biomarker studies are scarce in many parts of the world with high prevalence of tobacco use. Our goal was to establish a robust method for simultaneous analysis of urinary total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), N'-nitrosonornicotine (NNN), and cotinine at the Advanced Centre for Treatment, Research and Education in Cancer (ACTREC) in Mumbai, India. These biomarkers are validated measures of exposure to the carcinogenic tobacco nitrosamines 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and NNN and the addictive alkaloid nicotine, respectively. The established method is characterized by excellent accuracy, linearity, and precision, and was successfully applied to the analysis of 15 smokeless tobacco (SLT) users and 15 non-users of tobacco recruited in Mumbai. This is the first report of establishment of such procedure in a laboratory in India, which offers the first in-country capacity for research on tobacco carcinogenesis in Indian SLT users.
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Affiliation(s)
- Sampada S Nikam
- Department of Clinical Pharmacology, Advanced Centre for Training, Research and Education in Cancer (ACTREC), Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Murari Gurjar
- Department of Clinical Pharmacology, Advanced Centre for Training, Research and Education in Cancer (ACTREC), Mumbai, India
| | | | - Anand Patil
- Department of Clinical Pharmacology, Advanced Centre for Training, Research and Education in Cancer (ACTREC), Mumbai, India
| | | | - Peter Villalta
- Masonic Cancer Center, University of Minnesota, 2231 6th Street SE, Minneapolis, MN, 55455, USA
| | - Pankaj Chaturvedi
- Tata Memorial Centre, Mumbai, India
- Homi Bhabha National Institute, Mumbai, India
| | - Samir S Khariwala
- Department of Otolaryngology, Head and Neck Surgery, Medical School, University of Minnesota, Minneapolis, USA
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Training, Research and Education in Cancer (ACTREC), Mumbai, India.
- Homi Bhabha National Institute, Mumbai, India.
| | - Irina Stepanov
- Masonic Cancer Center, University of Minnesota, 2231 6th Street SE, Minneapolis, MN, 55455, USA.
- Department of Otolaryngology, Head and Neck Surgery, Medical School, University of Minnesota, Minneapolis, USA.
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, USA.
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29
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Landmesser A, Scherer M, Scherer G, Sarkar M, Edmiston JS, Niessner R, Pluym N. Assessment of the potential vaping-related exposure to carbonyls and epoxides using stable isotope-labeled precursors in the e-liquid. Arch Toxicol 2021; 95:2667-2676. [PMID: 34159432 PMCID: PMC8298337 DOI: 10.1007/s00204-021-03097-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/15/2021] [Indexed: 12/28/2022]
Abstract
The formation of carbonyls and epoxides in e-cigarette (EC) aerosol is possible due to heating of the liquid constituents. However, high background levels of these compounds have inhibited a clear assessment of exposure during use of ECs. An EC containing an e-liquid replaced with 10% of 13C-labeled propylene glycol and glycerol was used in a controlled use clinical study with 20 EC users. In addition, five smokers smoked cigarettes spiked with the described e-liquid. Seven carbonyls (formaldehyde, acetaldehyde, acrolein, acetone, crotonaldehyde, methacrolein, propionaldehyde) were measured in the aerosol and the mainstream smoke. Corresponding biomarkers of exposure were determined in the user’s urine samples. 13C-labeled formaldehyde, acetaldehyde and acrolein were found in EC aerosol, while all seven labeled carbonyls were detected in smoke. The labeled biomarkers of exposure to formaldehyde (13C-thiazolidine carboxylic acid and 13C-N-(1,3-thiazolidine-4-carbonyl)glycine), acrolein (13C3-3-hydroxypropylmercapturic acid) and glycidol (13C3-dihydroxypropylmercapturic acid) were present in the urine of vapers indicating an EC use-specific exposure to these toxicants. However, other sources than vaping contribute to a much higher extent by several orders of magnitude to the overall exposure of these toxicants. Comparing data for the native (unlabeled) and the labeled (exposure-specific) biomarkers revealed vaping as a minor source of user’s exposure to these toxicants while other carbonyls and epoxides were not detectable in the EC aerosol.
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Affiliation(s)
- Anne Landmesser
- ABF Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstrasse 5, 82152, Planegg, Germany.,Chair for Analytical Chemistry, Technische Universität München, Marchioninistraße, Munich, Germany
| | - Max Scherer
- ABF Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstrasse 5, 82152, Planegg, Germany
| | - Gerhard Scherer
- ABF Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstrasse 5, 82152, Planegg, Germany
| | - Mohamadi Sarkar
- Altria Client Services LLC, Center for Research and Technology, Richmond, VA, USA
| | - Jeffery S Edmiston
- Altria Client Services LLC, Center for Research and Technology, Richmond, VA, USA
| | - Reinhard Niessner
- Chair for Analytical Chemistry, Technische Universität München, Marchioninistraße, Munich, Germany
| | - Nikola Pluym
- ABF Analytisch-Biologisches Forschungslabor GmbH, Semmelweisstrasse 5, 82152, Planegg, Germany.
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30
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Li Y, Burns AE, Tran LN, Abellar KA, Poindexter M, Li X, Madl AK, Pinkerton KE, Nguyen TB. Impact of e-Liquid Composition, Coil Temperature, and Puff Topography on the Aerosol Chemistry of Electronic Cigarettes. Chem Res Toxicol 2021; 34:1640-1654. [PMID: 33949191 DOI: 10.1021/acs.chemrestox.1c00070] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
E-cigarette aerosol is a complex mixture of gases and particles with a composition that is dependent on the e-liquid formulation, puffing regimen, and device operational parameters. This work investigated mainstream aerosols from a third generation device, as a function of coil temperature (315-510 °F, or 157-266 °C), puff duration (2-4 s), and the ratio of propylene glycol (PG) to vegetable glycerin (VG) in e-liquid (100:0-0:100). Targeted and untargeted analyses using liquid chromatography high-resolution mass spectrometry, gas chromatography, in situ chemical ionization mass spectrometry, and gravimetry were used for chemical characterizations. PG and VG were found to be the major constituents (>99%) in both phases of the aerosol. Most e-cigarette components were observed to be volatile or semivolatile under the conditions tested. PG was found almost entirely in the gas phase, while VG had a sizable particle component. Nicotine was only observed in the particle phase. The production of aerosol mass and carbonyl degradation products dramatically increased with higher coil temperature and puff duration, but decreased with increasing VG fraction in the e-liquid. An exception is acrolein, which increased with increasing VG. The formation of carbonyls was dominated by the heat-induced dehydration mechanism in the temperature range studied, yet radical reactions also played an important role. The findings from this study identified open questions regarding both pathways. The vaping process consumed PG significantly faster than VG under all tested conditions, suggesting that e-liquids become more enriched in VG and the exposure to acrolein significantly increases as vaping continues. It can be estimated that a 30:70 initial ratio of PG:VG in the e-liquid becomes almost entirely VG when 60-70% of e-liquid remains during the vaping process at 375 °F (191 °C). This work underscores the need for further research on the puffing lifecycle of e-cigarettes.
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Affiliation(s)
- Yichen Li
- Department of Environmental Toxicology, University of California at Davis, Davis, California 95616, United States
| | - Amanda E Burns
- Department of Environmental Toxicology, University of California at Davis, Davis, California 95616, United States
| | - Lillian N Tran
- Department of Environmental Toxicology, University of California at Davis, Davis, California 95616, United States
| | - Karizza A Abellar
- Department of Chemistry, University of California at Davis, Davis, California 95616, United States
| | - Morgan Poindexter
- Center for Health and the Environment, University of California at Davis, Davis, California 95616, United States
| | - Xiaohan Li
- Center for Health and the Environment, University of California at Davis, Davis, California 95616, United States
| | - Amy K Madl
- Center for Health and the Environment, University of California at Davis, Davis, California 95616, United States
| | - Kent E Pinkerton
- Center for Health and the Environment, University of California at Davis, Davis, California 95616, United States
| | - Tran B Nguyen
- Department of Environmental Toxicology, University of California at Davis, Davis, California 95616, United States
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31
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Briggs K, Bell C, Breik O. What should every dental health professional know about electronic cigarettes? Aust Dent J 2021; 66:224-233. [PMID: 33428774 DOI: 10.1111/adj.12818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 01/02/2023]
Abstract
Electronic cigarettes (E-cigarettes) have become increasingly popular around the world. Currently, dental professionals' knowledge and attitudes are varied with many clinicians unclear regarding the impact of E-cigarette products on the oral and general health of their patients. With developing social and health-related challenges, advice of dental and medical associations and other regulatory bodies on E-cigarette use is changing. Growing evidence demonstrating the risks of E-cigarette usage has prompted a review of legislation in the United Kingdom (UK), United States of America (USA), Australia and Canada to include the sale and availability of E-cigarettes, particularly those containing nicotine. Further consideration within the scientific and public health community is being given to assessing demographic usage patterns particularly uptake by non-smokers and adolescents, efficacy as a cessation tool, the impact of vapour on bystanders and direct injuries via explosions as well as emerging lung injuries. This article aims to provide a summary of the most up to date evidence relating to E-cigarette use, the latest position of dental associations and the oral health implications of E-cigarettes compared to conventional smoking. The article also aims to collate this information in order to provide dental clinicians with guidance on how to advise patients, specifically in answering common questions posed regarding E-cigarette use.
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Affiliation(s)
- K Briggs
- General Dentist, Private Practice, Brisbane, Australia
| | - C Bell
- Associate Specialist Oral and Maxillofacial Surgery, Bristol University Hospitals Trust, Bristol, United Kingdom
| | - O Breik
- Oral and Maxillofacial Surgeon, Royal Brisbane and Women's Hospital, Brisbane, Australia
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32
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McDonough SR, Rahman I, Sundar IK. Recent updates on biomarkers of exposure and systemic toxicity in e-cigarette users and EVALI. Am J Physiol Lung Cell Mol Physiol 2021; 320:L661-L679. [PMID: 33501893 DOI: 10.1152/ajplung.00520.2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Electronic nicotine delivery systems (ENDS), or e-cigarettes, are emerging tobacco products that produce aerosols by heating e-liquids, which most often consist of propylene glycol and vegetable glycerin along with various flavoring compounds, bypassing the combustion that occurs in the use of traditional tobacco cigarettes. These products have seen a drastic increase in popularity in recent years both as smoking cessation devices as well as among younger generations, due in large part to the widespread perception among consumers that e-cigs are significantly less harmful to health than traditional tobacco cigarettes. Due to the novelty of ENDS as well as their rapidly increasing use, research into biomarkers of e-cig exposure and toxicity have lagged behind their popularity, leaving important questions about their potential toxicity unanswered. Research into potential biomarkers of acute and chronic e-cig use, and e-cigarette- or vaping-associated lung injury is necessary for informing both clinical and regulatory decision-making. We aim to provide an updated review of recent research into potential circulating, genomic, transcriptomic, and epigenetic biomarkers of exposure to and toxicity of e-cigs. We additionally highlight research areas that warrant additional study to gain a better understanding of health risks associated with ENDS use, as well as to provide validation of existing data and methods for measuring and analyzing e-cig-associated biomarkers in human and animal biofluids, tissues, and cells. This review also highlights ongoing efforts within the WNY Center for Research on Flavored Tobacco for research into novel biomarkers in extracellular vesicles that may be associated with short- and long-term ENDS use.
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Affiliation(s)
- Samantha R McDonough
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York
| | - Irfan Rahman
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York
| | - Isaac Kirubakaran Sundar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
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33
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Akiyama Y, Sherwood N. Systematic review of biomarker findings from clinical studies of electronic cigarettes and heated tobacco products. Toxicol Rep 2021; 8:282-294. [PMID: 33552927 PMCID: PMC7850959 DOI: 10.1016/j.toxrep.2021.01.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/21/2021] [Accepted: 01/21/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Worldwide adoption of electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) has increased exponentially over the past decade. These products have been proposed as non-combustible alternatives to traditional tobacco products such as cigarettes and may thus reduce the negative health consequences associated with tobacco smoke. However, the overall health impact and safety of using these products remains unclear. This review seeks to provide an updated summary of available evidence on changes to levels of tobacco-related biomarkers to aid the overall assessment of the consequences of using e-cigarettes and HTPs. METHODS A systematic review was conducted through major databases (Medline/PubMed, Scopus, EMBASE) searching for articles directly comparing biomarker levels in humans using e-cigarettes or HTPs and those using combustible cigarettes. We included peer reviewed articles with comparative or longitudinal design and extracted key information for our purpose (type of population, demographics, biomarkers measurements, and health effects). An initial qualitative analysis was performed followed by a summary of findings. RESULTS A total of 44 studies were included from initial citations. The vast majority of the literature reported reductions in levels of biomarkers of tobacco smoke exposure (BOE), especially nicotine, MHBMA, 3-HPMA, S-PMA, 1-OHP and NNAL, when using e-cigarettes and HTPs compared to combustible cigarettes. There was a slight tendency toward a larger reduction in these biomarkers levels with the use of e-cigarettes, although direct comparisons between e-cigarettes and HTPs were lacking. There was also a trend toward positive changes in levels of biomarkers of biological effect (BOBE) with the use of e-cigarettes and HTPs. CONCLUSIONS A comparison of levels of biomarkers of tobacco-related exposure collected in clinical studies revealed that the use of e-cigarettes and HTPs could lead to a significant reduction in exposure to harmful substances compared to combusted cigarettes. In tandem, the health status of e-cigarettes and HTP users, indexed by levels of biomarkers of biological effect showed potential for improvement compared to smoking. However, larger and longer-term population-based studies are needed to further clarify these findings.
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Key Words
- BAT, British American Tobacco
- BOBE, biomarkers of biological effect
- BOE, biomarkers of tobacco smoke exposure
- Biomarkers of biological effect (BOBE)
- Biomarkers of tobacco smoke exposure (BOE)
- CHTP, Carbon-Heated Tobacco Product
- Clinical study
- E-cigarettes, electronic cigarettes
- EHCSS, Electrically Heated Cigarette Smoking System
- EVPs, electronic vapor products
- Electronic cigarette
- FV, Fontem Ventures
- HC, heated cigarette
- HTPs, heated tobacco products
- Heated tobacco products
- JT, Japan Tobacco
- NOS scale, The Newcastle-Ottawa Scale
- NSPS, nicotine-salt pod system
- NTV, Novel Tobacco vapor products
- PMI, Philip Morris International
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RAI, Reynolds American Inc
- RCT, randomized controlled trial
- RJR, R.J. Reynolds Tobacco Company
- RJRVC, R.J. Reynolds Vapor Company
- RTP, reduced-toxicant-prototype cigarette
- THP, tobacco heating product
- THS, Tobacco Heating System
- UCS, Uncontrolled smoking conditions
- WHO, World Health Organization
- mTHS, Menthol Tobacco Heating System
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Affiliation(s)
- Yukio Akiyama
- Department of Environmental Management, University of Occupational and Environmental Health, Kitakyushu, Japan
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Szukalska M, Szyfter K, Florek E, Rodrigo JP, Rinaldo A, Mäkitie AA, Strojan P, Takes RP, Suárez C, Saba NF, Braakhuis BJ, Ferlito A. Electronic Cigarettes and Head and Neck Cancer Risk-Current State of Art. Cancers (Basel) 2020; 12:E3274. [PMID: 33167393 PMCID: PMC7694366 DOI: 10.3390/cancers12113274] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/03/2020] [Indexed: 01/11/2023] Open
Abstract
E-cigarettes have become increasingly popular in the last decade and are considered less harmful than traditional tobacco products due to the lower content of toxic and carcinogenic compounds. However, this is still a controversial issue. This paper contains a review of previous reports on the composition of e-cigarettes and their impact on the pathogenesis and risk of head and neck cancer (HNC). The objective of the review was to compare the molecular and health effects of e-cigarette use in relation to the effects of traditional cigarette smoking in the upper respiratory tract, and to assess the safety and effect of e-cigarettes on HNC risk. A review for English language articles published until 31 August 2020 was made, using a PubMed (including MEDLINE), CINAHL Plus, Embase, Cochrane Library and Web of Science data. The authors reviewed articles on both toxic and carcinogenic compounds contained in e-cigarettes and their molecular and health effects on the upper respiratory tract in comparison to tobacco cigarettes. The risk of developing head and neck squamous cell carcinoma (HNSCC) remains lower in users of e-cigarettes compared with tobacco smokers. However, more long-term studies are needed to better address the safety of e-cigarettes.
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Affiliation(s)
- Marta Szukalska
- Laboratory of Environmental Research, Department of Toxicology, Poznan University of Medical Sciences, 60-631 Poznan, Poland
| | - Krzysztof Szyfter
- Institute of Human Genetics, Polish Academy of Sciences, 60-479 Poznan, Poland;
| | - Ewa Florek
- Laboratory of Environmental Research, Department of Toxicology, Poznan University of Medical Sciences, 60-631 Poznan, Poland
| | - Juan P. Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias-University of Oviedo, 33011 Oviedo, Spain;
- Instituto de Investigación Sanitaria del Principado de Asturias, Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, CIBERONC, 33011 Oviedo, Spain;
| | | | - Antti A. Mäkitie
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, 00029 HUS Helsinki, Finland;
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institute and Karolinska Hospital, 141 86 Stockholm, Sweden
| | - Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, 1000 Ljubljana, Slovenia;
| | - Robert P. Takes
- Department of Otolaryngology-Head and Neck Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands;
| | - Carlos Suárez
- Instituto de Investigación Sanitaria del Principado de Asturias, Instituto Universitario de Oncología del Principado de Asturias, University of Oviedo, CIBERONC, 33011 Oviedo, Spain;
| | - Nabil F. Saba
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA 30322, USA;
| | | | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35100 Padua, Italy;
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Reilly SM, Cheng T, DuMond J. Method Validation Approaches for Analysis of Constituents in ENDS. TOB REGUL SCI 2020; 6:242-265. [PMID: 32789155 PMCID: PMC7416875 DOI: 10.18001/trs.6.4.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We assessed how many peer-reviewed publications reporting chemical quantities and/or yields from electronic nicotine delivery systems (ENDS) have included adequate method validation characteristics in the publication for appropriate interpretation of data quality for informing tobacco regulatory science. METHODS We searched 5 databases (Web of Knowledge, PubMed, SciFinder, Embase, EBSCOhost) for ENDS publications between January 2007 and September 2018. Of the 283 publications screened, 173 publications were relevant for analysis. We identified the publications that report a certain degree of control in data quality, ie, the publications that report marginally validated methods (MVMs). MVMs refer to the methods that: (1) report 3 or more International Conference on Harmonisation (ICH) method validation characteristics, (2) state the method was validated, (3) cite their own previous publication(s) that report MVMs, or (4) use a method within the accreditation scope of an accredited laboratory. RESULTS Overall, 97 publications (56%) report MVMs in their studies. This percentage also reflects the publication distribution for the majority of the 28 chemicals measured by MVMs. CONCLUSIONS This study highlights the need for reporting sufficient validation characteristics following appropriate guidance to ensure the accuracy and reliability of the published analytical data for proper data interpretations that may support policy.
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Affiliation(s)
- Samantha M Reilly
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD
| | - Tianrong Cheng
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD
| | - Jenna DuMond
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD
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Tebbutt J, Khan Z, Ariyaratnam R. A case report of oral nicotine-associated keratosis and a review of oral mucosal changes in tobacco and similar products. Br Dent J 2020; 228:757-760. [PMID: 32444744 DOI: 10.1038/s41415-020-1530-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is a strong association between tobacco use and the development of oral mucosal lesions, often with malignant potential. Nicotine is the primary component of tobacco responsible for addiction. The use of nicotine replacement therapy (NRT) aims to replace nicotine from cigarettes, allowing smoother transition to complete smoking cessation and greatly reducing risks of tobacco-related disease. The role of nicotine as a potential carcinogen is unknown. Use of NRT is associated with development of oral disorders, although it is rarely published. We detail the development of oral hyperkeratotic lesions directly associated with chronic overuse of nicotine replacement products. We also consider the current state of knowledge regarding development of oral lesions associated with other similar products. It is important for dental practitioners to be aware of oral effects associated with recommended nicotine replacement products, especially when offering smoking cessation advice to patients. It is vital that dental practitioners are aware of other potential risk factors for development of potentially malignant oral disorders, in order to make timely referrals of suspected lesions for appropriate investigation and review.
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Affiliation(s)
- Jessie Tebbutt
- Dental Core Trainee, University Dental Hospital of Manchester, UK.
| | - Zahid Khan
- Speciality Registrar in Oral Medicine, University Dental Hospital of Manchester, UK
| | - Raj Ariyaratnam
- Specialist in Oral Medicine and Oral Surgery, University Dental Hospital of Manchester, UK
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Ruszkiewicz JA, Zhang Z, Gonçalves FM, Tizabi Y, Zelikoff JT, Aschner M. Neurotoxicity of e-cigarettes. Food Chem Toxicol 2020; 138:111245. [PMID: 32145355 PMCID: PMC7089837 DOI: 10.1016/j.fct.2020.111245] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 02/29/2020] [Accepted: 03/03/2020] [Indexed: 02/07/2023]
Abstract
It appears that electronic cigarettes (EC) are a less harmful alternative to conventional cigarette (CC) smoking, as they generate substantially lower levels of harmful carcinogens and other toxic compounds. Thus, switching from CC to EC may be beneficial for smokers. However, recent accounts of EC- or vaping-associated lung injury (EVALI) has raised concerns regarding their adverse health effects. Additionally, the increasing popularity of EC among vulnerable populations, such as adolescents and pregnant women, calls for further EC safety evaluation. In this state-of-the-art review, we provide an update on recent findings regarding the neurological effects induced by EC exposure. Moreover, we discuss possible neurotoxic effects of nicotine and numerous other chemicals which are inherent both to e-liquids and EC aerosols. We conclude that in recognizing pertinent issues associated with EC usage, both government and scientific researchers must address this public health issue with utmost urgency.
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Affiliation(s)
- Joanna A Ruszkiewicz
- Molecular Toxicology Group, Department of Biology, University of Konstanz, Konstanz, Germany
| | - Ziyan Zhang
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Filipe Marques Gonçalves
- Biochemistry Graduate Program, Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Yousef Tizabi
- Department of Pharmacology, Howard University College of Medicine, Washington DC, United States
| | - Judith T Zelikoff
- Department of Environmental Medicine, New York University School of Medicine, Manhattan, NY, United States
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, United States.
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Raj AT, Sujatha G, Muruganandhan J, Kumar SS, Bharkavi SI, Varadarajan S, Patil S, Awan KH. Reviewing the oral carcinogenic potential of E-cigarettes using the Bradford Hill criteria of causation. Transl Cancer Res 2020; 9:3142-3152. [PMID: 35117678 PMCID: PMC8798817 DOI: 10.21037/tcr.2020.01.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/07/2019] [Indexed: 11/06/2022]
Abstract
The past decade has seen a surge in the use of e-cigarettes, which has prompted the medical community to assess any associated potential health hazards. A major concern was the risk of cancer. Chemical analysis of e-cigarettes has shown the presence of volatile organic compounds with the potential for carcinogenicity. Comparative toxicology analysis has shown e-cigarette to have relatively lower dosages of toxins than conventional combustible cigarettes. Based on comparative analysis, e-cigarettes have been increasingly advocated as a safe alternative to conventional cigarettes. It is vital to recognize that presence of relatively lower toxin level does not preclude carcinogenic potential. The nicotine present in the e-cigarette was presumed to be the major cytotoxic agents, thus nicotine-free e-cigarette was considered as inert. On the contrary, experimental studies on oral cell lines have shown DNA strand breaks on exposure to e-cigarette vapors with or without nicotine. In addition, dysregulations of genes associated with carcinogenic pathways have also been demonstrated in oral tissues exposed to e-cigarette vapors. Despite alarming molecular data, the oral carcinogenic potential of e-cigarette remains unclear, which can be attributed to the lack of long-term prospective and large-scale case-control studies. As e-cigarette users often have other well-established risk factors (conventional cigarette smoking, alcohol, etc.) as associated habits, it is difficult to assess e-cigarette as an independent risk factor for oral cancer. Thus, the present manuscript aims to review the published literature using the Brad Ford Hill criteria of causation to determine the oral carcinogenic potential of e-cigarettes.
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Affiliation(s)
- A Thirumal Raj
- Department of Oral Pathology and Microbiology, Sri Venkateswara Dental College and Hospital, Chennai, India
| | - Govindarajan Sujatha
- Department of Oral Pathology and Microbiology, Sri Venkateswara Dental College and Hospital, Chennai, India
| | - Jayanandan Muruganandhan
- Department of Oral Pathology and Microbiology, Sri Venkateswara Dental College and Hospital, Chennai, India
| | | | - Sk Indu Bharkavi
- Department of Oral Pathology and Microbiology, Sri Venkateswara Dental College and Hospital, Chennai, India
| | - Saranya Varadarajan
- Department of Oral Pathology and Microbiology, Sri Venkateswara Dental College and Hospital, Chennai, India
| | - Shankargouda Patil
- Department of Maxillofacial Surgery and Diagnostic Sciences, Division of Oral Pathology, College of Dentistry, Jazan University, Jazan, Saudi Arabia
| | - Kamran Habib Awan
- College of Dental Medicine, Roseman University of Health Sciences, South Jordan, UT, USA
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Yang I, Sandeep S, Rodriguez J. The oral health impact of electronic cigarette use: a systematic review. Crit Rev Toxicol 2020; 50:97-127. [PMID: 32043402 DOI: 10.1080/10408444.2020.1713726] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Electronic cigarette (e-cigarette) use is becoming more prevalent and is particularly popular among adolescents and conventional smokers. While the oral health sequelae of conventional smoking are well-established, the impact of e-cigarettes on oral health is still unknown. This study aims to systematically review the available research evidence on the oral health impact of e-cigarette use.Methods: This systematic review was conducted according to PRISMA guidelines and used the Effective Public Health Practice Project Quality Assessment Tool to evaluate the evidence. Three electronic databases (PubMed, Web of Science, and Embase) were systematically searched for studies including case reports. Two independent reviewers extracted data and synthesized the findings.Results: Ninety-nine articles were included in this systematic review. Analyses of the articles yielded seven categories based on symptom similarity and/or focus: mouth effects, throat effects, periodontal effects, dental effects, cytotoxic/genotoxic/oncologic effects, oral microbiome effects, and traumatic/accidental injury. The majority of mouth and throat symptoms experienced by e-cigarette users were relatively minor and temporary, with some evidence that conventional smokers who switched to e-cigarettes experienced mitigation of these symptoms. E-cigarette exposure increased the risk for deteriorating periodontal, dental and gingival health as well as changes to the oral microbiome. Extensive dental damage as a result of e-cigarette explosions were described in case reports. Components of e-cigarette vapor have known cytotoxic, genotoxic, and carcinogenic properties.Conclusions: Although switching to e-cigarettes may mitigate oral symptomatology for conventional smokers, findings from this review suggest that a wide range of oral health sequelae may be associated with e-cigarette use. Well-designed studies to investigate oral health outcomes of e-cigarette use are needed.
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Affiliation(s)
- Irene Yang
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Shelly Sandeep
- Emory University Midtown Hospital, Emory University, Atlanta, GA, USA
| | - Jeannie Rodriguez
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
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Bozier J, Chivers EK, Chapman DG, Larcombe AN, Bastian NA, Masso-Silva JA, Byun MK, McDonald CF, Crotty Alexander LE, Ween MP. The Evolving Landscape of e-Cigarettes: A Systematic Review of Recent Evidence. Chest 2020; 157:1362-1390. [PMID: 32006591 DOI: 10.1016/j.chest.2019.12.042] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 01/12/2023] Open
Abstract
Smoking continues to be a burden to economies and health-care systems across the world. One proposed solution to the problem has been e-cigarettes; however, because they are a relatively new product in the market, little is known about their potential health impacts. Furthermore, e-cigarettes continue to evolve at a rapid rate, making it necessary to regularly review and summarize available studies. Although e-cigarettes are marketed as a smoking cessation tool by some manufacturers, the reality is that many nonsmokers, including youth, are using them. This review focuses on two major demographic groups (smokers and nonsmokers) and evaluates the most recent data (early 2017 to mid 2019) regarding the potential health effects of e-cigarettes. We assessed peer-reviewed studies on the health impacts of e-cigarettes, with a particular focus on common questions asked by policy makers, clinicians, and scientists: (1) What are the effects of e-cigarettes compared with air/not smoking?; (2) Is there any direct evidence of harm or benefit to humans?; (3) Is there a risk from secondhand exposure?; (4) What are the risks and/or benefits of e-cigarettes compared with tobacco cigarette use?; (5) Are there risks or benefits to specific populations (eg, people with COPD or asthma, pregnant women [and their offspring])?; (6) What are the effects of flavoring chemicals?; (7) What are the effects of including nicotine in e-liquids?; (8) How often is nicotine concentration labeling incorrect?; and (9) What are the risks when e-cigarettes explode?
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Affiliation(s)
- Jack Bozier
- School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia; Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | | | - David G Chapman
- School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia; Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Alexander N Larcombe
- Telethon Kids Institute, Perth, WA, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Nicole A Bastian
- Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia
| | - Jorge A Masso-Silva
- Department of Medicine, Division of Pulmonary Critical Care & Sleep, University of California San Diego, San Diego, CA
| | - Min Kwang Byun
- Department of Medicine, Division of Pulmonary Critical Care & Sleep, University of California San Diego, San Diego, CA; Division of Pulmonology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Christine F McDonald
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia; Institute for Breathing and Sleep, Heidelberg, VIC, Australia; School of Medicine, University of Melbourne, VIC, Australia
| | - Laura E Crotty Alexander
- Department of Medicine, Division of Pulmonary Critical Care & Sleep, University of California San Diego, San Diego, CA; Pulmonary Critical Care Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Miranda P Ween
- School of Medicine, University of Adelaide, Adelaide, SA, Australia; Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.
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Stallings-Smith S, Ballantyne T. Ever Use of E-Cigarettes Among Adults in the United States: A Cross-Sectional Study of Sociodemographic Factors. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 56:46958019864479. [PMID: 31328601 PMCID: PMC6647205 DOI: 10.1177/0046958019864479] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
E-cigarette use among adolescents is well-documented, but less is known about adult users of e-cigarettes. The purpose of this study was to examine associations between sociodemographic factors and e-cigarette use in a nationally representative sample of adults in the United States. Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) for years 2015-2016 were analyzed to assess e-cigarette use among 5989 adults aged ≥18 years. Multivariable logistic regression was conducted to examine associations between the sociodemographic exposures of age, sex, race, marital status, education level, employment status, and poverty-income ratio and the outcome of e-cigarette use. The weighted prevalence of ever use of e-cigarettes was 20%. Compared with adults aged ≥55 years, odds of e-cigarette use were 4.77 times (95% confidence interval [CI] = 3.63-6.27) higher among ages 18 to 34 years and 2.16 times (95% CI = 1.49-3.14) higher among ages 35 to 54 years. Higher odds of e-cigarette use were observed among widowed/divorced/separated participants compared with those who were married/living with a partner, among participants with less than high school (odds ratio [OR] = 1.47; 95% CI = 1.08-2.00) or high school/general educational development (GED) education (OR=1.41; 95% CI = 1.12-1.77) compared with those with college degrees/some college, and among those with incomes below the poverty level (OR=1.31; 95% CI = 1.01-1.69) compared with above the poverty level. For non-smokers of conventional cigarettes, higher odds of e-cigarette use were observed among males compared with females, Mexican Americans/Other Hispanics compared with non-Hispanic whites, and non-working participants compared with those who were working. Overall findings indicate that individuals who are widowed/divorced/separated, individuals with lower education, and with incomes below the poverty level are likely to report ever use of e-cigarettes. As increasing evidence demonstrates negative health consequences, e-cigarette initiation may ultimately contribute to additional smoking-related health inequalities even among non-smokers of conventional cigarettes.
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Genotoxic and Carcinogenic Potential of Compounds Associated with Electronic Cigarettes: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1386710. [PMID: 31950030 PMCID: PMC6948324 DOI: 10.1155/2019/1386710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/23/2019] [Accepted: 08/27/2019] [Indexed: 11/17/2022]
Abstract
Background Many studies, comparing the health associated risks of electronic cigarettes with conventional cigarettes focus mainly on the common chemical compounds found between them. Aim Review chemical compounds found exclusively in electronic cigarettes and describe their toxic effects, focusing on electronic-cigarette-only and dual electronic-cigarette and conventional cigarette users. Data Sources Literature search was carried out using PubMed. Study Eligibility Criteria Articles related exclusively to conventional and electronic cigarettes' chemical composition. Articles which reported to be financed from tobacco or electronic cigarettes industries, not reporting source of funding, not related to the chemical composition of electronic and conventional cigarettes and not relevant to tobacco research were excluded. Methods and Results Chemical compounds reported in the selected studies were tabulated using the Chemical Abstracts Service registry number for chemical substances information. A total of 50 chemical compounds were exclusively reported to be present in electronic cigarettes. Crucial health risks identified were: eye, skin, and respiratory tract irritation, with almost 50% of incidence, an increment of 10% in cytotoxic effects, when compared to compounds in common with conventional cigarettes and around 11% of compounds with unknown effects to human health. Limitations Articles reporting conflicts of interest. Conclusions and Implications of Key Findings Despite being considered as less harmful for human health, compounds found in electronic cigarettes are still a matter of research and their effects on health are yet unknown. The use of these devices is not recommended for first time users and it is considered hazardous for dual users.
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Isik Andrikopoulos G, Farsalinos K, Poulas K. Electronic Nicotine Delivery Systems (ENDS) and Their Relevance in Oral Health. TOXICS 2019; 7:toxics7040061. [PMID: 31817732 PMCID: PMC6958319 DOI: 10.3390/toxics7040061] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/27/2019] [Accepted: 12/04/2019] [Indexed: 02/07/2023]
Abstract
The number and popularity of electronic nicotine delivery systems (ENDS) and especially e-cigarettes (e-cigs) have been increasing in the last decade. Although ENDS owe their popularity to excluding the harmful chemicals that are present in tobacco smoke, there is a debate whether they are safe, regulated, and as harmless as they are assumed to be and have potential unknown long-term effects. Involvement of cigarette smoking to the progression of periodontal diseases, other adverse oral health outcomes, and its detrimental effects to oral health are well-described. ENDS producer companies claim that these products can improve oral health by providing alternatives to smoking. However, the effect of e-cigs on oral health is not fully understood and is still debated among many scientists and clinicians. The number of studies addressing the potential toxic effect of ENDS or e-cig aerosol on oral cells is limited along with the clinical studies which are still preliminary, and their sample size is limited. The long-term effects of inhaled aerosols and the potential synergistic effect of the e-cigs components are not known. It is essential and of utmost importance to determine whether exposure to ENDS aerosol contributes to the progression of periodontal diseases and how it affects periodontal ligament and gingival cells which are believed to be its first targets. This review briefly summarizes the available evidence about the effects of e-cigs on periodontal health including several pathophysiological events, such as oxidative stress, DNA damage, inflammation, cellular senescence, dysregulated repair, and periodontal diseases.
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Affiliation(s)
| | - Konstantinos Farsalinos
- Department of Pharmacy, University of Patras, Rio, 26500 Patras, Greece; (G.I.A.); (K.F.)
- Department of Cardiology, Onassis Cardiac Surgery Center, 17674 Kallithea, Greece
- National School of Public Health, Leof. Alexandras 196, 111521 Athens, Greece
| | - Konstantinos Poulas
- Department of Pharmacy, University of Patras, Rio, 26500 Patras, Greece; (G.I.A.); (K.F.)
- Institute of Research and Innovation NONSMOKE TEAM, Patras Science Park, Stadiou, Platani, Rio, 26504 Patras, Greece
- Correspondence: ; Tel.: +30-2610-962353
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Ma B, Stepanov I, Hecht SS. Recent Studies on DNA Adducts Resulting from Human Exposure to Tobacco Smoke. TOXICS 2019; 7:E16. [PMID: 30893918 PMCID: PMC6468371 DOI: 10.3390/toxics7010016] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/09/2019] [Accepted: 03/13/2019] [Indexed: 12/22/2022]
Abstract
DNA adducts are believed to play a central role in the induction of cancer in cigarette smokers and are proposed as being potential biomarkers of cancer risk. We have summarized research conducted since 2012 on DNA adduct formation in smokers. A variety of DNA adducts derived from various classes of carcinogens, including aromatic amines, polycyclic aromatic hydrocarbons, tobacco-specific nitrosamines, alkylating agents, aldehydes, volatile carcinogens, as well as oxidative damage have been reported. The results are discussed with particular attention to the analytical methods used in those studies. Mass spectrometry-based methods that have higher selectivity and specificity compared to 32P-postlabeling or immunochemical approaches are preferred. Multiple DNA adducts specific to tobacco constituents have also been characterized for the first time in vitro or detected in vivo since 2012, and descriptions of those adducts are included. We also discuss common issues related to measuring DNA adducts in humans, including the development and validation of analytical methods and prevention of artifact formation.
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Affiliation(s)
- Bin Ma
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Irina Stepanov
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Stephen S Hecht
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA.
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Buettner-Schmidt K, Miller DR, Maack B. Disparities in Rural Tobacco Use, Smoke-Free Policies, and Tobacco Taxes. West J Nurs Res 2019; 41:1184-1202. [PMID: 30774036 PMCID: PMC6613179 DOI: 10.1177/0193945919828061] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tobacco use and exposure to secondhand smoke (SHS) remain leading causes of preventable disease, disability, and mortality in the United States. Rural populations are among those being left behind in the recent declining smoking rates and have become a focus of discussions on tobacco-related disparities. This article describes tobacco-related disparities in rural populations including tobacco use, exposure to SHS, smoke-free policies, and tobacco taxes. Nurses, as social justice and tobacco control policy advocates, are needed especially at the local level, where much of the policy work occurs and where nursing's voice is respected and can be powerful.
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Affiliation(s)
| | | | - Brody Maack
- 1 North Dakota State University, Fargo, ND, USA
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46
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Sultan AS, Jessri M, Farah CS. Electronic nicotine delivery systems: Oral health implications and oral cancer risk. J Oral Pathol Med 2018; 50:316-322. [PMID: 30507043 DOI: 10.1111/jop.12810] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 12/02/2018] [Indexed: 12/11/2022]
Abstract
There is a paucity of evidence surrounding the potential detrimental effects of electronic nicotine delivery systems (ENDS) for both systemic and oral health. The effects of conventional cigarettes on the development of oral cancer are well known; however, the role of ENDS in oral carcinogenesis is yet to be elucidated. Furthermore, the exponential rise of the use of ENDS by the general public means that dental healthcare providers are more likely to encounter questions on their safety in the oral cavity, and on their effectiveness as a smoking cessation aid. Herein, we review the most up to date literature on the systemic and oral health complications of ENDS. Moreover, evidence-based recommendations on the use of ENDS as a smoking cessation tool within the dental setting are discussed.
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Affiliation(s)
- Ahmed S Sultan
- Department of Oncology and Diagnostic Sciences, School of Dentistry, University of Maryland, Baltimore, Maryland
| | - Maryam Jessri
- Australian Centre for Oral Oncology Research & Education, UWA Dental School, University of Western Australia, Nedlands, Western Australia, Australia
| | - Camile S Farah
- Australian Centre for Oral Oncology Research & Education, UWA Dental School, University of Western Australia, Nedlands, Western Australia, Australia
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