Toxicity assessment of electronic cigarettes

Relationship between electronic cigarette use, dual smoking habits, and psychological distress among youth in Northern Thailand: A cross-sectional study

INTRODUCTION

Amidst the escalating trend of electronic cigarette (e-cigarette) use and dual smoking habits among youth, understanding their potential impact on psychological well-being is imperative. Limited research has explored this relationship, particularly among youth in settings where e-cigarettes are banned. This study investigates the relationship between current e-cigarette and traditional cigarette use patterns and the presence of depression and anxiety symptoms among youth in Thailand.

METHODS

Using a cross-sectional survey encompassing 3424 individuals aged 15-24 years in Northern Thailand from December 2021 to September 2022, we accessed cigarette and e-cigarette usage over the past 30 days alongside depression and anxiety symptoms over the past two weeks. Multivariable logistic regression was employed to analyze the association of these variables, adjusting for sociodemographic factors.

RESULTS

Among the surveyed youths, 10.8% reported cigarette use, 6.2% utilized e-cigarettes, and 3.3% were dual users within the past 30 days. Regarding mental health, 33.96% exhibited moderate-severe to severe depression, while 52.54% experienced anxiety at similar levels. After adjusting for covariates, both current e-cigarette users and dual users exhibited heightened depression symptoms (AOR=1.80; 95% CI: 1.30-2.51, and AOR=2.30; 95% CI: 1.49-3.55, respectively) and only e-cigarette use had increased odds of increased anxiety levels (AOR=1.70; 95% CI: 1.24-2.32) compared to non-users. Notably, current cigarette smokers demonstrated no association with depression but had decreased odds of higher levels of anxiety compared to non-users (AOR=0.73; 95% CI: 0.55-0.96).

CONCLUSIONS

A substantial number of Thai youths are using e-cigarettes and experiencing psychological distress. E-cigarette use is associated with heightened levels of depression and anxiety, whereas cigarette smoking is not associated with depression but is likely to be associated with an increased reporting of anxiety. These contradictory findings highlight the need for comprehensive investigations, especially when e-cigarettes are prohibited.

Use of and Beliefs toward Novel Tobacco and Nicotine Products among Portuguese University Students: A Pandemic Survey

Over the last decade, novel tobacco and nicotine product experimentation and use have dramatically increased among the youth, even in countries with strong tobacco control and anti-smoking social norms. We performed an online questionnaire-based cross-sectional study in March-June 2021, targeting students from the University of Beira Interior, Portugal. The aim was to assess the experimentation and use of tobacco and nicotine products and students' beliefs towards these products. Of the 452 participants, 67.0% were female; the mean age was 21.9 ± 3 years. Most students (60.4%) reported experimenting with tobacco/nicotine products; 31.2% were current users; polyconsumption was common. Of the current users, all used cigarettes, 41.1% used heated tobacco, 20.6% e-cigarettes, and 14.9% used water pipes. Our multivariate analysis showed that being male, being in the third year of study, and cohabiting or socializing with smokers were strongly associated with tobacco/nicotine use. While most students agree that heated tobacco and e-cigarettes are addictive, that they are not less harmful than cigarettes, and that second-hand exposure may cause health problems, few tobacco/nicotine users are ready to quit, and few students support a smoke-free university campus. These findings indicate high experimentation and the regular dual use of novel tobacco and nicotine products and suggest a pro-smoking social norm among university students.

E-cigarettes in Nigeria: A scoping review of evidence

Background and Aims

E-cigarettes will continue to be a public health issue in Nigeria. To curb the growing menace of the e-cigarette use in Nigeria through evidence-based approach, it is crucial to first map the empirical research landscape of e-cigarettes in Nigeria. No known study has mapped the existing empirical evidence and gaps concerning e-cigarettes in Nigeria; hence, this scoping review was conducted.

Methods

This scoping review adopted the research design by Arksey and O'Malley. Four databases (PubMed, SCOPUS, CINAHL Complete, and APA PsycINFO) were searched to retrieve literature on e-cigarettes in Nigeria. With the aid of Rayyan web application, all retrieved literature were deduplicated and screened based on the review's eligibility criteria. Only those peer-reviewed journal papers meeting the inclusion criteria were included in the review. Relevant data from the included papers were charted, collated, and summarized.

Results

A total of six papers were included in this review. The reviewed papers reported a lifetime prevalence of e-cigarette use (or vaping) ranging from 5.8% to 19.8%, with a current e-cigarette use prevalence of 11.8%, among different population groups in Nigeria. The major determinants of e-cigarette use, as reported in these articles, include being a youth, having a health condition, severe anxiety, tobacco use, peer influence, and current alcohol use. Dry mouth and oral lesions (gingival inflammation and oral ulcers) were also identified to be the medical conditions associated with e-cigarette use in Nigeria. Lastly, one of the included papers identified a lack of clear regulation on e-cigarettes in Nigeria.

Conclusion

There is an urgent need for more scientific investigations on the sociodemographic, economic, health, and regulatory landscape of e-cigarettes in Nigeria, as robust empirical evidence is needed for the effective planning, implementation, and evaluation of evidence-based policies and interventions on e-cigarettes control and regulation in Nigeria.

Multidimensional assessment of the biological effects of electronic cigarettes on lung bronchial epithelial cells

Cigarette smoke (CS) exposure is known to cause injury to respiratory tract epithelial cells and is a contributing factor in the development of chronic obstructive pulmonary disease and lung cancer. Electronic cigarettes (e-cigarettes) are gaining popularity as a potential substitute for conventional cigarettes due to their potential for aiding smoking cessation. However, the safety of e-cigarettes remains uncertain, and scientific evidence on this topic is still limited. In this study, we aimed to investigate the effects of CS and e-cigarette smoke (ECS) of different flavors on human lung bronchial epithelial cells. Real-time smoke exposure was carried out using an air-liquid interface system, and cell viability was assessed. RNA-Seq transcriptome analysis was performed to compare the differences between CS and ECS. The transcriptome analysis revealed a significantly higher number of differentially expressed genes in CS than in ECS. Moreover, the impact of mint-flavored e-cigarettes on cells was found to be greater than that of tobacco-flavored e-cigarettes, as evidenced by the greater number of differentially expressed genes. These findings provide a reference for future safety research on traditional cigarettes and e-cigarettes, particularly those of different flavors. The use of omics-scale methodologies has improved our ability to understand the biological effects of CS and ECS on human respiratory tract epithelial cells, which can aid in the development of novel approaches for smoking cessation and lung disease prevention.

Use of Tobacco Products and Suicide Attempts Among Elementary School-Aged Children

Importance

The use of tobacco products, including e-cigarettes and vaping, has rapidly increased among children. However, despite consistent associations found between smoking cigarettes and suicidal behaviors among adolescents and adults, there are limited data on associations between emerging tobacco products and suicidal behaviors, especially among preadolescent children.

Objective

To examine whether the use of tobacco products is associated with nonsuicidal self-injury (NSSI), suicidal ideation (SI), and suicide attempts (SAs) among preadolescent children.

Design, Setting, and Participants

This cohort study, conducted from September 1, 2022, to September 5, 2023, included participants in the Adolescent Brain Cognitive Development study, a population-based cohort of 11 868 US children enrolled at 9 and 10 years of age. The cross-sectional investigation focused on 3-year periods starting from the baseline to year 2 of follow-up. Statistical analysis was performed from October 1, 2022, to June 30, 2023.

Main Outcomes and Measures

Children's use of tobacco products was assessed based on youth reports, including lifetime experiences of various nicotine-related products, supplemented with hair toxicologic tests. Main outcomes were children's lifetime experiences of NSSI, SI, and SAs, assessed using the K-SADS-5 (Kiddie Schedule for Affective Disorders and Schizophrenia for the DSM-5). Multivariate logistic regression was conducted to examine the associations of the use of tobacco products with NSSI, SI, and SAs among the study participants. Sociodemographic, familial, and children's behavioral, temperamental, and clinical outcomes were adjusted in the analyses.

Results

Of 8988 unrelated study participants (median age, 9.8 years [range, 8.9-11.0 years]; 4301 girls [47.9%]), 101 children (1.1%) and 151 children (1.7%) acknowledged lifetime use of tobacco products at baseline and at 18-month follow-up, respectively. After accounting for various suicide risk factors and potential confounders, children reporting use of tobacco products were at a 3 to 5 times increased risk of SAs (baseline: n = 153 [adjusted odds ratio (OR), 4.67; 95% CI, 2.35-9.28; false discovery rate (FDR)-corrected P < .001]; year 1: n = 227 [adjusted OR, 4.25; 95% CI, 2.33-7.74; FDR-corrected P < .001]; and year 2: n = 321 [adjusted OR, 2.85; 95% CI, 1.58-5.13; FDR-corrected P = .001]). Of all facets of impulsivity measures that were significant correlates of use of tobacco products, negative urgency was the only independent risk factor for SAs (adjusted OR, 1.52 [95% CI, 1.31-1.78]; FDR-corrected P < .001). In contrast, children's alcohol, cannabis, and prescription drug use were not associated with SAs.

Conclusions and Relevance

This study of US children suggests that the increased risk of SAs, consistently reported for adolescents and adults who smoke cigarettes, extends to a range of emerging tobacco products and manifests among elementary school-aged children. Further investigations are imperative to clarify the underlying mechanisms and to implement effective preventive policies for children.

Recent advances in the analysis of electronic cigarette liquids and aerosols: Sample preparation and chromatographic characterization

Electronic cigarette (e-cigarette) usage has risen dramatically worldwide in recent years. It has been publicized as a safer alternative to the conventional combustible cigarette. This, however, has not yet been supported by robust toxicological research evidence. Analysis of the chemical compositions of e-liquids and generated aerosols is an important step in evaluating the toxicity effects of e-cigarettes. Currently, a broad spectrum of analytical methods have been employed for qualitative and quantitative analysis of chemical compositions of e-cigarette liquids and aerosols. The aim of this article is to review the advances in the chromatographic characterization of chemical composition of the latter in the recent five years. In addition, sample preparation methods for e-liquids and aerosols are surveyed and discussed. A study of the relevant literature indicates that, expectedly, gas chromatography and liquid chromatography with a variety of detection systems, particularly mass spectrometry, have been the main analytical techniques used in this field. Sample preparation procedures primarily include headspace sampling, dilute-and-shoot approach, liquid-liquid extraction and sorbent-based extraction for e-liquids and for aerosols (the latter usually with laboratory-built collection devices). Some challenges of current e-cigarette analytical research, and an overview on prospective work are also presented.

Respiratory health effects of e-cigarette substitution for tobacco cigarettes: a systematic review

BACKGROUND

E-cigarettes (electronic nicotine delivery system, ENDS) have been presented as a harm reduction strategy for people who smoke tobacco cigarettes but who cannot achieve abstinence, or for those who wish to continue to enjoy nicotine and the habit of smoking. What are the health effects of the substitution of ENDS for tobacco cigarettes? This systematic review evaluates the evidence of human clinical tests on the respiratory effects of ENDS use in participants who smoke tobacco cigarettes.

METHODS

A registered and published protocol was developed conforming to PRISMA 2020 and AMSTAR2 standards. The literature search was conducted in PubMed, Scopus, and the CENTRAL Cochrane Library and updated to May 2022. Three supplementary searches and a grey literature search were performed. Studies were evaluated with the JBI quality tools and the Oxford Catalogue of Bias. Due to the heterogeneity (diversity) of the studies, a narrative data synthesis was performed on the test findings plus three sub-group analyses.

RESULTS

The review consists of sixteen studies and twenty publications. Spirometry tests comprised the majority of the data. In total, 66 respiratory test measurements were reported, out of which 43 (65%) were not significant. Statistically significant findings were mixed, with 9 tests showing improvements and 14 measuring declines, none of which was clinically relevant. Ten studies were rated at a high risk of bias, and six had some concerns primarily due to inadequate research designs and the conduct of the studies. Reporting bias was documented in thirteen studies.

CONCLUSIONS

Most of the studies showed no difference in respiratory parameters. This indicates that ENDS substitution for smoking likely does not result in additional harm to respiratory health. Due to the low quality of the studies, confidence in the conclusions is rated as low. Robust studies with a longer duration and sufficient power are required to validate any potential benefits or possible harms of ENDS substitution. Registration PROSPERO #CRD42021239094, International Registered Report Identifier (IRRID): DERR1-10.2196/29084.

The toxic effects of electronic cigarette aerosol and cigarette smoke on cardiovascular, gastrointestinal and renal systems in mice

Electronic cigarette (EC) has been suggested to be less harmful than cigarette smoking, but the research on the full extent of their harm reduction potential is still lacking. This study aimed to evaluate the influence of EC aerosol and cigarette smoke (CS) on cardiovascular, gastrointestinal, and renal functions in mice after prolonged exposure. Forty-eight C57BL/6J male mice were randomly grouped and then exposed to fresh air (control), mung bean-flavored EC aerosol with low and high dose (EC1L, 6 mg/kg; EC1H, 12 mg/kg), watermelon-flavored EC aerosol with low and high dose (EC2L, 6 mg/kg; EC2H, 12 mg/kg), and finally a cigarette smoke (CS, 6 mg/kg), respectively. After 10 weeks of exposure, the heart rate increased for both the EC and CS groups, and the effect of CS on blood oxygen saturation was significantly higher than that of the EC group (P < 0.01). Proteomic analysis of the heart tissue showed that the overlapped differential expression protein from the EC and CS exposures was Crip2. For the gastrointestinal system, oral mucosa was significantly damaged in CS group. Compare with CS, EC had significantly fewer negative effects on most of the indictors which focused on in this study.

User-generated content and influencer marketing involving e-cigarettes on social media: a scoping review and content analysis of YouTube and Instagram

BACKGROUND

Evidence suggests that experimentation with e-cigarettes among young people is increasing. Social media is widely used by young people with user-generated content and influencer marketing particularly influential in promoting products. This paper documents a snapshot of online user-generated content and influencer marketing related to e-cigarettes on YouTube and Instagram.

METHODS

Scoping review of relevant e-cigarette-related content on two social media platforms popular with youths, YouTube and Instagram, between June and August 2021. Content analysis was undertaken to examine text, audio, and video content, recording age restrictions, health warnings, page characteristics, and post characteristics. Narrative post content was coded using a coding frame that was developed inductively in response to emergent categories.

RESULTS

Vaping was portrayed positively on social media; of the posts analysed, 86.5% (n = 90 of 104) of Instagram posts and 66.0% (n = 64 of 97) of YouTube videos. Warnings about age restrictions and health (e.g., nicotine addiction/toxicity) did not feature in the majority of posts; 43.3% (n = 42) of YouTube videos (n = 42) contained an age warning compared to 20.2% of Instagram posts (n = 21). While 25.8% (n = 25) of YouTube videos and 21.2% of Instagram (n = 22) posts contained a health warning.

CONCLUSION

Of concern is the fact that the vast majority of YouTube and Instagram content about e-cigarettes promoted their use, and typically the content does not contain age and/or health warnings. These findings may highlight a priority for governmental policy to restrict the ability of marketers to reach youths with social media content promoting e-cigarettes.

Preliminary toxicological assessment of heated tobacco products: A review of the literature and proposed strategy

Heated tobacco products (HTP) have become increasingly common in many countries worldwide. The principle of heating tobacco, without combustion, to produce a nicotine-containing aerosol with remarkably reduced levels of other known toxins, compared to combusted tobacco cigarettes, is now well established. As these products are intended as alternatives to traditional combusted products, during the early stages of their development, it is important for manufacturers to ensure that the design of the product does not lead to any unintentionally increased or new risk for the consumer, compared to the traditional products that consumers seek to replace. There is limited guidance from tobacco product regulations concerning the requirements for performing such preliminary toxicological assessments. Here, we review the published literature on studies performed on HTPs in the pursuit of such data, outline a proposed approach that is consistent with regulatory requirements, and provide a logical approach to the preliminary toxicological assessment of HTPs.

Clinical testing of the cardiovascular effects of e-cigarette substitution for smoking: a living systematic review

Some persons who smoke have substituted e-cigarettes for tobacco cigarettes, either completely or partially. What effect does this have on cardiovascular functioning? We conducted a living systematic review on human clinical studies measuring the cardiovascular effects of e-cigarette substitution for smoking. The Scopus, PubMed, and CENTRAL Cochrane Library databases were searched on January 31 and April 29, 2021. Three secondary searches and a grey literature search were conducted. Included study designs were randomized controlled trials, quasi-experimental clinical trials, and cohort studies. Risk of bias and study quality were evaluated with the JBI Critical Appraisal tools and the Oxford Catalogue of Bias. The systematic review covered 25 studies comprising 1810 participants who smoked. Twenty studies were rated at high risk of bias, and five as some concerns. A tabular synthesis by direction of effect was conducted due to heterogeneity in the data. Nearly two-thirds of the test analyses indicated that e-cigarette use had no significance difference compared with tobacco cigarettes on heart rate, blood pressure, and in other cardiovascular tests. In two studies, participants with hypertension experienced a clinically relevant reduction in systolic blood pressure after 1 year of e-cigarette use. E-cigarette substitution incurs no additional cardiovascular risks, and some possible benefits may be obtained, but the evidence is of low to very low certainty. An update search on May 30, 2022 retrieved five studies that did not alter our conclusion.Registration PROSPERO #CRD42021239094.

In Vitro Biological Effects of E-Cigarette on the Cardiovascular System-Pro-Inflammatory Response Enhanced by the Presence of the Cinnamon Flavor

The potential cardiovascular effects of e-cigarettes remain largely unidentified and poorly understood. E-liquids contain numerous chemical compounds and can induce exposure to potentially toxic ingredients (e.g., nicotine, flavorings, etc.). Moreover, the heating process can also lead to the formation of new thermal decomposition compounds that may be also hazardous. Clinical as well as in vitro and in vivo studies on e-cigarette toxicity have reported potential cardiovascular damages; however, results remain conflicting. The aim of this study was to assess, in vitro, the toxicity of e-liquids and e-cigarette aerosols on human aortic smooth muscle cells. To that purpose, cells were exposed either to e-liquids or to aerosol condensates obtained using an e-cigarette device at different power levels (8 W or 25 W) to assess the impact of the presence of: (i) nicotine, (ii) cinnamon flavor, and (iii) thermal degradation products. We observed that while no cytotoxicity and no ROS production was induced, a pro-inflammatory response was reported. In particular, the production of IL-8 was significantly enhanced at a high power level of the e-cigarette device and in the presence of the cinnamon flavor (confirming the suspected toxic effect of this additive). Further investigations are required, but this study contributes to shedding light on the biological effects of vaping on the cardiovascular system.

E-cigarette addiction and harm perception: Does initiation flavor choice matter?

Introduction

The 21^st century was marked by a dramatic increase in adolescent e-cigarette use in the United States (US). The popularity of non-traditional flavor types, including fruit and pastry, is thought to contribute toward growing product use nationally, leading to a variety of federal and state regulations limiting the use of non-traditional flavors in the US. The relationship between flavor type and increased adolescent use suggests a possible link between flavor use and addiction and harm perception. This study assessed if the flavor type used when initiating e-cigarette use predicted addiction and harm perceptions.

Methods

The study utilized data from the multi-wave youth Population Assessment of Tobacco Health Study. It explored the impact initiating e-cigarette use with traditional versus non-traditional flavor types among cigarette users on the outcome variables: e-cigarette addiction and harm perception. Both e-cigarette addiction and harm perception were measured using self-report, Likert scale questionnaires. Descriptive statistics characterized the study variables and linear regression analyses performed to test whether flavor initiation type is associated with addiction and harm perception.

Results

The study sample consisted of 1,043 youth (weighted N = 1,873,617) aged 12 to 17 years who reported at least one instance of e-cigarette use. After adjusting for age, age of onset, sex, race and annual household income there was no statistically significant difference in addiction levels between those initiating with traditional versus non-traditional flavors (p = 0.294). Similarly, traditional versus non-traditional flavor initiation did not show a statistically significant difference in adolescent e-cigarette harm perceptions (p = 0.601).

Conclusions

Traditionally flavored e-cigarette initiation produces similar risk for addiction and harm perceptions as non-traditionally flavored initiation. These findings suggest that banning non-traditional flavors alone may be ineffective in curbing e-cigarette addiction and harm perception. Additional research is needed to better understand which e-cigarette product characteristics and behaviors may be associated with greater addiction and reduced harm perceptions.

Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies

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.

E-cigarettes and youth: an unresolved Public Health concern

The use of electronic cigarettes (e-cigarette) and vaping devices started as a potential aid for cessation and reducing the harmful consequences of cigarette smoking, mainly in the adult population. Today e-cigarette use is highly increasing in vulnerable populations, especially young and pregnant women, due to the misconception of its harmless use.

Despite the growing acknowledgment in e-cigarette as a potential harmful device, and due to mixed information found concerning its beneficial aid for smokers, along with an insufficient clinical study done in human models, it is important to further evaluate the possible benefits and risks of non-combusting, vaping nicotine or non-nicotine delivery devices.

In this review we tried to summarize the latest updated information found in the literature, concentrating mainly in the variety of adverse effects of e-cigarette use and its contribution for recent and future health concerns.

A Review of Toxicity Mechanism Studies of Electronic Cigarettes on Respiratory System

Electronic cigarettes (e-cigarettes) have attracted much attention as a new substitute for conventional cigarettes. E-cigarettes are first exposed to the respiratory system after inhalation, and studies on the toxicity mechanisms of e-cigarettes have been reported. Current research shows that e-cigarette exposure may have potentially harmful effects on cells, animals, and humans, while the safety evaluation of the long-term effects of e-cigarette use is still unknown. Similar but not identical to conventional cigarettes, the toxicity mechanisms of e-cigarettes are mainly manifested in oxidative stress, inflammatory responses, and DNA damage. This review will summarize the toxicity mechanisms and signal pathways of conventional cigarettes and e-cigarettes concerning the respiratory system, which could give researchers a better understanding and direction on the effects of e-cigarettes on our health.

Assessing variability of aerosols generated from e-Cigarettes

While some in vitro and in vivo experiments have studied the toxic effects of e-cigarette (e-cig) components, the typical aerosol properties released from e-cigarettes have not been well characterized. In the present study, we characterized the variability in mass concentration and particle size distribution associated with the aerosol generation of different devices and e-liquid compositions in an experimental setup. The findings of this study indicate a large inter-day variability in the experiments, likely due to poor quality control in some e-cig devices, pointing to the need for a better understanding of all the factors affecting exposures in in vitro and in vivo experiments, and the development of standardized protocols for generation and measurement of e-cig aerosols.

Comparison of the in vivo genotoxicity of electronic and conventional cigarettes aerosols after subacute, subchronic and chronic exposures

Tobacco smoking is classified as a human carcinogen. A wide variety of new products, in particular electronic cigarettes (e-cigs), have recently appeared on the market as an alternative to smoking. Although the in vitro toxicity of e-cigs is relatively well known, there is currently a lack of data on their long-term health effects. In this context, the aim of our study was to compare, on a mouse model and using a nose-only exposure system, the in vivo genotoxic and mutagenic potential of e-cig aerosols tested at two power settings (18 W and 30 W) and conventional cigarette (3R4F) smoke. The standard comet assay, micronucleus test and Pig-a gene mutation assay were performed after subacute (4 days), subchronic (3 months) and chronic (6 months) exposure. The generation of oxidative stress was also assessed by measuring the 8-hydroxy-2'-deoxyguanosine and by using the hOGG1-modified comet assay. Our results show that only the high-power e-cig and the 3R4F cigarette induced oxidative DNA damage in the lung and the liver of exposed mice. In return, no significant increase in chromosomal aberrations or gene mutations were noted whatever the type of product. This study demonstrates that e-cigs, at high-power setting, should be considered, contrary to popular belief, as hazardous products in terms of genotoxicity in mouse model.

Progress in quantification of nicotine content and form distribution in electronic cigarette liquids and aerosols

Each electronic cigarette (e-cigarette) is a battery-powered system which converts electronic cigarette liquids (e-liquids) into the inhalable phase by heating the solution when it is in use. After four generations of development, e-cigarettes tend to be more customized and user-operable. The main components in the e-liquid and the aerosol are vegetable glycerin, propylene glycol, nicotine, organic acid and some flavor ingredients. Among them, nicotine is closely associated with the irritation and physiological satisfaction caused by tobacco products, and it is the core functional substance of e-cigarettes. For this reason, the quantification of nicotine content and nicotine form distribution mainly focuses on the components of the e-liquid and the released aerosol. Up to now, various technologies and methods have been applied in the analysis and research of nicotine content and nicotine form distribution in the e-liquid and its aerosol. GC-MS is often used as the most viable tool for the analysis of volatile organic compounds and can be widely applied in the measurement of nicotine related chemicals; there are a number of quantitation strategies using LC-MS, LC-MS/MS or ¹H NMR for the analysis of e-cigarette samples. We also reviewed the four main methods for determining the distribution of nicotine forms, which are pH value derivation, solvent extraction, SPME and NMR methods. These research methods are of great significance to the upgrading and development of e-cigarette products.

In Vitro Systems for Toxicity Evaluation of Microbial Volatile Organic Compounds on Humans: Current Status and Trends

Microbial volatile organic compounds (mVOC) are metabolic products and by-products of bacteria and fungi. They play an important role in the biosphere: They are responsible for inter- and intra-species communication and can positively or negatively affect growth in plants. But they can also cause discomfort and disease symptoms in humans. Although a link between mVOCs and respiratory health symptoms in humans has been demonstrated by numerous studies, standardized test systems for evaluating the toxicity of mVOCs are currently not available. Also, mVOCs are not considered systematically at regulatory level. We therefore performed a literature survey of existing in vitro exposure systems and lung models in order to summarize the state-of-the-art and discuss their suitability for understanding the potential toxic effects of mVOCs on human health. We present a review of submerged cultivation, air-liquid-interface (ALI), spheroids and organoids as well as multi-organ approaches and compare their advantages and disadvantages. Furthermore, we discuss the limitations of mVOC fingerprinting. However, given the most recent developments in the field, we expect that there will soon be adequate models of the human respiratory tract and its response to mVOCs.

Considerations on dosimetry for in vitro assessment of e-cigarette toxicity

Electronic cigarettes (or e-cigarettes) can be used as smoking cessation aid. Some studies tend to show that they are less hazardous than tobacco cigarettes, even if it does not mean they are completely safe. The huge variation in study designs assessing in vitro toxicity of e-cigarettes aerosol makes it difficult to make comparisons and draw robust and irrefutable conclusions. In this paper, we review this heterogeneity (in terms of e-cigarette products, biological models, and exposure conditions) with a special focus on the wide disparity in the doses used as well as in the way they are expressed. Finally, we discuss the major issue of dosimetry and show how dosimetry tools enable to align data between different exposure systems or data from different laboratories and therefore allow comparisons to help further exploring the risk potential of e-cigarettes.

Association of Mixed Use of Electronic and Conventional Cigarettes and Exposure to Secondhand Smoke With Prediabetes

CONTEXT

Despite previous studies regarding the association between smoking and diabetes, the effects of electronic cigarettes and secondhand smoke (SHS) on glucose metabolism and insulin sensitivity have not been fully elucidated.

OBJECTIVE

To examine the association of mixed electronic and conventional cigarette use and exposure to SHS with prediabetes.

DESIGN

Data from the 2014-2018 Korean National Health and Nutrition Examination Survey were analyzed.

SETTING

Nationwide population-based.

PARTICIPANTS

Of 39 199 participants, 22 385 participants (9490 men, 12 895 women) without diabetes were included. The main independent variables were smoking behaviors, including exposure to SHS.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Prediabetes (hemoglobin A1C of 5.7-6.4%).

RESULTS

Of 22 385 participants without diabetes, 6735 had prediabetes. Mixed cigarette use was associated with a 1.57-fold increase in the odds of prediabetes when compared with never-smoking [odds ratio (OR) = 1.57, 95% CI = 1.29-1.92] and a 1.27-fold increase when compared with conventional cigarette use only (OR = 1.27, 95% CI = 1.07-1.52). Participants who were current nonsmokers, but mixed users in the past had an increased risk of prediabetes (OR = 1.54, 95% CI = 1.04-2.13). There was no significant association between prediabetes and current nonsmoking in individuals with previous conventional cigarette use only. Among never-smokers, exposure to SHS significantly increased the risk of prediabetes (OR = 1.16, 95% CI = 1.04-1.30).

CONCLUSIONS

Mixed use of electronic and conventional cigarettes and exposure to SHS increased the risk of prediabetes. Further studies are required to comprehensively investigate the molecular biology underlying the effects of previous and current mixed use of electronic cigarettes and SHS on glucose metabolism.

Diluted aqueous extract of heat-not-burn tobacco product smoke causes less oxidative damage in fibroblasts than conventional cigarette

Smoke from conventional cigarettes (C-cigarettes) contains various reactive oxygen species and toxic chemicals, which potentially cause oxidative damage not only to airways but also to the whole body, leading eventually to diseases, including emphysema, advanced atherosclerosis, and cancer. Many heat-not-burn tobacco products (HTPs) have been commercialized recently in Japan to maintain the smoking population by advertising that HTPs are less toxic. However, there were few studies reported from neutral organizations whether HTPs are indeed less damaging. To evaluate the potential capacity of HTPs to induce oxidative stress, we here compared two different HTPs with two types of C-cigarettes, using human fibroblast IMR90SV cells and 5% aqueous extracts in 10-ml phosphate-buffered saline (50-ml smoke/10 s). HTPs exhibited significantly lower oxidative toxicity in comparison to C-cigarettes. Whereas C-cigarettes induced ferroptosis in fibroblasts, the effects of HTPs were significantly reduced by measuring the levels of peroxides, pro-inflammatory cytokine expression, autophagy, catalytic Fe(II) and 8-hydroxy-2'-deoxyguanosine. Notably, major portions of C-cigarettes-induced pathogenic responses were inhibited by catalase. However, HTPs still induced p62 autophagy-adaptor at 5%-dilution and caused lethal effects to fibroblasts with undiluted solution. In conclusion, HTPs smoke per se can be toxic despite less toxicity in comparison to C-cigarettes, which warrants further investigation.

ICP-MS Determination of 23 Elements of Potential Health Concern in Liquids of e-Cigarettes. Method Development, Validation, and Application to 37 Real Samples

The lack of interest in the determination of toxic elements in liquids for electronic cigarettes (e-liquids) has so far been reflected in the scarce number of accurate and validated analytical methods devoted to this aim. Since the strong matrix effects observed for e-liquids constitute an exciting analytical challenge, the main goal of this study was to develop and validate an ICP-MS method aimed to quantify 23 elements in 37 e-liquids of different flavors. Great attention has been paid to the critical phases of sample pre-treatment, as well as to the optimization of the ICP-MS conditions for each element and of the quantification. All samples exhibited a very low amount of the elements under investigation. Indeed, the sum of their average concentration was of ca. 0.6 mg kg-1. Toxic elements were always below a few tens of a μg per kg-1 and, very often, their amount was below the relevant quantification limits. Tobacco and tonic flavors showed the highest and the lowest concentration of elements, respectively. The most abundant elements came frequently from propylene glycol and vegetal glycerin, as confirmed by PCA. A proper choice of these substances could further decrease the elemental concentration in e-liquids, which are probably barely involved as potential sources of toxic elements inhaled by vapers.

The chemistry and toxicology of vaping

Vaping is the process of inhaling and exhaling an aerosol produced by an e-cigarette, vape pen, or personal aerosolizer. When the device contains nicotine, the Food and Drug Administration (FDA) lists the product as an electronic nicotine delivery system or ENDS device. Similar electronic devices can be used to vape cannabis extracts. Over the past decade, the vaping market has increased exponentially, raising health concerns over the number of people exposed and a nationwide outbreak of cases of severe, sometimes fatal, lung dysfunction that arose suddenly in otherwise healthy individuals. In this review, we discuss the various vaping technologies, which are remarkably diverse, and summarize the use prevalence in the U.S. over time by youths and adults. We examine the complex chemistry of vape carrier solvents, flavoring chemicals, and transformation products. We review the health effects from epidemiological and laboratory studies and, finally, discuss the proposed mechanisms underlying some of these health effects. We conclude that since much of the research in this area is recent and vaping technologies are dynamic, our understanding of the health effects is insufficient. With the rapid growth of ENDS use, consumers and regulatory bodies need a better understanding of constituent-dependent toxicity to guide product use and regulatory decisions.

Airway-On-A-Chip: Designs and Applications for Lung Repair and Disease

The lungs are affected by illnesses including asthma, chronic obstructive pulmonary disease, and infections such as influenza and SARS-CoV-2. Physiologically relevant models for respiratory conditions will be essential for new drug development. The composition and structure of the lung extracellular matrix (ECM) plays a major role in the function of the lung tissue and cells. Lung-on-chip models have been developed to address some of the limitations of current two-dimensional in vitro models. In this review, we describe various ECM substitutes utilized for modeling the respiratory system. We explore the application of lung-on-chip models to the study of cigarette smoke and electronic cigarette vapor. We discuss the challenges and opportunities related to model characterization with an emphasis on in situ characterization methods, both established and emerging. We discuss how further advancements in the field, through the incorporation of interstitial cells and ECM, have the potential to provide an effective tool for interrogating lung biology and disease, especially the mechanisms that involve the interstitial elements.

Toxicity of electronic cigarettes: A general review of the origins, health hazards, and toxicity mechanisms

Electronic cigarettes (E-cigarette) are an alternative for traditional cigarette smokers to quit smoking. Based on the current understanding, electronic cigarettes have rapidly become popular among existing smokers and former non-smokers. However, increasing research at different levels reveals that e-cigarettes are unsafe. This review provides an overview of the toxicology of e-cigarettes based on existing in vivo and in vitro studies and compares their toxicity with that of traditional cigarettes. Moreover, we describe the associated toxicity components in e-cigarettes, as well as the potential mechanism by which e-cigarettes exert toxic effects. As is known to all, the nicotine in traditional cigarettes and e-cigarettes has certain toxicity. Besides, a few studies have shown that propylene glycol and vegetable glycerin mixture and flavoring agents in e-cigarettes also are the key components causing adverse effects in animals or cells. There is insufficient scientific evidence on the toxicity of e-cigarettes due to the lack of standardized research methods, prompting the need to conduct a comprehensive toxicity assessment of e-cigarette toxicity to elucidate the safety issues of e-cigarettes. Eventually, a basis for decision-making on whether people use e-cigarettes will be obtained.

Respiratory and Cardiovascular Health Effects of e-Cigarette Substitution: Protocol for Two Living Systematic Reviews

Background

Despite the clear risks of tobacco use, millions of people continue to smoke. Electronic nicotine delivery systems (ENDS), commonly called e-cigarettes, have been proposed as a substitute for those who are unwilling or unable to quit. Current systematic and narrative reviews on the health effects of ENDS use, particularly respiratory and cardiovascular effects, have come to differing conclusions.

Objective

We conducted two systematic reviews to critically assess and synthesize available human studies on the respiratory and cardiovascular health effects of ENDS substitution for people who smoke. The primary goal is to provide clinicians with evidence on the health effects of ENDS substitution to inform their treatment recommendations and plans. The twin goal of the reviews is to promote health literacy in ENDS users with facts on the health effects of ENDS.

Methods

These two reviews will be living systematic reviews. The systematic reviews will be initiated through a baseline review. Studies will be evaluated using the JBI quality assessment tools and a checklist of biases drawn from the Centre for Evidence Based Medicine Catalogue of Bias. A narrative synthesis is planned because of the heterogeneity of data. A search for recently published studies will be conducted every 3 months, and an updated review will be published every 6 months for the duration of the project or possibly longer.

Results

The baseline and updated reviews will be published in a peer-reviewed journal. The findings of the reviews will be reported in a white paper for clinicians and a fact sheet for people who use ENDS.

Conclusions

The substitution of ENDS for cigarettes is one way to potentially reduce the risks of smoking. Clinicians and their patients need to understand the potential benefits and possible risks of substituting ENDS for cigarettes. Our living systematic reviews seek to highlight the best and most up-to-date evidence in this highly contentious and fast-moving field of research.

Trial Registration

PROSPERO CRD42021239094; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=239094

International Registered Report Identifier (IRRID)

DERR1-10.2196/29084

A randomized controlled study in healthy participants to explore the exposure continuum when smokers switch to a tobacco heating product or an E-cigarette relative to cessation

Background

Cigarette smoking is associated with a number of diseases, such as cancer and cardiovascular diseases. Recently, there has been an increase in the use of electronic cigarettes (ECs) and tobacco-heating products (THPs) as an alternative to cigarettes, which may reduce the health burden associated with smoking. However, an exposure continuum when smokers switch to ECs or THPs compared to complete smoking cessation is not well established.

Methods

148 healthy smokers were randomized to either continue smoking cigarettes, switch to using the glo THP or a prototype EC, or completely quit any nicotine or tobacco product use for 5 days, after a 2-day baseline period. During this study breath and 24-h urine samples were collected for Biomarker of Exposure (BoE) analysis.

Results

After a 5-day switching period BoE levels showed a substantial significant decrease in levels from baseline in the groups using the glo THP, the prototype EC, and having quit all nicotine and tobacco use. On an exposure continuum, smokers who completely quit nicotine had the lowest levels of assessed BoEs, followed by those who switched to the EC and then those who switched to glo THP use. Participants who continued to smoke had the highest levels of BoEs.

Conclusions

THP or EC use over a 5-day period resulted in significant reductions in exposure to smoke toxicants, in some cases to levels similar to those for nicotine cessation. These results show that on an exposure continuum, nicotine cessation gives the greatest reduction in exposure to tobacco smoke toxicants, closely followed by the EC and the glo THP. These significant reductions in exposure to toxicants suggest that the glo THP and EC have the potential to be Reduced Risk Products.

Study Registration

ISRCTN80651909.

Association of Cigarette Type Initially Smoked With Suicidal Behaviors Among Adolescents in Korea From 2015 to 2018

IMPORTANCE

Assessment of whether past electronic cigarette (e-cigarette) use or initiating smoking with e-cigarettes is associated with suicidal behaviors among adolescents is needed to inform future research and public health interventions.

OBJECTIVE

To evaluate the association between starting smoking with e-cigarettes or conventional cigarettes and suicidal behaviors among Korean adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data on adolescents in grades 7 through 12 who participated in the nationwide Korea Youth Risk Behavior Web-Based Survey between 2015 and 2018.

EXPOSURES

Type of cigarette initially smoked: electronic or conventional.

MAIN OUTCOMES AND MEASURES

Multiple logistic regression analysis was performed to examine the association between initial cigarette type and suicidal behaviors, including suicidal ideation and suicide planning and attempts. All participants completed questionnaires about their history of suicidal behavior and were categorized into groups according to the type of cigarette used at initiation of smoking and any subsequent change (or lack of change) in the type of cigarette used.

RESULTS

A total of 255 887 Korean adolescents (51.2% male; mean (SD) age, 15.0 [1.8] years) were included in the primary analysis. Among 131 094 male adolescents, 3310 boys (2.5%) initially used e-cigarettes and 27 368 boys (20.9%) initially used conventional cigarettes. Among 124 793 female adolescents, 952 girls (0.8%) initially used e-cigarettes and 9296 girls (7.4%) initially used conventional cigarettes. Of those who initially used e-cigarettes, 178 of 3310 boys (5.4%) and 134 of 952 girls (14.1%) attempted suicide. Of those who initially used conventional cigarettes, 946 of 27 368 boys (3.5%) and 911 of 9296 girls (9.8%) attempted suicide. Adolescents who initially used e-cigarettes had a higher risk of suicidal behaviors, including suicide planning (boys: adjusted odds ratio [AOR], 1.63 [95% CI, 1.40-1.89]; P < .001; girls: AOR, 1.55 [95% CI, 1.23-1.95]; P < .001) and suicide attempts (boys: AOR, 1.55 [95% CI, 1.28-1.87]; P < .001; girls, AOR, 1.64 [95% CI, 1.29-2.10]; P < .001) compared with those who initially used conventional cigarettes. Changing from e-cigarettes to conventional cigarettes was associated with a higher risk of suicide attempts among both boys (AOR, 1.89; 95% CI, 1.39-2.57; P < .001) and girls (AOR, 2.36; 95% CI, 1.53-3.64; P < .001) compared with changing from conventional cigarettes to e-cigarettes.

CONCLUSIONS AND RELEVANCE

In this study, the initial use of e-cigarettes vs conventional cigarettes was associated with suicidal behaviors among adolescents. In future research on the association of e-cigarette use with adolescent mental health and interventions for suicide prevention, the type of cigarette initially used and changing the cigarette type should be considered.

Electronic Cigarettes and Oral Health

Novel nicotine products, particularly electronic cigarettes (e-cigarettes), have become increasingly popular over the past decade. E-cigarettes are sometimes regarded as a less harmful alternative to tobacco smoking, and there is some evidence of their potential role as a smoking cessation aid. However, there are concerns about their health consequences, particularly in users who are not tobacco smokers, and also when used long term. Given the mode of delivery of these products, there is potential for oral health consequences. Over the past few years, there have been an increasing number of studies conducted to explore their oral health effects. In vitro studies have reported a range of cellular effects, but these are much less pronounced than those resulting from exposure to tobacco smoke. Microbiological studies have indicated that e-cigarette users have a distinct microbiome, and there is some indication this may be more pathogenic compared to nonusers. Evidence of oral health effects from clinical trials is still limited, and most studies to date have been small in scale and usually cross-sectional in design. Epidemiological studies highlight concerns over oral dryness, irritation, and gingival diseases. Interpreting data from e-cigarette studies is challenging, given the different populations that have been investigated and the continual emergence of new products. Overall, studies reveal potential oral health harms, underscoring the importance of efforts to reduce use in nonsmokers. However, in smokers who are using e-cigarettes as an aid to help them quit, the benefits of quitting tobacco smoking may outweigh any negative oral health impacts of e-cigarette use, particularly in the short term. Future research is needed to understand the clinical significance of some of the biological changes observed by following different cohorts of users longitudinally in carefully designed clinical studies and pragmatic trials supported by high-quality in vitro studies.

Critical appraisal of the European Union Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) Preliminary Opinion on electronic cigarettes

BACKGROUND

In preparation for the 2021 revision of the European Union Tobacco Products Directive, the Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) has posted its Preliminary Opinion on Electronic Cigarettes. They concluded that e-cigarettes only achieve a sub-optimal level of protection of human health. In this paper, we provide evidence that the Opinion's conclusions are not adequately backed up by scientific evidence and did not discuss the potential health benefits of using alternative combustion-free nicotine-containing products as substitute for tobacco cigarettes.

METHODS

Searches for articles were conducted in PubMed and by citation chasing in Google Scholar. Articles were also retrieved with a review of references in major publications. Primary data from World Health Organization surveys, the conclusions of reviews, and peer-reviewed non-industry studies were cited to address errors and omissions identified in the Opinion.

RESULTS

The Opinion omitted reporting on the individual and population health benefits of the substitution of e-cigarettes (ENDS) for cigarette smoking. Alternative hypotheses to the gateway theory were not evaluated. Its assessment of cardiovascular risk is contradicted by numerous reviews. It cites ever-use data that do not represent current patterns of use. It did not report non-nicotine use. It presented erroneous statements on trends in ENDS prevalence. It over-emphasized the role of flavours in youth ENDS initiation. It did not discuss cessation in sufficient length.

CONCLUSIONS

For the delivery of a robust and comprehensive final report, the members of the Working Group of the Scientific Committee on Health, Environmental and Emerging Risks will need to consider (1) the potential health benefits of ENDS substitution for cigarette smoking, (2) alternative hypotheses and contradictory studies on the gateway effect, (3) its assessment of cardiovascular risk, (4) the measurements of frequency of use, (5) non-nicotine use, (6) the role of flavours, and (7) a fulsome discussion of cessation.

Severe neurological nicotine intoxication by e-cigarette liquids: Systematic literature review

Electronic cigarettes are a popular, easily purchased, alternative source of nicotine that is considered safer than conventional tobacco. However, Intentional or accidental exposure to e-liquid substances, mainly nicotine, can lead to serious, potentially fatal toxicity. Emergency and critical care physicians should keep in mind acute intoxication of this poison with a biphasic toxic syndrome. We highlight its potentially fatal outcome and suggest monitoring the adverse effects of nicotine according to a multimodal protocol integrating somatosensory evoked potentials, electroencephalography and neuroimaging data with anamnestic report and toxicological and laboratory data.

Comparison of the biological impact of aerosol of e-vapor device with MESH® technology and cigarette smoke on human bronchial and alveolar cultures

Exposure to aerosol from electronic vapor (e-vapor) products has been suggested to result in less risk of harm to smokers than cigarette smoke (CS) exposure. Although many studies on e-vapor products have tested the effects of liquid formulations on cell cultures, few have evaluated the effects of aerosolized formulations. We examined the effects of acute exposure to the aerosol of an e-vapor device that uses the MESH® technology (IQOS® MESH, Philip Morris International) and to CS from the 3R4F reference cigarette on human organotypic bronchial epithelial culture and alveolar triculture models. In contrast to 3R4F CS exposure, exposure to the IQOS MESH aerosol (Classic Tobacco flavor) did not cause cytotoxicity in bronchial epithelial cultures or alveolar tricultures despite its greater concentrations of deposited nicotine (3- and 4-fold, respectively). CS exposure caused a marked decrease in the frequency and active area of ciliary beating in bronchial cultures, whereas IQOS MESH aerosol exposure did not. Global mRNA expression and secreted protein profiles revealed a significantly lower impact of IQOS MESH aerosol exposure than 3R4F CS exposure. Overall, our whole aerosol exposure study shows a clearly reduced impact of IQOS MESH aerosol relative to CS in bronchial and alveolar cultures, even at greater nicotine doses.

Comparison of the chemical composition of aerosols from heated tobacco products, electronic cigarettes and tobacco cigarettes and their toxic impacts on the human bronchial epithelial BEAS-2B cells

The electronic cigarettes (e-cigs) and more recently the heated tobacco products (HTP) provide alternatives for smokers as they are generally perceived to be less harmful than conventional cigarettes. However, it is crucial to compare the health risks of these different emergent devices, in order to determine which product should be preferred to substitute cigarette. The present study aimed to compare the composition of emissions from HTP, e-cigs and conventional cigarettes, regarding selected harmful or potentially harmful compounds, and their toxic impacts on the human bronchial epithelial BEAS-2B cells. The HTP emitted less polycyclic aromatic hydrocarbons and carbonyls than the conventional cigarette. However, amounts of these compounds in HTP aerosols were still higher than in e-cig vapours. Concordantly, HTP aerosol showed reduced cytotoxicity compared to cigarette smoke but higher than e-cig vapours. HTP and e-cig had the potential to increase oxidative stress and inflammatory response, in a manner similar to that of cigarette smoke, but after more intensive exposures. In addition, increasing e-cig power impacted levels of certain toxic compounds and related oxidative stress. This study provides important data necessary for risk assessment by demonstrating that HTP might be less harmful than tobacco cigarette but considerably more harmful than e-cig.

Addressing the challenges of E-cigarette safety profiling by assessment of pulmonary toxicological response in bronchial and alveolar mucosa models

Limited toxicity data on electronic cigarette (ECIG) impede evidence-based policy recommendations. We compared two popular mixed fruit flavored ECIG-liquids with and without nicotine aerosolized at 40 W (E-smoke) with respect to particle number concentrations, chemical composition, and response on physiologically relevant human bronchial and alveolar lung mucosa models cultured at air–liquid interface. E-smoke was characterized by significantly increased particle number concentrations with increased wattage (25, 40, and 55 W) and nicotine presence. The chemical composition of E-smoke differed across the two tested flavors in terms of cytotoxic compounds including p-benzoquinone, nicotyrine, and flavoring agents (for example vanillin, ethyl vanillin). Significant differences in the expression of markers for pro-inflammation, oxidative stress, tissue injury/repair, alarm anti-protease, anti-microbial defense, epithelial barrier function, and epigenetic modification were observed between the flavors, nicotine content, and/ or lung models (bronchial or alveolar). Our findings indicate that ECIG toxicity is influenced by combination of multiple factors including flavor, nicotine content, vaping regime, and the region of respiratory tree (bronchial or alveolar). Toxic chemicals and flavoring agents detected in high concentrations in the E-smoke of each flavor warrant independent evaluation for their specific role in imparting toxicity. Therefore, multi-disciplinary approaches are warranted for comprehensive safety profiling of ECIG.

How effective are electronic cigarettes for reducing respiratory and cardiovascular risk in smokers? A systematic review

Background

Electronic cigarettes (e-cigarettes) are widely promoted as harm-reduction products for smokers, and smokers commonly perceive them as less harmful than combustible cigarettes. One of the key questions regarding public health consequences of e-cigarettes is the magnitude of harm reduction achievable by smokers who switch from combustible cigarettes to e-cigarettes. We conducted a systematic literature review of epidemiological studies that estimated odds of respiratory and cardiovascular outcomes among former smokers who use e-cigarettes compared to current smokers.

Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We searched the PubMed and Embase databases in September 2020 to identify epidemiological studies that compared odds of cardiovascular and respiratory outcomes among former smokers who transitioned to e-cigarettes relative to odds among current smokers not using e-cigarettes (current exclusive smokers). We included studies that provided direct estimates of relevant odds ratios (ORs). We also included studies where indirect estimates of relevant ORs could be calculated based on published results. Two reviewers independently extracted data and conducted quality appraisals.

Results

Six population-based studies with sample sizes ranging from 19,475 to 161,529 respondents met review inclusion criteria, five of which were cross-sectional and one longitudinal. Three studies reported respiratory outcomes and three reported cardiovascular outcomes. ORs of respiratory outcomes (including chronic obstructive pulmonary disease, chronic bronchitis, emphysema, asthma, and wheezing) in former smokers who transitioned to e-cigarettes versus current exclusive smokers were below 1.0, ranging from 0.58 (95%CI 0.36–0.94) to 0.66 (95%CI 0.50–0.87; all p < 0.05). All ORs for cardiovascular outcomes (including stroke, myocardial infarction, and coronary heart disease) did not differ significantly from 1.0.

Conclusion

Though our review included a small number of studies, it provided consistent results. Former smokers who transitioned to e-cigarettes showed ~ 40% lower odds of respiratory outcomes compared to current exclusive smokers. Switching from smoking to e-cigarette does not appear to significantly lower odds of cardiovascular outcomes. Since the utility of cross-sectional studies for causal inference remains limited, both randomized controlled trials and prospective cohort studies are needed to better evaluate contributions of e-cigarettes as harm reduction tools for smokers.

Are In Silico Approaches Applicable As a First Step for the Prediction of e-Liquid Toxicity in e-Cigarettes?

Recent studies have raised concerns about e-cigarette liquid inhalation toxicity by reporting the presence of chemicals with European Union CLP toxicity classification. In this scenario, the regulatory context is still developing and is not yet up to date with vaping current reality. Due to the paucity of toxicological studies, robust data regarding which components in e-liquids exhibit potential toxicities, are still inconsistent. In this study we applied computational methods for estimating the toxicity of poorly studied chemicals as a useful tool for predicting the acute toxicity of chemicals contained in e-liquids. The purpose of this study was 3-fold: (a) to provide a lower tier assessment of the potential health concerns associated with e-liquid ingredients, (b) to prioritize e-liquid ingredients by calculating the e-tox index, and (c) to estimate acute toxicity of e-liquid mixtures. QSAR models were generated using QSARINS software to fill the acute toxicity data gap of 264 e-liquid ingredients. As a second step, the potential acute toxicity of e-liquids mixtures was evaluated. Our preliminary data suggest that a computational approach may serve as a roadmap to enable regulatory bodies to better regulate e-liquid composition and to contribute to consumer health protection.

History repeats itself: Role of characterizing flavors on nicotine use and abuse

The popularity of e-cigarettes has skyrocketed in recent years, and most vapers use flavored e-cigarette products. Consumption of flavored e-cigarettes exceeds that of combustible cigarettes and other tobacco products among adolescents, who are particularly vulnerable to becoming nicotine dependent. Flavorings have been used by the tobacco industry since the 17th century, but the use of flavors by the e-cigarette industry to create products with "characterizing" flavors (i.e. flavors other than tobacco or menthol) has sparked a public health debate. This review addresses the possibility that characterizing flavors make nicotine more appealing, rewarding and addictive. It also discusses ways in which preclinical and clinical studies could improve our understanding of the mechanisms by which flavors may alter nicotine reward and reinforcement. This article is part of the special issue on 'Contemporary Advances in Nicotine Neuropharmacology'.

Cytotoxic and genotoxic effects of e-liquids and their potential associations with nicotine, menthol and phthalate esters

In this study, we determined DNA damage and chromosome breakage (indicators of genotoxicity) and cell viability (an indicator of cytotoxicity) in human lymphoblastoid TK6 and Chinese hamster ovary (CHO) cells treated with 33 e-liquids using in vitro single cell gel (comet), micronucleus (MN), and trypan blue assays, respectively. We also measured the contents of nicotine, five phthalate esters, and DL-menthol in the e-liquids to examine their effects on DNA damage, chromosome breakage, and cell viability. Our chemical analyses showed that: (1) six e-liquids had nicotine ≥2-fold higher than the manufacture's label claim (2-3.5 mg); (2) both dimethyl- and dibutyl-phthalate levels were >0.1 μg/g, i.e., their threshold limits as additives in cosmetics; and (3) the DL-menthol contents ranged from 0.0003 to 85757.2 μg/g, with those of two e-liquids being >1 mg/g, the threshold limit for trigging sensory irritation. Though all the e-liquids induced DNA damage in TK6 cells, 20 resulted in cell viabilities ≤75%, indicating cytotoxicity, yet the inverse relationship between cell viability and DNA damage (r = -0.628, p = 0.003) might reflect their role as pro-apoptotic and DNA damage inducers. Fifteen e-liquids induced MN% in TK6 cells ≥3-fold that of untreated cells. Some of the increase in %MN might be false due to high cytotoxicity, yet six brands showed acceptable cell viabilities (59-71%), indicating chromosome damage. DNA damage and %MN increased when the TK6 cells were exposed to metabolic activation. The CHO cells were less sensitive to the genotoxic effects of the e-liquids than the TK6 cells. DL-menthol was found to be associated with decreased cell viability and increased DNA damage, even at low levels. We cannot dismiss the presence of other ingredients in e-liquids with cytotoxic/genotoxic properties since out of the 63 different flavors, 47 induced DNA damage (≥3-folds), and 26 reduced cell viability (≤75%) in TK6 cells.

Selected Harmful and Potentially Harmful Constituents Levels in Commercial e-Cigarettes

A broad range of commercially available electronic cigarette (e-cigarette) systems were tested for levels of emissions of harmful and potentially harmful constituents (HPHC), with a particular focus on the carbonyls: acetaldehyde, acrolein, and formaldehyde. The tobacco-specific nitrosamines N'-nitrosonornicotine and 4-(methylnitrosamino)-1-(3-bipyridyl)-1-butanone; the elements arsenic, cadmium, chromium, lead, and nickel; benzene; 1,3-butadiene; and benzo(a)pyrene were also quantified. The results show that except for the levels of carbonyls, all types of e-cigarettes performed in a similar manner, and emission levels for HPHCs were generally not quantifiable. However, levels of carbonyls, especially formaldehyde, were highly variable. Overall, the lowest levels of formaldehyde were observed in cartridge systems, which generally achieved substantial reductions in yields in comparison with cigarette smoke. Formaldehyde levels in open tank systems were variable; however, the median formaldehyde levels across different brands were substantially lower than the formaldehyde levels in cigarette smoke. The results for variable-power devices operated at the highest voltage confirmed existing literature data regardless of orientation and differences in puffing regimes. Furthermore, our results show that many products deliver consistent HPHC yields over a broad range of testing conditions (with minimal variability from one device to another, under a range of puffing conditions). However, some products exhibit high variability in emissions of HPHCs. The use of air blanks is further highlighted to assess nonproduct-related contributions to HPHC levels to avoid misrepresentation of the data. Overall, our results highlight that some but not all electronic cigarettes deliver low levels of carbonyls consistently across the full e-liquid depletion cycle under different test conditions. The need for further research and standardization work on assessment of variable-voltage electronic cigarettes is emphasized.