Relation between Tobacco Smoking/Electronic Smoking and Albuminuria/Vascular Stiffness in Young People without Cardiovascular Diseases

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Potentially modifiable factors associated with health-related quality of life among people with chronic kidney disease: baseline findings from the National Unified Renal Translational Research Enterprise CKD (NURTuRE-CKD) cohort

Background

Many non-modifiable factors are associated with poorer health-related quality of life (HRQoL) experienced by people with chronic kidney disease (CKD). We hypothesize that potentially modifiable factors for poor HRQoL can be identified among CKD patients, providing potential targets for intervention.

Method

The National Unified Renal Translational Research Enterprise Chronic Kidney Disease (NURTuRE-CKD) cohort study recruited 2996 participants from nephrology centres with all stages of non-dialysis-dependent CKD. Baseline data collection for sociodemographic, anthropometric, biochemical and clinical information, including Integrated Palliative care Outcome Scale renal, Hospital Anxiety and Depression score (HADS) and the 5-level EuroQol-5D (EQ-5D-5L) as HRQoL measure, took place between 2017 and 2019. EQ-5D-5L dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) were mapped to an EQ-5D-3L value set to derive index value. Multivariable mixed effects regression models, adjusted for known factors affecting HRQoL with recruitment region as a random effect, were fit to assess potentially modifiable factors associated with index value (linear) and within each dimension (logistic).

Results

Among the 2958/2996 (98.7%) participants with complete EQ-5D data, 2201 (74.4%) reported problems in at least one EQ-5D-5L dimension. Multivariable linear regression identified independent associations between poorer HRQoL (EQ-5D-3L index value) and obesity (body mass index ≥30.0 kg/m2, β -0.037, 95% CI -0.058 to -0.016, P = .001), HADS depression score ≥8 (β -0.159, -0.182 to -0.137, P < .001), anxiety score ≥8 (β -0.090, -0.110 to -0.069, P < .001), taking ≥10 medications (β -0.065, -0.085 to -0.046, P < .001), sarcopenia (β -0.062, -0.080 to -0.043, P < .001) haemoglobin <100 g/L (β -0.047, -0.085 to -0.010, P = .012) and pain (β -0.134, -0.152 to -0.117, P < .001). Smoking and prescription of prednisolone independently associated with problems in self-care and usual activities respectively. Renin-angiotensin system inhibitor (RASi) prescription associated with fewer problems with mobility and usual activities.

Conclusion

Potentially modifiable factors including obesity, pain, depression, anxiety, anaemia, polypharmacy, smoking, steroid use and sarcopenia associated with poorer HRQoL in this cohort, whilst RASi use was associated with better HRQoL in two dimensions.

The genitourinary impacts of electronic cigarette use: a systematic review of the literature

PURPOSE

Electronic cigarette (e-cig) use is prevalent. The health implications of e-cig use on the genitourinary (GU) system are uncertain. This systematic review aims to evaluate how e-cig use impacts the GU system.

METHODS

A systematic search was conducted in PubMed, Embase and Ovid alongside citation searching. Review articles, non-English papers, animal model/cell line studies or articles only on combustible cigarettes were excluded. Quality assessment was undertaken using the Joanna Briggs Institute checklists. The primary endpoint was the impact of e-cig use on bladder cancer incidence. Secondary outcomes included urinary carcinogens, chronic kidney disease (CKD), reproductive disorders, and other GU diseases.

RESULTS

The search yielded 244 articles, 28 were ultimately included. One study assessed risk of bladder cancer and found the use of e-cig was associated with an increased odds ratio of 1.577 for its diagnosis. Twenty-one articles measured potential urinary carcinogens-including crotonaldehyde and benzene-associated with bladder cancer. Two articles evaluated the association of e-cig use with CKD and reported mixed outcomes. Three articles reported on reproductive disorders, specifically, stuttering priapism and changes to sperm quantity and quality. One study reported on other GU diseases, specifically burns to the GU system. After quality assessment, all articles were deemed to be of acceptable quality for inclusion.

CONCLUSIONS

E-cig use was associated with an increased risk of bladder cancer, increased exposure to carcinogenic compounds, mixed evidence on CKD, increased risk of reproductive disorders and burns to the GU system. Further studies are needed to understand long-term GU effects.

A lifestyle pattern characterised by high consumption of sweet and salty snacks, sugar sweetened beverages and sedentary time is associated with blood pressure in families at risk for type 2 diabetes mellitus in Europe. The Feel4Diabetes Study

BACKGROUND

Individuals from families at high-risk for type 2 diabetes mellitus (T2DM) are also at high risk for hypertension (HTN) and cardiovascular disease. Studies identifying lifestyle patterns (LPs) combining dietary, physical activity or sedentary variables and examining their possible role with respect to developing blood pressure (BP) are limited. The present study aimed to examine the association of different LPs with BP levels in families at high risk for T2DM in Europe.

METHODS

In total, 1844 adults (31.6% males) at high-risk for T2DM across six European countries were included in this cross-sectional study using data from the baseline assessment of the Feel4Diabetes Study. BP measurements and dietary and physical activity assessments were conducted, and screen times were surveyed. LPs were revealed with principal component analysis of various data regarding diet, physical activity, screen time and smoking.

RESULTS

Three LPs were identified. LP3 (high consumption of sweet and salty snacks, sugar sweetened soft drinks and juices, and high amount of screen time) was positively associated with diastolic BP (B, 0.52; 95% confidence interval = 0.05-0.99) and the existence of HTN (odds ratio = 1.12; 95% confidence interval = 1.00-1.25). Participants in the highest tertile of LP3 spent mean 3 h of screen time, consumed 1.5 portions of sweet and/or salty snacks and 1 L of soft drinks on a daily basis, were associated with 12% higher risk of HTN.

CONCLUSIONS

Focusing on the combination of eating and lifestyle behaviours may more accurately identify, and therefore guide preventive measures tailored to the specific needs of high-risk populations.

Arterial stiffness and biological parameters: A decision tree machine learning application in hypertensive participants

Arterial stiffness, measured by arterial stiffness index (ASI), could be considered a main denominator in target organ damage among hypertensive subjects. Currently, no reported ASI normal references have been reported. The index of arterial stiffness is evaluated by calculation of a stiffness index. Predicted ASI can be estimated regardless to age, sex, mean blood pressure, and heart rate, to compose an individual stiffness index [(measured ASI-predicted ASI)/predicted ASI]. A stiffness index greater than zero defines arterial stiffness. Thus, the purpose of this study was 1) to determine determinants of stiffness index 2) to perform threshold values to discriminate stiffness index and then 3) to determine hierarchical associations of the determinants by performing a decision tree model among hypertensive participants without CV diseases. A study was conducted from 53,363 healthy participants in the UK Biobank survey to determine predicted ASI. Stiffness index was applied on 49,452 hypertensives without CV diseases to discriminate determinants of positive stiffness index (N = 22,453) from negative index (N = 26,999). The input variables for the models were clinical and biological parameters. The independent classifiers were ranked from the most sensitives: HDL cholesterol≤1.425 mmol/L, smoking pack years≥9.2pack-years, Phosphate≥1.172 mmol/L, to the most specifics: Cystatin c≤0.901 mg/L, Triglycerides≥1.487 mmol/L, Urate≥291.9 μmol/L, ALT≥22.13 U/L, AST≤32.5 U/L, Albumin≤45.92 g/L, Testosterone≥5.181 nmol/L. A decision tree model was performed to determine rules to highlight the different hierarchization and interactions between these classifiers with a higher performance than multiple logistic regression (p<0.001). The stiffness index could be an integrator of CV risk factors and participate in future CV risk management evaluations for preventive strategies. Decision trees can provide accurate and useful classification for clinicians.

The impact of e-cigarette exposure on different organ systems: A review of recent evidence and future perspectives

The use of electronic cigarettes (e-cigs) is rapidly increasing worldwide and is promoted as a smoking cessation tool. The impact of traditional cigs on human health has been well-defined in both animal and human studies. In contrast, little is known about the adverse effects of e-cigs exposure on human health. This review summarizes the impact of e-cigs exposure on different organ systems based on the rapidly expanding recent evidence from experimental and human studies. A number of growing studies have shown the adverse effects of e-cigs exposure on various organ systems. The summarized data in this review indicate that while e-cigs use causes less adverse effects on different organs compared to traditional cigs, its long-term exposure may lead to serious health effects. Data on short-term organ effects are limited and there is no sufficient evidence on long-term organ effects. Moreover, the adverse effects of secondhand and third hand e-cigs vapour exposure have not been thoroughly investigated in previous studies. Although some studies demonstrated e-cigs used as a smoking cessation tool, there is a lack of strong evidence to support it. While some researchers suggested e-cigs as a safer alternative to tobacco smoking, their long-term exposure health effects remain largely unknown. Therefore, more epidemiological and prospective studies including mechanistic studies are needed to address the potential adverse health effects of e-cigs to draw a firm conclusion about their safe use. A wide variation in e-cigs products and the lack of standardized testing methods are the major barriers to evaluating the existing data. Specific regulatory guidelines for both e-cigs components and the manufacturing process may be effective to protect consumer health.

Arterial stiffness nomogram identification by cluster analysis: A new approach of vascular phenotype modeling

Arterial stiffness, measured by arterial stiffness index (ASI), can be considered as a major denominator in cardiovascular diseases. Thus, it remains essential to highlight patient phenotyping profiles with high ASI values. A nomogram of arterial stiffness was evaluated by calculation of ASI nomogram. Theoretical ASI can be performed according to age, sex, mean blood pressure, and heart rate, allowing to form an individual ASI nomogram [(measured ASI - theoretical ASI)/theoretical ASI]. An ASI nomogram > 0 defined AS. This study investigates among UK Biobank participants without cardiovascular diseases, the hypothesis that K-means cluster analysis can be used to identify homogeneous phenotyping subgroups of participants according to ASI levels and then, the phenotype differences observed between these clusters. ASI nomogram was applied on 132 851 participants. K-means clustering was implemented with 10 clusters (optimal CCC value of 105.246). One cluster showed 100% rate of AS, corresponding to 25 393 participants (41.6% of the AS participants) with ASI nomogram = .26 (.22), ASI = 11.6 (2.3)m/s. A second cluster showed a 100% of non-AS, corresponding to 27 844 participants (38.8% of the participants with no arterial stiffness) with ASI nomogram = -.22 (.13), ASI = 7.1 (1.44)m/s. Threshold values of independent factors for differencing these two clusters were total cholesterol > 5.409 mmol/L (P < .001), triglycerides > 1.286 mmol/L (P < .001), smoking pack years > 11.8 pack/years, CRP > .99 (P < .001), daily alcohol consumption > 1.794 units/days and BMI > 26.641 kg/m² (P < .001). Cluster analysis allowed to highlight homogeneous participants profile with or without AS. Determine the markers differencing these clusters participates in the management of cardiovascular preventive strategies.

Chronic health effects associated with electronic cigarette use: A systematic review

Introduction

Over the last decade, e-cigarette use has been on the rise but with growing health concerns. The objective of this systematic review was to update findings for chronic health outcomes associated with e-cigarette use from the 2018 National Academies of Sciences, Engineering, and Medicine (NASEM) report.

Methods

Three bibliographic databases were searched to identify studies comparing the chronic health effects of e-cigarette users (ECU) to non-smokers (NS), smokers, and/or dual users indexed between 31 August 2017 and 29 January 2021. Two independent reviewers screened abstracts and full texts. Data were extracted by one reviewer and verified by a second one. Outcomes were synthesized in a narrative manner using counts and based on statistical significance and direction of the association stratified by study design and exposure type. Risk of bias and certainty of evidence was assessed. The protocol was prospectively registered on Open Science Framework https://osf.io/u9btp.

Results

A total of 180 articles were eligible. This review focused on 93 studies for the 11 most frequently reported outcomes and from which 59 reported on daily e-cigarette use. The certainty of evidence for all outcomes was very low because of study design (84% cross-sectional) and exposure type (27% reported on exclusive ECU, i.e., never smoked traditional cigarettes). Overall, the summary of results for nearly all outcomes, including inflammation, immune response, periodontal and peri-implant clinical parameters, lung function, respiratory symptoms, and cardiovascular disease, suggested either non-significant or mixed results when daily ECU was compared to NS. This was also observed when comparing exclusive ECU to NS. The only notable exception was related to oral health where most (11/14) studies reported significantly higher inflammation among daily ECU vs. NS. Compared to the smokers, the exclusive-ECUs had no statistically significant differences in inflammation orperiodontal clinical parameters but had mixed findings for peri-implant clinical parameters.

Conclusions

This review provides an update to the 2018 NASEM report on chronic health effects of e-cigarette use. While the number of studies has grown, the certainty of evidence remains very low largely because of cross-sectional designs and lack of reporting on exclusive e-cigarette exposure. There remains a need for higher quality intervention and prospective studies to assess causality, with a focus on exclusive e-cigarette use.

How Electronic Cigarette Affects the Vascular System

The popularity of the electronic cigarette has soared in the last decades. However, the health effect of smoking electronic cigarettes on the vascular system is unclear. This systematic review examines the electronic cigarettes’ effect on the vascular system from recent evidence. A systematic search was conducted in MEDLINE (PubMed) database from January 2016 to August 2021 for studies assessing the vascular effect of chronic use of electronic cigarettes on human and animal. The Cochrane Risk of Bias 2, NIH Quality Assessment for Cross-Sectional Study, and SYRCLE’s Risk of Bias were used to assess the risk of bias in interventional, observational, and animal study, respectively. A narrative synthesis of evidence is provided to describe results. From 101 retrieved studies related to electronic cigarettes effect on the vascular system, a total of 16 studies are included in this review. The overall results indicated that electronic cigarette use is associated with adverse events in the vascular, including the incident of elevated oxidative stress, endothelial dysfunction, inflammation, arterial stiffness, and the development of atherosclerotic lesion. Further studies should broaden perspectives and reveal more about the mechanism of how electronic cigarettes impact on vascular system.

Early Diagnosis of Kidney Damage Associated with Tobacco Use: Preventive Application

Although long-term smoking has been associated with chronic kidney disease, its effect on kidney function in early stages has not been clarified. Therefore, the proposed objectives were: (1) to identify subclinical kidney damage in smokers, through a panel of biomarkers; (2) to evaluate the progression of subclinical kidney damage after two years of consumption in these patients; and (3) study whether quitting smoking reduces kidney damage. A prospective study was carried out (patients recruited from a primary care centre and a clinical smoking unit). Kidney function was assessed using a panel of biomarkers and compared between smokers and non-smokers, taking into account potential risk factors for kidney damage. These results show, for the first time in the literature, the relationship between smoking and early (subclinical) kidney damage and provide a panel of biomarkers capable of detecting this condition (Neutrophil gelatinase-associated lipocalin, Kidney injury molecule-1, N-acetyl-beta-D-glucosaminidase, transferrin, and ganglioside-activating protein GM2). This study also indicates that subclinical damage is maintained when use continues, but can be reversed if patients stop smoking. The use of these biomarkers as diagnostic tools can be a preventive measure in the development of chronic kidney disease associated with smoking and in the prevention of acute events associated with potentially nephrotoxic pharmacological treatment in smokers. Trial registration number: NCT03850756.

Arterial Stiffness Determinants for Primary Cardiovascular Prevention among Healthy Participants

Background: Arterial stiffness (AS), measured by arterial stiffness index (ASI), can be considered as a major denominator in cardiovascular (CV) diseases. Thus, it remains essential to highlight the risk factors influencing its increase among healthy participants. Methods: According to European consensus, AS is defined as ASI > 10 m/s. The purpose of this study was to investigate the determinants of the arterial stiffness (ASI > 10 m/s) among UK Biobank normotensive and healthy participants without comorbidities and previous CV diseases. Thus, a cross-sectional study was conducted on 22,452 healthy participants. Results: Participants were divided into two groups, i.e., ASI > 10 m/s (n = 5782, 25.8%) and ASI < 10 m/s (n = 16,670, 74.2%). All the significant univariate covariables were included in the multivariate analysis. The remaining independent factors associated with AS were age (OR = 1.063, threshold = 53.0 years, p < 0.001), BMI (OR = 1.0450, threshold = 24.9 kg/m2, p < 0.001), cystatin c (OR = 1.384, threshold = 0.85 mg/L, p = 0.011), phosphate (OR = 2.225, threshold = 1.21 mmol/L, p < 0.001), triglycerides (OR = 1.281, threshold = 1.09 mmol/L, p < 0.001), mean BP (OR = 1.028, threshold = 91.2 mmHg, p < 0.001), HR (OR = 1.007, threshold = 55 bpm, p < 0.001), Alkaline phosphate (OR = 1.002, threshold = 67.9 U/L, p = 0.004), albumin (OR = 0.973, threshold = 46.0 g/L, p < 0.001), gender (male, OR = 1.657, p < 0.001) and tobacco use (current, OR = 1.871, p < 0.001). Conclusion: AS is associated with multiple parameters which should be investigated in future prospective studies. Determining the markers of increased ASI among healthy participants participates in the management of future CV risk for preventive strategies.

Effect of Water-Pipe Smoking on the Normal Development of Zebrafish

Background: Among all types of tobacco consumption, Water-Pipe Smoking (WPS) is the most widely used in the Middle East and second-most in several other countries. The effect of WPS on normal development is not yet fully understood, thus the aim of this study is to explore the acute toxicity effects of WPS extract on zebrafish larvae. Methods: In this study, we compared the effects of WPS smoke condensates at concentrations varying from 50 to 200 µg/mL on developmental, cardiac, and behavioural (neurotoxicity) functions. Gene expression patterns of cardiac biomarkers were also evaluated by RT-qPCR. Results: Exposing zebrafish embryos to 50, 100, 150 and 200 µg/mL WPS for three days did not affect the normal morphology of Zebrafish embryos, as the tail flicking, behavioural and locomotion assays did not show any change. However, WPS deregulated cardiac markers including atrial natriuretic peptide (ANP/NPPA) and brain natriuretic peptide (BNP/NPPB). Furthermore, it induced apoptosis in a dose-dependent manner. Conclusion: Our data demonstrate that WPS can significantly affect specific cardiac parameters during the normal development of zebrafish. Further investigations are necessary to elucidate the pathogenic outcome of WPS on different aspects of human life, including pregnancy.

E-cigarette Smoking (Vaping) and Markers of Vascular Wall Damage in Young Subjects without Cardiovascular Disease

Aim: to investigate the effect of nicotine-containing vapes in comparison with traditional tobacco smoking on markers of vascular wall damage: high sensitivity C-reactive protein (hsCRP), albuminuria (AU), and ankle-brachial index (ABI).

Material and Methods: We examined 369 young subjects without cardiovascular diseases (age median 21 [20;21] years) (159 men and 210 women). The hsCRP levels in the serum were assessed by immunochromatographic express method. AU was investigated in daily urine by a quantitative reflex photometry. ABI was determined by plethysmography.

Results: All subjects were divided into groups: non-smokers (n=196, 53.1%), smokers of traditional cigarettes (n=83, 22.5%) and smokers of nicotine-containing vapes (n=90, 24.4%). The groups did not differ in main anthropometric data. Median hsCRP levels in smokers (14.30 [11; 16.5] mg/l in tobacco-smokers and 13.15 [9.65; 17.5] mg/l in vapers) were significantly higher vs nonsmokers (3.0 [2; 5.6] mg/l). In tobacco-smokers (33.0  [21.5;  60]  mg)  and  vape  smokers  (45.0  [20;  115]  mg),  the  median  AU  was  statistically  significantly  higher  than  in  non-smokers  (12.0 [10; 20] mg). ABI levels were significantly lower in the groups of tobacco smokers (0.98 [0.91; 0.99]) and vapers (0.85 [0.79; 0.93]) when compared with nonsmokers (1.125 [1.01; 1.18]), and the median ABI in vapers was lower than in tobacco smokers (p<0.001). In the group of tobacco smokers, the hsCRP level correlated with the smoker's index (rs=0.31, p<0.05), and AU (rs=0.54, p<0.05) and ABI (rs=-0.28, p<0.05) with a daily inhaled nicotine dose. In the group of vapers, CRP was associated with smoking experience (rs=0.338, p<0.05), AU with a daily inhaled nicotine dose (rs=0.79,  p<0.05), and  ABI with  BMI (rs=-0.33,  p<0.05), heart  rate (rs=-0.24,  p<0.05) and  smoking experience  (rs=-0.235, p<0.05). According to the results of multivariate regression analysis the hsCRP level was related with only the smoking experience (B=0.91±0.19, p=0.000005), AU level with the daily inhaled nicotine dose (B=1.59±0.7, p=0.0121) and smoking experience (B=3.07±1.23, p=0.0179), and ABI level with only smoking experience (B=-0.09±0.004, p=0.0419).

Conclusion: In smokers, both traditional and vapers, the levels of hsCRP, AU are significantly higher, and the ABI is lower than in healthy young nonsmokers. The most significant influence on the level of hsCRP is exerted by the experience of  tobacco  and  vape  smoking;  to  the  AU  level  – the experience of tobacco and vaping and the daily inhaled nicotine dose, and by the value of the ABI – the experience of vaping.