Two major issues are associated with the recreational (non-therapeutic), long-term use of nicotine: (i) its dependence forming capacity and (ii) potential toxicity (1). The late professor M.A.H. R
Clive Bates, a long-standing smoking and tobacco industry adversary, recently stated with respect to promoting NGPs (in particular ECs): “…
There are three major implications of nicotine when broadly used as recreational drug in NGPs:
The toxic effects of nicotine and its role in human health when used long-term Nicotine’s addictive properties, potentially leading to a nicotine dependence of consumers Nicotine’s role in public health, e.g., by facilitating young people to initiate usage of NGPs and (at worst) switch to more harmful products such as cigarettes (‘gateway effect’).
Almost all scientists would agree to the statement that most of the harm is caused by smoking, not nicotine (4). Nevertheless, many questions remain open.
A systematic review of the addiction and appeal issue of ECs (but certainly would also apply to other NGPs) revealed that higher nicotine concentrations and the availability of a variety of flavors in the products might facilitate complete substitution for CCs (5). The authors further conclude that future regulations should take into account their impact on smokers of CC, for whom the new products may be cessation tools or reduced-harm alternatives.
The N
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There are a number of research fields in the area of nicotine’s health risks implicated with the use of NGPs, which are not dealt with in detail in this review:
The important issue of addiction is not in the center of this review. The reader is referred to other recent reviews on this issue (1, 5). Another important aspect in the context of nicotine consumer products is nicotine’s poisoning and lethal doses (accidental or suicidal). Also, this problem is not dealt with in more detail in this review. Until recently, the human lethal dose for nicotine was assumed to be in the range of 30–60 mg. A recent verification suggested that the fatal dose is probably much higher (500–1000 mg) (11). These issues are considered in detail in other recent reviews (1, 7). Acute adverse effects of nicotine products as reported in clinical studies or long-term field studies with NRT products (see for example (12)) are also not considered in this review. In a meta-analysis comprising more than 177,000 individuals, significantly increased risks for a number of adverse effects in NRT users were reported, including heart palpitations, chest pains, nausea, vomiting, gastrointestinal complaints, insomnia, skin irritations (nicotine patches), mouth and throat soreness (oral NRTs), mouth ulcers (oral NRTs), hiccoughs and coughing (oral NRTs) (13). Findings of a randomized clinical trial (RCT) on nicotine patch users over 52 weeks support the safety of long-term use of this NRT product (14). This review will not further discuss acute adverse effects of nicotine but focus on disorders, physiological changes and disorders upon chronic use of nicotine products. Also, effects of using ECs and HTPs on bystanders (passive or secondhand exposure) were not considered in this review. It should, however, be mentioned that neither ECs nor HTPs generate any sidestream smoke (the main contributor to environmental tobacco smoke, ETS). Rather, secondhand exposure by ECs or HTPs can only originate form the exhaled aerosols. Appropriate studies were reviewed in recent monographs (1, 7). Exposure of NGP users to nicotine and toxicants has been investigated rather elaborately on two levels: (i) release of nicotine and toxicants under common use patterns by chemical analysis and (ii) uptake of these chemicals by measuring suitable biomarkers of exposure (BOEs) in body fluids or users. The area of BOEs in users of NGPs is not systematically covered in this review. The reader is referred to recent reviews and articles dealing with this topic in detail (1, 15, 16). The data available suggest that, on average, nicotine uptake is somewhat higher in smokers compared to users of the other NGPs (15, 16). Long-term use of the various products leads to comparable nicotine uptake between smokers and NGP users (1).
There are presently unavoidable limitations in the evaluation of nicotine’s role in health effects when using NGPs:
NGPs, in particular electronic cigarettes (ECs), heated tobacco products (HTPs) and nicotine pouches (NPs) are on the market for clearly less than 20 years. Therefore, long-term effects with endpoints of diseases or even mortalities are as yet out of range. Despite of that, some scientists are already convinced that for example EC use constitute a severe health risk (17). For the evaluation of certain chronic nicotine effects, studies with Swedish snus and nicotine replacement therapy products (NRTs: nicotine gums, patches, inhalators) are included in this review. As a result of the relative short market availability of the NGPs, the number of consumers, in particular mid-term to long-term consumers, is low and NGP users in general may be younger than smokers of CCs (18). Furthermore, NGP use patterns are not yet well settled. Therefore, it is not unlikely that during the switching phase from CCs to NGPs, there will be some dual use, which might be difficult to assess correctly. As a consequence, dual use (CC combined with NGP use) in human studies dealt with in this review, needs to be considered when evaluating the results. A practical classification for dual users of CC and EC has been proposed by B Development, modification and improvements of NGPs is an ongoing process with the manufacturers. Presently, at least the fourth generation of ECs is available on the market (20). Release of nicotine and toxicants from NGPs vary with design features and can certainly influence the biological effects on the user. In other words, the point in time (year), when a study with NGPs is conducted could be relevant in terms of product-related nicotine uptake and its effects in the body. The role of nicotine could be best elucidated, if NGPs with and without nicotine would be compared. This, in principle, should be possible in vapers using e-liquids containing or not containing nicotine. There are, however, too few users available who use nicotine-free ECs, thus preventing a comparison with nicotine-containing ECs (1). This approach (with/without nicotine), therefore, is limited to controlled, experimental studies. Biomarkers of potential harm (BOPHs), also termed biomarkers of biological effects (BOBEs) or biomarkers of risk, would represent a suitable alternative for classical epidemiological endpoints (diseases, mortality) to assess long-term health risks much earlier than to await 3 to 4 decades of NGP use (21). However, there are as yet limitations in the validations of BOBEs in terms of their prediction power for diseases and mortality. Most studies using BOBEs are, therefore, limited to acute or mid-term investigations (1, 22). When evaluating the detrimental effects of nicotine taken up with NGP (or NRT) use, the route of uptake has to be considered. Therefore, inhalation (EC, HTP, nicotine inhaler), buccal absorption (snus, NP, nicotine gum) and dermal uptake (nicotine patch) are distinguished in this review.
Specific, study-related limitations will be discussed in the relevant sections of this review.
In the endeavor to examine the role of nicotine in health risks implicated with the use of NGPs, our focus are clearly results from human studies. However, given the limitations listed above,
The main purpose of this review is to elucidate the long-term toxicity of nicotine in human users of nicotine products, rather than its dependence-forming properties and the resulting consequences for public health. Addiction to nicotine will become less a problem, as long as accompanying chemicals absorbed with nicotine from a product are less toxic (23). The review is structured according to the most important smoking-related diseases and detrimental effects. Due to the fact that the role of nicotine is always of foremost interest, a chapter on beneficial effects of nicotine in various diseases and disorders is added, so that literature was briefly summarized and evaluated for the following topics:
Cardiovascular diseases (CVD) Cancer (various organs) Respiratory diseases (RD) Oral health Oxidative stress and inflammation (various cells and organs) Metabolic syndrome Reproduction Other disorders and diseases Beneficial effects of nicotine
Relevant articles were retrieved from various databases, including:
PubMed Google Scholar ABF in-house literature database containing about 180,000 articles on the topic smoking and health
Recent reviews and monographs dealing with the topic of interest were evaluated, including:
US Surgeon General Report of 2014 “The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General” (24) US Surgeon General Report of 2010 “How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease” (25) N C M
Reference lists of recent suitable articles from the above sources were screened for further relevant articles on the topic of interest.
In total, about 500 articles were retrieved for more detailed screening by applying the inclusion criteria described in the following section.
Human studies considered for evaluation must have investigated users of the NGPs electronic cigarettes (ECs), heated tobacco products (HTPs), nicotine pouches (NPs), nicotine replacement therapy (NRT) products (skin patches, chewing gum, lozenges, inhaler), smokeless tobacco (SLT) products (snus, oral snuff). Furthermore, at least one biological endpoint (disease, disorder, tissue or cell damage, physiological changes, biomarkers of effect or potential harm) must have been studied. Observed changes related to product use must be compared to at least one of the comparator conditions: non-users (NU), smokers of combustible cigarettes (CC), baseline (BL) prior to NGP use. Animal (
Three aspects were considered in order to evaluate the role of nicotine in effects observed in human users of nicotine products: (i) sufficient scientific evidence that nicotine directly participates in a physiological (or pathophysiological) mechanism (e.g., by acting via a nicotine-specific receptor), (ii) evidence cited by the authors of a study showing that nicotine is likely (or unlikely) to be involved, (iii) judgement by the authors of this review considering (i), (ii) and the presented study data, using a simple coding system (see explanation in the following section).
The human studies considered in this review are briefly summarized in Tables 1–8. All tables are of the same structure and provide the following information:
Tables 1–8 are divided in seven subsections of various diseases, disorders and biological markers. The results of which are summarized below. The vast majority of the studies on CVD, but also for the other diseases discussed in this review, have been performed with ECs. However, with respect to the participation of nicotine in pathogenesis, most of the findings are assumed to be valid also for the other nicotine-containing NGPs.
Cardiovascular diseases (CVD) are one of the leading causes of (premature) death worldwide. Tobacco use, in particular cigarette smoking, is a well-established risk factor for CVD (24). CVD comprise a variety of detrimental outcomes, such as myocardial infarction (MI), stroke, atherosclerosis, hypertension, arterial stiffness and others. CVD is a multi-factorial disease with several comorbidities. Risk factors in addition to smoking are metabolic disorders, diet, physical inactivity, etc. Therefore, it is extremely difficult to disentangle the contribution of one factor such as NGP use or the role of one chemical such as nicotine. In recent years, there has been growing concern about the impact of NGPs (ECs, HTPs, nicotine pouches, snus) and other nicotine-containing products, such as nicotine replacement therapy (NRT) products on cardiovascular health.
Studies have identified several potential mechanisms by which NGPs could contribute to the development of CVD, including altered hemodynamics, endothelial dysfunction, vascular reactivity, and enhanced thrombogenesis (26). Nicotine but also other aerosol components of ECs and HTPs, such as acrolein and other aldehydes, have also been linked to adverse cardiovascular effects (27).
Nicotine, in particular, has been implicated in the development of CVD. However, the cardiovascular effects of nicotine depend on the dose delivered and its distribution kinetics, which necessitates further investigation with new generation nicotine-containing products (NGPs).
Column 1 | Author, year, country (Reference) | (self-explaining) | |
Column 2 | Study type | The following types are differentiated: cross-over, cross-sectional, RCT (randomized controlled trials), longitudinal, case-control, prospective | |
Column 3 | User groups/Duration of product use | If available number (N) in each group, duration and daily consumption of product use, mean age of group is provided. If not indicated other, groups contain both sexes. Important study design features are also provided. | |
Column 4 | Endpoints and findings | Major endpoints are given in bold. Abbreviations, see corresponding section at the beginning of the review. | |
Column 5 | Comments (bias, compliance, etc.) | The authors’ main conclusion is provided (labeled as such, AO). Comments on issues with product compliance (in particular exclusive use of an NGP over a longer time period), generally originate from the review authors (ARO). | |
Column 6 | Conclusions of nicotine’s role | Statement from the study authors (indicated as such, AO) or review authors are provided (ARO). In red, a simplified code for nicotine (N)’s role in generating the reported effects is stated: | |
? | |||
0 | |||
0.5 | |||
1.0 | |||
Combinations of codes are possible. | |||
Column 7 | Limitations (L) / Gaps (G) / Proposals (P) | These evaluations in general originate from the review authors (AOR). Proposals are provided, if the endpoints of the study look promising and an improved study is assumed to provide valuable data. |
Despite these concerns, some studies suggest that nicotine-containing products, such as nicotine gum, may be safe for use in individuals with pre-existing cardiovascular disease (28). In this chapter and particularly in Table 1, studies are presented that may further elucidate the role of nicotine in the development of CVD. Before human, animal and
Cardiovascular diseases (CVD) are responsible for a significant proportion of (premature) deaths worldwide. Atherosclerosis is a key factor in the development of CVD, and it primarily develops in vascular regions with disturbed blood flow (25). Oxidative stress, endothelial cell activation, and inhibited release of endothelial nitric oxide (NO) are key molecular events that contribute to atherosclerosis (29). Cigarette smoking plays a significant role in all stages of plaque formation in atherosclerosis. Smoking causes oxidative stress, upregulation of inflammatory cytokines, endothelial dysfunction, and reduces the bioavailability of NO (30). This leads to the formation of vulnerable plaques, platelet activation, stimulation of the coagulation cascade, and impaired anti-coagulative fibrinolysis. Nicotine is involved in almost all steps of this process except fibrinolysis. Smoking causes vascular dysfunction by reducing NO bioavailability, which is one of the first steps initiated by smoking in the pathogenesis to CVD. Smoking also leads to the formation of foam cells (macrophages, which are loaded up with oxLDL), which is another step in early atherogenesis (31, 32).
Smoking also has a number of cardiovascular effects, including acute ischemic events and more chronic atherogenesis-related effects, such as systemic hemodynamic effects, coronary blood flow, myocardial remodeling, arrhythmogenesis, thrombogenesis, endothelial dysfunction, inflammation, angiogenesis, dyslipidemia, hypertension, and insulin resistance (25, 33,34,35,36). Acute smoking increases plasma norepinephrine and epinephrine, as well as heart rate, blood pressure (BP), blood glycerol, and the blood lactate/pyruvate ratio. These effects can be regarded as inherent nicotine effects, mediated by nicotine-specific receptors (nAChRs) (37). The dose-response between cigarettes per day and the risk of CVD is reported to be nonlinear (25).
A key role in pathogenesis of atherosclerosis is assigned to the vascular extracellular matrix (ECM) (38). Of importance are matrix metalloproteases (MMPs), which upon activation mediate degradation of ECM of the atherosclerotic plaque, inflammation and proliferation of smooth muscle cells, all of which exacerbate atherosclerosis and MI (38).
Smoke constituents involved in CVD include nicotine, CO, and particulate matter. Smoking is a major risk factor for CVD and is found to be responsible for 15–20% of all CVD cases. Smoking cessation can reverse most of the steps in the development of CVD, opening the chance that switching from smoking to a harm-reduced product could be beneficial.
Table 1 contains short summaries and evaluations of human studies on NGP use and CVD endpoints (see page 42).
Nicotine stimulates the sympathetic nervous system through the release of epinephrine and norepinephrine, resulting in an increase in heart rate, reduction in heart rate variability (HRV), endothelial dysfunction with reduced myocardial blood flow and increased myocardial demand for oxygen and nutrients associated with increased risks of myocardial ischemia, MI and sudden death (6). Other mechanisms for detrimental effects of nicotine on the cardiovascular system are myocardial remodeling caused by persistent sympathetic stimulation, arrhythmogenesis (mediated through catecholamine release) and thrombogenic effects. The latter have been shown in animal studies, but human studies with NRT and smokeless tobacco did not show increased platelet activation (6).
Table 1 lists 7 publications on MI and use of nicotine products other than CC. Use of SLT, snuff or snus was investigated in 5 studies (39,40,41,42,43), use of ECs in 2 studies (44, 45). Study types comprise case-control (2×), prospective (2×), cross-sectional (2×). One publication was a meta-analysis, which includes the evaluation of up to 9 epidemiological studies (42). Users of oral tobacco were found to have a significantly increased risk for MI compared to non-users (NU), if the study was conducted in the USA (42). But inconsistent results were reported in Swedish studies (39,40,41, 43). Cigarette smokers (CC), when included in the evaluations, always showed a significantly increased risk for MI compared to NU. Vaping (EC) was also reported to increase the risk for MI compared to NU (44, 45).
These finding are similar to a recent systematic review with meta-analysis of 4 cross-sectional studies on MI risk in vapers (46). EC users compared to non-EC or non-CC users had significantly increased relative risks for MI of 1.30. EC only users compared to CC only users were found to have a significantly reduced risk of 0.61, whereas in most of the studies described in Table 1, the extent of risk for EC users was very close to that of cigarette smokers (CC).
From none of the studies, the role of nicotine in the emergence of MI can be directly deduced. However, in some of the publications, evidence was cited that nicotine might play a role in the development of MI, most probably through its sympathomimetic effects on the cardiovascular system. Together with the consideration in Section 3.1, nicotine’s role in the emergence of MI can be summarized as ‘possibly participating’ (in the code defined in the table above: 0–0.5). An overall summary of the probability of the involvement of nicotine in the development of MI and all diseases/disorders treated in the following is presented in Section 12.2.
As indicated in Table 1 (Columns 5 and 7), a general issue and limitation of all studies presented is that self-reported long-term use of NGPs might be biased or simply wrong. It is likely that part of the self-reported past or current exclusive users of NGPs were actually past or current dual-and/or poly-users (NGP + CC). The reported increase in relative risks for exclusive NGP users have to be interpreted with caution (47). Objective and improved information on past and present product use would be required in order to prevent possible bias.
In Table 1, 5 publications are listed on the risk of stroke for users of NGPs (48,49,50,51,52). The study types comprise one prospective (48), 3 cross-sectional (49, 50, 52) and one meta-analysis (51), which included 6 cross-sectional studies. In one study, the risk of Swedish snuff (48) was investigated, all other studies dealt with ECs. In the snuff study, no increased risk for stroke in users compared to NU was found (48). In the meta-analysis of B
For EC use, inconclusive results were reported. Risk for stroke was significantly elevated in those vapers, who reported everyday use of EC and those, who were former CC smokers. Unexpectedly, some studies found even higher risk for stroke in EC or dual users than in CC smokers (49, 52).
Involvement of nicotine in stroke development cannot be deduced from any of these studies. An involvement of nicotine in the pathogenesis of stroke, particularly ischemic stroke, is discussed by some authors. Overall, we would evaluate the participation of nicotine for stroke development ‘partly participating’ (0–0.5).
The cross-sectional studies on stroke have some principal weaknesses, which are similar to those discussed for the MI studies. These comprise potential misreports on NGP use, particularly the issue as described before, on the self-reported exclusive NGP use which were actual dual users. Furthermore, cross-sectional studies in principle cannot prove causality due to the issue of temporality. Smokers feeling very early symptoms of a disease might be more likely to switch to a presumably safer product, thus increasing the assessable risk in the user group of this product.
Increase in atherosclerotic plaques, apart from increase in systolic and diastolic blood pressure, as well as impaired endothelial nitric oxide synthase signaling are among the most important changes leading to CVD in users of tobacco and nicotine products, including NGPs (53).
Development of atherosclerosis and effects on the cardiovascular system of ECs, the most frequently investigated NGPs have been reviewed by D
Two of the SLT studies (56, 57) showed evidence that development of atherosclerosis might be associated with product use, three did not (58,59,60). It is worth mentioning that the two studies showing an increased risk for SLT users were prospective studies with mortality or morbidity for ‘general CVD’ as epidemiological endpoint. Vascular plaque formation and intima thickness were not found to be significantly different in SLT users compared to NU (59, 60). In contrast to that, vapers (EC) were reported to have intima thicknesses significantly higher than NU, but significantly lower than smokers (CC) (61).
Involvement of nicotine in the pathogenesis of atherosclerosis was observed in a cross-over study comparing ECs with and without nicotine in acute release of epithelial cell-and platelet-derived extracellular vesicles (EVs) (63). No or only weak evidence for a participation of nicotine in atherogenesis is deducible form the other studies. The overall score tends to 0 (Table 1), suggesting probably no involvement of nicotine.
Arterial stiffness indicates endothelial dysfunction and can be regarded as an early event in CVD, particularly atherosclerosis (25, 64). This disorder is most frequently characterized by three indicators: Flow-mediated vasodilation (FMD), pulse-wave velocity (PWV) and augmentation index (AI). FMD can be measured as an acute response in systemic as well as coronary arteries to an exposure and is mediated by the endothelium through the release of dilator substances such as nitric oxide (NO). A decrease in FMD indicates an epithelial dysfunction. Pulse wave Doppler (PWD, technique to measure the blood flow velocity) is determined by measuring the carotid and femoral pulse pressures and the time delay between the two waves. An increase in PWD indicates arterial stiffness. AI is another marker for arterial stiffness and can be also derived by analysis of the pulse-wave curve.
Table 1 shows 16 studies on NGP use and arterial stiffness (65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81). Also shown are the results of a meta-analysis comprising 8 studies (82). Four studies investigated the association of arterial stiffness with SLT use (65,66,67, 80), the others with EC use. Interestingly, in 5 publications (68,69,70,71, 73) e-liquids with and without nicotine were evaluated so that a possible involvement of nicotine can be directly deduced. Although the results in terms of changes in FMD, PWV and AI are somewhat heterogeneous, some general finding can be inferred. Acute use of nicotine-containing products (CC, EC, SLT), mostly shown in crossover type of studies, was found to decrease FMD and increase PWV and AI. Usually, the levels of these variables after NGP use are between those of smokers (CC) and NU. Long-term effects of snus (80) and EC use (74) may be deduced from two studies. No significant difference in baseline FMD levels was reported between smokers (CC for > 1 year), vapers (EC for > 1 year) and NU (74). Long-term use of snus ($ 15 years) was found to increase PWV and AI significantly compared to NU (80).
According to the N
Results from a cross-over study including smoking (CC) and using a nasal nicotine spray revealed reduction of FMD under both conditions (83). The FMD-decreasing effect of CC was greater, although the nicotine exposure was similar under both conditions. The authors conclude that nicotine is responsible for this endothelial dysfunction, however, the mechanisms of the nicotine effects remain unclear.
EC use increases arterial stiffness in young smokers through the release of norepinephrine by nicotine (84). The extent of the effect in terms of BP and PWV was lower than that of smoking (CC).
Another study found that, in contrast to CC use, vaping caused no changes in arterial stiffness (85). The authors speculate that lower bioavailability of nicotine from EC or an additional effect of other substances present in CC but absent in EC aerosol might be responsible for this observation.
Taken together, the role of nicotine in the generation of arterial stiffness is controversial. While some studies found clear evidence for a participation (score: 1), other did not (score: 0). For the acute decrease in FMC, most likely nicotine is responsible. What is lacking are investigations of possible long-term effects of NGP use.
These observations were also described in a recent systemic review with meta-analysis on the effect of vaping (EC) and cardiovascular health, comprising 27 studies (86).
Hypertension is defined as chronically elevated BP, e.g., systolic blood pressure (SBP) > 160 mm Hg and diastolic blood pressure (DBP) > 100 mm Hg. In Table 1, four relatively large studies are listed, two with SLT users (87, 88) conducted in Sweden, two with vapers (EC) (89, 90) conducted in the USA and South Korea, respectively. In all studies, the risk for hypertension was significantly elevated in NGP users compared to NU. The authors of these studies cited evidence that nicotine might be causally related to the development of hypertension.
In a review on SLT use and hypertension (91), 12 studies were evaluated which relatively consistent show, according to the authors, a clinical relevant increase in heart rate (HR), SBP and DBP. The authors conclude that SLT use should be considered a potential cause of sodium retention and poor BP control because of its nicotine, sodium and licorice content.
However, as indicated in Table 1, due to misreport or vague recollection of product use, particularly of the product use history as well as some inherent limitations of cross-sectional studies (3 of the 4 studies were cross-sectional studies) the results have to be interpreted with caution.
In our judgement, nicotine, is probably involved in the development of hypertension (0.5–1).
In Table 1, this subclass of cardiovascular changes upon use of NRTs contains 19 entries on this topic (92,93,94,95,96,97,98,99), including mostly cross-over type of studies (N = 11), but also one meta-analysis (100) comprising 14 studies and one review (105). Most frequently, EC use was investigated in comparison to either NU or smokers (CC). In a few studies the effect of SLT, HTP and NRT products (nicotine gum and inhaler) are reported. Despite the large heterogeneity of the scientific approaches, the overall results show a relatively homogenous picture: use of nicotine-containing NGPs acutely increase HR, SBP and DBP.
In one study (95), vaping (ECs with and without nicotine) was found to nicotine-dependently decrease the heart rate variability (HRV), indicating a risk for CVD.
Of interest are also two longitudinal studies over time periods of 6 (99) and 12 weeks (109). In the 6-week study, smokers (CC) who partially replaced CCs by ECs did not show any change in SBP and DBP after 6 weeks (99). In the 12-week study, which followed a similar approach, significant decreases in HR, SBP and DBP were observed (109). Almost all studies evaluated in Table 1 provide medium to strong evidence (0.5–1) that nicotine is causally related to acute increases in HR and BP. The same conclusions can be derived from the studies briefly described below.
In a double-blind cross-over study with 15 male non-smokers, subjects received a placebo and a 2 mg-nicotine tablet (110). Despite an only modest increase in plasma nicotine levels (3.6 ng/mL), significant increases under nicotine conditions over placebo in HR, SBP and carotidfemoral PWV was observed. The authors conclude that also small nicotine doses may acutely deteriorate the elastic properties of the aorta.
A living, systematic review on cardio-dynamic effects such as HR and BP came to the conclusion that EC substitution incurs no additional cardiovascular risks, rather some possible benefits (2 studies showed a reduction of SBP in HT patients after 1 year of EC use) may be obtained, but the evidence is of low to very low certainty (111).
In a recent review on the health effect of vaping (112), a section on effects of nicotine
Overall, the evaluated literature provided strong evidence for a causal role of nicotine in the acute increase in HR and BP. The chronic effects of nicotine on HR and BP are less well investigated and require further research.
In Table 1, subclass “Other BOBEs for CVD risk”, 13 studies have been entered (76, 113,114,115,116,117,118,119,120,121,122,123,124). A large number of various BOBEs were investigated, of those the following were selected for a brief summary and evaluation in this section: HDL, LDL, TG, WBC, s-ICAM-1, fibrinogen, 8-epi-PGF2α, 11-dh-TXB2.
It should be noted here that the evaluations and summaries of the table entries are not comprehensive in terms of biological endpoints investigated in the studies presented in the tables. Rather, the summaries and evaluations represent selections, which we think convey a typical picture of the available literature. (There are a number of general BOPH for oxidative stress (oxLDL, HDL, 8-isoprostane, s-NOX-2-derived peptide), inflammation (CRP), endothelial function (FMD, PWV) and platelet function (E-selectin, P-selectin) which are also relevant for the generation of CVD. Studies on these BOPH, if not included in Table 1, will be also presented in Table 5.)
The NGPs investigated with the selected BOBEs include SLT (113,114,115), NRT (nicotine patch) (116), ECs (76, 117, 119, 121, 122, 124) and HTPs (118); (120, 123). For the selected CVD-related biomarkers, it can be stated that use of the NGPs improves or at least does not worsen the possibly implicated risks for developing CVD in comparison to levels observed in smokers (CC). There were 5 studies including a longitudinal approach, one study on nicotine patch users over 77 days (116), one study with vapers (EC), covering 24 months (119) and three studies with HTP users covering 90–180 days (118, 120, 123). All longitudinal studies showed improvement in CVD-BOBEs at the final follow-up visits when the NGPs were used compared to the baseline level, when CCs were used. It is interesting to note that the authors of the nicotine patch study (116) conclude that nicotine might inhibit the normalization (increase) of the HDL levels, because HDL increased only after the subjects had also quit using the NRT product.
For almost all of the evaluated studies in section 3.2, both the study authors and the authors of this review were of the opinion that nicotine plays no role in the pathogenesis or its involvement cannot be judged from the study data (0/?).
In the following, results of animal studies were briefly summarized, which try to work out the effect of either pure nicotine or nicotine as a constituent of NGPs (most frequently ECs with and without nicotine) on the development of CVD.
A mouse model (ApoE−/− mice) was reported to show nicotine and cotinine plasma levels after intermittent exposure to EC aerosol very similar to human vapers, thus representing a suitable tool for
Rats were treated with nicotine (0.6 mg/kg, i.p.) for 28 h (126). Compared to a saline control, chronic nicotine administration impaired aortic reactivity, probably via redox imbalance (increased MDA, decreased SOD and GSH) and vascular remodeling mechanism.
In a long-term (60 weeks) study with mice exposed to EC aerosol derived from e-liquid with 0, 6 and 24 mg/mL nicotine, impaired endothelium-dependent and endothelium-independent vasodilation were observed with nicotine-containing exposure occurring earlier and more severe than without nicotine. The effects were similar to those found with smoke (CC) exposure (127). The authors concluded that long-term vaping can induce CVD similar to smoking. The same mouse model and exposure regime was applied in another study to further elucidate the mechanism how EC aerosol induced vascular epithelial dysfunction (VED) (128). According to the authors’ interpretation, EC aerosol activates NADPH oxidase and uncouples eNOS, causing superoxide generation and vascular oxidant stress that triggers VED and hypertension with predisposition to other CVD. The observed effects were nicotine dose-dependent, with the zero nicotine dose still having detrimental effects to the air exposure control group.
A main issue when comparing exposure effects, particularly those related to CVD, observed in animal studies with those measured in human vapers or users of other NGPs is that the treatment of animals is usually associated with stress responses which are also risk factors for CVD (1).
In a 12-week study with ApoE knock-out mice exposed to EC aerosol with 0 and 2.4% nicotine and saline (control), the nicotine group but not the nicotine-free and saline groups showed detrimental changes such as decreased left ventricular fractional shortening and ejection fraction, increase in serum FFA and cardiac MDA as well as atherosclerotic lesions (129, 130). The authors concluded that these results indicate profound adverse effects of e-cigarettes with nicotine on the heart in obese mice and raise questions about the safety of the nicotine e-cigarettes use (129, 130).
A 6-month study with ApoE knock-out mice exposed to CC smoke, PG/VG aerosol with (ECN) and without nicotine (EC0) revealed that ejection fraction, fractional shortening, cardiac output, and isovolumic contraction time remained unchanged following EC0 exposure, while ECN caused an increase in isovolumic relaxation time similar to CC smoke exposure (131). ECN also increased PWV and arterial stiffness, but to a significantly lower extent than CC smoke did. The authors conclude that EC aerosol exposure induce substantially lower biological responses associated with CVD compared to CC smoke. The contribution of nicotine in the EC aerosol to the observed effects appear to be medium to small.
E
Mice treated with nicotine for 14 days were found to have profound aggravation of the immune response after ischemia/reperfusion injury (133). According to the authors, these observations are not only relevant for stroke occurrence but also for nicotine-related inflammatory responses in other organs.
In an attempt to identify which smoke or aerosol component might be responsible for the acute impairment of the endothelial function (measure as a decrease in FMD in rats), nicotine (as high and low levels in CC smoke), particles (as inert carbon particles), acrolein and acetaldehyde were measured (134). All agents tested showed similar reductions of FMD compared to air. The effect was prevented by bilateral vagotomy. The authors conclude that acute endothelial dysfunction by disparate inhaled products is caused by
W
In a mouse model (ApoE−/−), exposure to EC aerosol (2 h/d, 5 d/week, 16 weeks; e-liquid with 2.4% nicotine) was found to increase level of damaged mitochondrial DNA in circulating blood and induce the expression of TLR9, which in turn elevates the release of pro-inflammatory cytokines (IL-6, TNF-α) in monocytes/macrophages and consequently lead to atherosclerosis (136). In addition, the authors report enhanced TLR9-expression in human femoral artery atherosclerotic plaques from EC users and a significant increase of oxidative mitochondria DNA lesions (8-OHdG) in the plasma of EC-exposed mice. Unfortunately, the authors did not include a nicotine-free EC group or discuss the potential role of nicotine in the observed effects. Rats were exposed to EC aerosol with and without nicotine, CC smoke and fresh air (137). E-cig exposure did not increase myocardial infarct size or worsen the no-reflow phenomenon, but EC aerosol with nicotine (not so without nicotine, CC smoke or fresh air) induced deleterious changes in LV structure leading to cardiovascular dysfunction and increased systemic arterial resistance after coronary artery occlusion followed by reperfusion.
In summary, animal studies have limitations when intended to extrapolate to human nicotine product users since animal treatment (particularly by inhalation) can be associated with stress responses, which are also risk factors for CVD. In mice and rats, chronic nicotine administration impaired aortic reactivity, probably via redox imbalance, and vascular remodeling mechanisms. Long-term vaping in mice exposed to EC aerosol derived from e-liquid with nicotine showed impaired endothelium-dependent and endothelium-independent vasodilation (similar to smoking) and increased the risk of CVD. Nicotine played a detrimental role in the process of oxidative stress, inflammation, lipid accumulation, and sympathetic dominance. However, the contribution of nicotine in EC aerosol to the observed effects appears to be medium to small. In mice treated with nicotine, there was profound aggravation of the immune response after ischemia/reperfusion injury, a process important for stroke.
Overall, animal studies suggest that nicotine is involved in a number of patho-physiological processes related to the development of CVD.
In the following, some findings of
Nicotine was reported to stimulate DNA synthesis and proliferation of vascular endothelial cells
In
K
A series of reviews and monographs dealing with the CVD risks of nicotine products (with particular focus on ECs) are available. A brief summary is provided below.
B
In a recent review, B
The NASEM report of 2018 (6) came to the following conclusions with respect of the association between EC use and CVD:
No evidence for an association between vaping and clinical cardiovascular outcomes (CVD, stroke, peripheral artery disease); Substantial evidence that vaping acutely increases HR; Moderate evidence that vaping acutely increases DBP; Limited evidence that vaping acutely (short-term) increases SBP, changes biomarker of oxidative stress; biomarkers, increases endothelial dysfunction, arterial stiffness and autonomic control; Insufficient evidence that vaping is associated with long-term changes in HR, BP and cardiac geometry and function.
According to the N
The C
An umbrella review of P
A recent review investigated the impact of ECs on CV health with a special focus on causal pathways and public health implications (147). The authors stated that additives in the e-liquid such as nicotine and flavors are mostly responsible for the effects, which include prolonged sympathoexcitatory CV autonomic effects such as increased HR and BP as well as decreased oxygen saturation. Vaping is therefore a risk factor for developing atherosclerosis, hypertension, arrhythmia, MI and heart failure. According to the authors, studies on the long-term effects of EC use are urgently needed (147).
With respect to the urgent requirement of long-term studies our review comes to the same conclusions as the previously cited review (147). However, in our opinion it is not justified to state that vapers are at increased risk of developing various CVDs as C
Quite a number of human, animal, and
Smoking CC is reported to be responsible for 15–20% of the total population CVD. Epidemiology shows that there is no linear dose-response relationship between smoking (CC) and CVD. Smoking-related effects on the cardiovascular system are mostly reversible, this means that switching from CC to NGPs could be beneficial.
Human studies on HR and BP revealed acute increases in NGP users, but lower than in smokers (CC). Causal participation of nicotine through its sympathomimetic properties is plausible.
Use of SLT products (including snus), NRT products, and ECs showed partly inconsistent results and partly significant increased risks for MI, stroke, atherosclerotic changes, and hypertension. The role of nicotine in the development of these CVD is unclear. In cross-sectional studies, there are issues with causality, temporality as well as misclassification in product use (false self-reports and vague recollection of product use, particularly in exclusive NGP user groups).
Arterial stiffness is an important predictor of CVD. Acute studies showed an increase in PWV and AI compared to sham use, the effect, however, was found to be lower than smoking (CC). An involvement of nicotine appears to be possible. The effect of chronic NGP use was as yet hardly investigated and results so far are inconclusive. Long-term studies are required to determine the involvement of nicotine, if any, in the development of arterial stiffness.
BOBEs have been used to assess the potential risks associated with the use of NGPs. Some improvements (indicating lower CVD risk) have been observed in medium-term (90–360 days) and long-term (24 months) studies in subjects who switched from CCs to NGPs (ECs or HTPs). No clear evidence for the participation of nicotine is reported or can be deduced from the data. More long-term studies are required to determine the involvement of nicotine in BOBEs.
Animal and
In conclusion, the use of NGPs has been associated with both acute and chronic effects on the cardiovascular system. While nicotine has been implicated in acute effects, its role in chronic processes leading to CVD is still unclear. Long-term studies are required to better understand the effects of NGPs on the cardiovascular system and the involvement of nicotine in these effects. Epidemiological and field studies may potentially be biased by misclassification of products user groups (particularly NGP only users). An objective assessment of long-term product use would be of major importance.
Induction of cancer by tobacco smoking has been scientifically elucidated since the 1950s. Tobacco smoke contains more than 70 known carcinogens as well as a large number of cocarcinogens, tumor promotors, epigenetically active chemicals as well as toxicants, which all can contribute to and promote the process of chemical carcinogenesis (148,149,150). The IARC (149) has determined a causal relationship between cigarette smoking (CC) and various cancers, including cancer of the lung, bladder, kidneys, oral and nasal cavity, larynx, pharynx, esophagus, pancreas, stomach, cervix and myeloid leukemia.
With respect to the purpose of this review, it has to be emphasized that the development of cancer requires several decades, which is much longer than the NGPs are in use. Furthermore, it is extremely difficult to take into account possible residual effects of prior smoking. Therefore, it is clear that presently no proper studies are available for evaluating the cancer risk of NGP use, let alone the contribution of nicotine.
In this context, we like to mention that the IARC answered to the question “
Tobacco smoking can be involved in carcinogenesis by various mechanisms (25). CC smoking is associated with the uptake of more than 70 carcinogens, which, either as un-metabolized parent compound or after metabolic activation, can form DNA adducts. DNA adducts, as a rule, are repaired, but upon persistence, they can form the origin of mutations. If mutations occur in genes which are critical for tumorgenesis such as oncogenes or tumor-suppressor genes, a loss of normal cell growth can be the consequence, which finally may end up in cancer. Apart from tumor initiators, tobacco smoke also contains cocarcinogens (e.g., catechol, alkyl catechols) and tumor promotors, which primarily do not interact with DNA but stimulate cell proliferation and thus tumor growth. An important difference between genotoxic tumor initiators and cocarcinogens and tumor promotors is that effects of the latter two are reversible. Furthermore, it is scientifically accepted that no threshold dose exists for carcinogen, below which no cancer risk can be assumed (151). The fact that smoking cessation decreases the cancer risk, indicates that cocarcinogens and promotors play an important role in smoking-related carcinogenesis (25). Furthermore, epigenetic effects, which impact gene-regulation by either increasing or decreasing DNA methylation can significantly influence tumorigenesis.
Also epigenetic effects are supposed to be mainly reversible. Other possible mechanisms how smoking can have an impact on cancer development include induction of phase 1 enzymes (e.g., cytochrome P450 enzymes) responsible for the formation of the ultimate carcinogens, inhibition of phase 2 enzymes (responsible for conjugation and detoxifications of carcinogens), inhibition of repair enzymes, impairment of the immune system and stimulation of tumor-angiogenesis.
A simplified scheme of the described mechanistic pathways to smoking-related cancers (in general chemical carcinogenesis) is shown in Figure 1 (modified from (25)).
In quite a large number of studies, the exposure to carcinogens has been investigated in users of NGPs, usually compared to smokers (CC) and NU (e.g., (152,153,154,155,156,157,158)), for review see (16). The aspect of exposure to toxicants, including carcinogens, is not discussed in this review. Overall reduction in the product use-related exposure to carcinogens is 95% in NGP users compared to smokers (CC). An exception are tobacco-specific nitrosamines (TSNAs) in SLT (excluding Swedish snus) which might release similar or even higher amounts of TSNAs compared to CC. This is mentioned several times throughout this review.
B
C
Table 2 contains 10 studies, 4 of them investigated cancer as an endpoint (56, 161,162,163), whereas the other studies investigated epigenetic effects (mainly DNA methylation) in blood (164, 165) or saliva (166) or in epithelial cells from the oral cavity (167) and the lung (168) (see page 62). One cancer study (169) was not a study with a classical epidemiological approach (prospective or case-control), but was a longitudinal observational study with a limited number of participants (in total 912 subjects: smokers, vapers, dual users).
All cancers as endpoints were evaluated in studies with SLT (56, 161, 162), NRT (nicotine gum) (163) and ECs (169). None of these studies showed significant associations between NGP use and cancer risk. Only in three studies (56, 161, 169), the overall cancer risk of smoking (CC) was investigated, one showed a significant increase (56).
No significant relationship between SLT use and pancreatic cancer was found, although a significant trend with increasing consumption of SLT was observed (162). Cigarette smoking (CC) was not investigated in this study.
No significant association between NRT use and cancer of the lung and the gastrointestinal (GI) tract was reported (163). CC use was found to significantly increase the risk of lung cancer, but not of GI cancer.
DNA methylation and implicated gene regulations were investigated in the 5 studies of Table 2. In all of them, EC use compared to smoking (CC) was in the focus of the study. One study also included SLT users (165). The provided data show clear evidence that EC use (and probably also use of other NGPs) are distinct from CC users and NU with some overlap. An increase in genotoxicity levels associated with vaping habits was also deduced from a recent study of peripheral blood samples from vapers (EC), smokers (CC) and NU (170). Vapers showed changes at the epigenetic level specifically associated with the loss of methylation of the LINE-1, which were reflected in its representative RNA expression detected in vapers.
In terms of biological effects, changes, perturbations, physiological malfunctions, disorders or even cancer formation, there are too many gaps for any reasonable predictions.
With respect to an involvement of nicotine, the evaluated studies show either no evidence for a participation of nicotine in tumorigenesis and/or a role of nicotine cannot be deduced from the provided data (0/?). There might be some weak evidence that TSNAs from SLT are involved in the development of pancreatic cancer (162). The carcinogenic potential of smokeless tobacco (SLT) has been reviewed by Hecht
There are a number of epidemiological studies on cancer and use of oral tobacco with controversial results, depending on the point in time of study and the geographical region (e.g., USA, Scandinavia, India) where the study was conducted (172, 173). Older SLT products could have high TSNA levels resulting in significantly higher NNK and NNN exposure of the users than exhibited by smokers (CC). Therefore, these SLT products cannot be regarded as NGPs suitable for tobacco harm reduction, at least not for cancer endpoints. With respect to the focus of this review (role of nicotine in the development of diseases), cancer studies with older SLT products will not be included in the evaluation. As a result, we decided to only consider SLTs with very low levels of TSNAs as NGPs.
The potential carcinogenicity of chronic NGP use and the avertable role of nicotine was evaluated in a number of recent monographs and reviews.
The NASEM (6) concluded that nicotine probably does not increase the risk of cancer. This statement is mainly based on the Lung Health Study (163), which followed users of NRT products for 7.5 years, found no evidence for an increased cancer risk. The NASEM further stated that nicotine might be a tumor promotor, but it would be unlikely to increase the human cancer risk (6). This evaluation is also shared by COT (7).
The EU-based Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) (143) reviewed the most recent scientific and technical information on ECs and concluded for cancer in the respiratory tract: “
T
In a model calculation, the following order of life-time cancer risks was reported (175): combustible cigarettes (CC) o heat-not-burn (HTP) o e-cigarettes (EC) $ nicotine inhaler (NRT), with EC use representing < 1% of the cancer risk associated with CC use.
In a recent review by M
Taken together, the presented evidence suggests that chronic use of NGPs has as yet not shown to increase the cancer risk. Although theoretical possible, there is also no evidence that long-term use of nicotine is involved in human carcinogenesis. However, for obvious reasons no long-term cancer studies with NGPs are currently available.
As mentioned above, nicotine can exert quite a number of effects in the mammalian organism, impacting the brain, cardiovascular system, lung and many others. Nicotine may be involved in the modulation of many physiological processes such as the activity of certain ligand-gated ion channels known as nicotinic acetylcholine receptors (nAChRs) modulating cell proliferation, apoptosis, immune response, oxidative stress, tumor proliferation, metastasis, promotion of lung cancer, cell proliferation, angiogenesis, migration and invasion (178). Several of these are directly or indirectly associated with cancer development.
In the following, evidence is presented from animal and
M
In similar experiments, M
In a study with mice exposed to EC aerosol, L
Exposure of male ApoE−/− mice to air, EC aerosol derived from e-liquids with 6 and 36 mg nicotine/mL showed nicotine dose-dependent increases in epigenomic DNA methylation in WBC as well as an increase in plasma mitochondrial DNA and 8-OHdG levels (183). The authors concluded that the epigenomic-wide CpG site methylation pattern overlaps with previously published methylation sites in vapers/smokers and that the methylation pattern correlates well with enhanced systematic inflammation reported in animal models and human vapers.
Nicotine has also been suspected to be a precursor for carcinogenic metabolites such as NNK and NNN. H
T
Already in 2011, S
Based on various human, animal and
Cigarette smoking is an established risk factor for cancer of various organs, including lung, bladder, kidneys and pancreas. Tobacco smoke contains more than 70 carcinogens which are involved in the turmorigenesis by acting as initiators, cocarcinogens and promotors. Epigenetic effects mediated by the DNA methylation grade leading to up- and downregulation of genes possibly involved in tumorigenesis gained increasing interest and was also shown to be significantly altered by smoke exposure.
A participation of nicotine has long been assumed and could occur on a number of different mechanisms, including metabolism to carcinogens (NNK, NNN), epigenetic effects, angiogenesis, cell growth stimulation.
For obvious reasons, only a few human cancer studies with NGPs (including SLTs, NRT products and ECs) are available. There is no evidence that these products significantly increase the cancer risk, suggesting that nicotine is not a driving factor in carcinogenesis. The results of long-term animal studies with cancer endpoints are as yet inconclusive.
Human and animal studies reveal that exposure to EC aerosols (other NGPs have not yet been investigated) significantly change the epigenetic DNA methylation profile in cells of target organs (lung, oral cavity) or blood cells. Overlap with smokers or NU is reported to be low, suggesting that the methylation profiles are rather specific for the exposure. Consequences in terms of disorders, diseases or even cancer are currently unknown.
Overall, while the studies presented suggest that NGPs may be a less harmful alternative to smoking in terms of cancer risk, more research is needed to understand the long-term effects of nicotine and other components of these products on cancer development.
As major mechanisms for effects in the respiratory tract, which are common in users of inhalable nicotine products (CCs, ECs, HTPs), D dysregulated mucin expression followed by impaired ciliary clearance build-up of apoptotic and necrotic epithelial and immune cells, engraved by impaired efferocytosis increased release of inflammatory mediators (cytokines, proteases, ROS) impaired pathogen phagocytosis by macrophages and neutrophils reduced chemotaxis by neutrophils, (vi) disruption of the epithelial barrier (187). As a result of these processes, the respiratory tract of chronically exposed subjects is much more vulnerable to pathogen load and infections.
Smoking-related (nonmalignant) respiratory diseases include chronic bronchitis, COPD, emphysema and the worsening of asthma. According to the US Surgeon General Report of 2010 (25), definitions of these RD are as follows:
Chronic obstructive pulmonary disease (COPD) | A preventable and treatable disease characterized by airflow limitation that is not fully reversible. The limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences. |
Emphysema | Permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. In patients with COPD, either condition may be present. However, the relative contribution of each to the disease process is often difficult to discern. |
Asthma | A chronic inflammatory disease of the airways in which many cell types play a role — in particular, mast cells, eosinophils, and T lymphocytes. In susceptible persons, the inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and/or in the early morning. These symptoms are usually associated with widespread and variable airflow obstruction that is at least partly reversible either spontaneously or with treatment. The inflammation also causes an associated increase in airway responsiveness to a variety of stimuli. |
Tobacco smoke toxicants such as acrolein and formaldehyde are regarded to be responsible for initiating oxidative stress (e.g., by the formation of ROS), inflammatory processes and a proteinase/anti-proteinase imbalance. These processes are key players in the development of respiratory diseases in smokers (188, 189).
Intact lung defense systems, including nasal hair, convoluted passages of nasal sinuses, coughing, sneezing, swallowing, mucociliary cells, normal flora, inflammatory cells, alveolar macrophages represent the first barrier against the inhalable toxicants (25). Impairment of these defenses for example by smoking are the first step for the development of various respiratory diseases (RDs).
A decline in lung function is also a typical consequence of long-term smoking. Spirometrically determined parameters such as forced expired volume in 1 second (FEV1), forced vital capacity (FVC) and forced expired flow at 25–75% (Figure 2) can be measured non-invasively and, therefore, are frequently applied in clinical and epidemiological studies.
As in smoking, the aerosol of inhalable NGPs (ECs, HTPs) may affect various areas of the lungs by interaction with the epithelial cells of the trachea, bronchial tubes and branchings as well as the alveoli (191, 192).
In principle, vaping and use of other inhalable NGPs can induce respiratory diseases by similar mechanisms as for smokers (CC). Inflammatory processes, which can be monitored by a series of biomarkers are suggested to be in the focus (193, 194).
It is almost self-evident that oral NGPs such as snus or nicotine pouches (NPs) as well as nicotine gums (NGs) have no direct detrimental effects on the respirtory tract. The same applies for nicotine taken up with these products. NASEM stated three pathways, how nicotine could be involved in respiratory diseases in vapers:
decreases viral and bacterial clearance impaired cough nicotinic acetylcholine receptor activity in the airways and cystic fibrosis transmembrane conductance regulator dysfunction (6).
From two short-term studies, the NASEM (6) and the COT (7) concluded that using ECs with nicotine but not without nicotine could impair the mucociliary clearance process in the lung.
Overall, the NASEM report stated only limited to moderate evidence for lung damaging effects of vaping (6).
The majority of vapers are former smokers and thus could bear pre-existing lung damages which could be aggravated by vaping and, therefore, would lead to a confounded evaluation of the risks associated with EC (1) or HTP use. M
Table 3 contains 40 entries with short descriptions of investigations on respiratory tract effects of NGP use (101, 119, 195,196,197,198,199,200,201,202,203,204,205,206,207,208,209,210,211,212,213,214,215,216,217,218,219,220,221,222,223,224,225,226,227,228,229,230,231,232) (see page 65). In all studies EC use was compared to either smoking (CC) or NU (or both). In only one study, an HTP was investigated (215). Studies are mostly of cross-sectional type (21 studies). However, also 5 longitudinal studies with observational periods between 1 and 5 years were included (196,197,198,199, 223). It is noteworthy that there are 5 studies (201, 208, 209, 222, 226), all of the cross-over type, in which the effects of ECs with and without nicotine were compared. These studies would provide direct evidence on the role of nicotine in the observed effects. Finally, Table 3 also contains two meta-analyses comprising 13 (231) and 11 cross-sectional studies (232).
Both meta-analyses investigated the association between vaping and asthma and found a significantly increased risk (odds ratio (OR) = 1.2–1.3), which is only slightly lower than that observed for CC or dual (CC/EC) users (231, 232). These finding were in accordance with two EC studies in Table 3 (200, 212) and one HTP study (215) but opposed to another EC study (216). All asthma studies have a number of limitations, which are mentioned in Table 3.
Lung function parameters such as FEV1 and FVC were most frequently determined in the studies listed in Table 3. Reported results are heterogeneous, comprising impaired, unchanged and increased values of spirometric variables. Consistent results in terms of lung function and COPD (measured as CAT score) were reported by POLOSA and coworkers (198, 199, 223): in a longitudinal study lasting for up to 5 years, smokers (CC) who switched to EC showed no change or slightly improved lung function values and CAT scores compared to subjects who continued to use CCs. The evaluation of 3 cross-sectional studies revealed no increased risk for COPD and other respiratory diseases such as chronic bronchitis, emphysema and wheezing in vapers (216), whereas P
P
FeNO, an acute BOBE of respiratory inflammation as well as CVD showed heterogeneous changes (unchanged, decreased and increased levels) upon vaping in several studies (see Table 3). In a long-term study over one year, with those subjects who quit smoking and used ECs for staying abstinent, an increase compared to baseline levels was reported (196). An increased risk in vapers for chronic bronchitis was found in a longitudinal study over 1 year (197). Various BOBEs were measured in either BAL, EBC or sputum (Table 3). The obtained results do not allow to draw clear conclusions, whether vaping is associated with detrimental effects in the respiratory tract.
The presence or absence of nicotine in e-liquids of ECs was found to have no acute effect on lung functions (FEV1 etc.), FeNO (208, 209, 222), while acute increase in airway resistance (208), EMP, changes in the transcriptome in small airway epithel (SAE) and upregulation of inflammasome genes were reported to be nicotine-dependent (201, 226).
Overall, findings on respiratory effects of ECs described in Table 3 are partly contradictory and as yet inconclusive. The same is true for the possible involvement of nicotine on these effects. More research in this field, particularly on the effects of long-term NGP use is required in order to draw solid conclusions.
Other recent monographs and reviews in this area of research are in accordance with these conclusions:
The EU-based Scientific Committee on Health, Environmental and Emerging Risks (SCHEER) (143) reviewed the most recent scientific and technical information on ECs and concluded for respiratory diseases: “
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Results from the National Health and Nutrition Examination Survey (NHANES) showed higher prevalence of asthma and COPD in EC and dual users (EC + CC) than in smokers (CC only) and NU (235). Vapers with asthma were significantly younger than any of the other groups with this disease, suggesting that other factors may play a role as well. A possible reason for this observation could be that young subjects with asthma symptoms start with ECs, assuming that these are less detrimental for them.
In a recent state-of-the-art review on respiratory effects of vaping (236), it was found that human, animal and
Based on more or less the same available evidence as the previously cited reviews, B
In a recent state-of-the-art review, J
The literature on health impact of using ECs or HTPs in COPD patients was evaluated in a review (238). The authors conclude that, while ECs and HTPs may offer some benefits in reducing harm from CC, their long-term effects on COPD are still unclear.
Chronic exposure of mice to EC aerosol revealed that in the presence of nicotine, increased airway hyper-reactivity, distal airspace enlargement, mucin production, cytokine and protease expression was observed. These changes were not found when nicotine was absent (239). Experiments with normal human bronchial epithelial cells showed impaired ciliary beat frequency, airway surface liquid volume, as well as increased IL-6 and IL-8 secretion with nicotine, but not without nicotine (239).
In a study with mice exposed to PG and VG aerosol, with and without nicotine, detrimental effects in terms of lung inflammation and function were observed, independent of the presence of nicotine (240).
In a review on EC use and lung diseases, R
The same working group (243) reported that sub-chronic EC exposure of mice (2 h/d, 5 d/week, over 30 d) with or without nicotine affected lung inflammation and repair responses/extracellular matrix remodeling, which were mediated by the nicotinic receptor nAChRα7 in a sex-dependent manner. The authors speculate that, as an agonist, nicotine might have pro- and anti-inflammatory roles, which might explain these results (243). In this case, it has to be assumed that other EC aerosol constituents (e.g., aldehydes) can have similar detrimental effects in the lung, however acting via a different mechanism than nicotine.
G
In a mice inhalation study with various aerosols, including ECs with and without different flavor and nicotine (2 × 30 min/d, 6 d/week, 0–18 d), it was found that ECs with nicotine suppressed airway inflammation, but did not alter airway hyper-responsiveness and remodeling (246).
An inhalation study with rats exposed for 28 d to nicotine-free aerosol generated at 1.5 and 0.25 Ω enhanced xanthine oxidase and P450 enzymes to a higher degree at the low resistance condition (247). A nicotine-containing EC aerosol was not tested.
In a mice study, it was also observed that nicotine-free EC aerosol exposure (2 h/d, 6 d/week, 8 weeks) increased airway resistance and affected how the lungs react to tobacco cigarette smoke exposure in dual users (248). A nicotine-containing EC aerosol was not tested.
Exposure of mice to PG aerosols with and without nicotine (2 h/d, 3 d) were reported to alter the circadian molecular clock genes in the lung in only the nicotine-exposed animals, which, according to the authors, may have consequences for the lung cellular and biological functions (249). Mice exposed to PG/VG aerosol with and without nicotine over 4 months did not develop pulmonary inflammation or emphysema in contrast to smoke- (CC) exposed mice (250). EC-exposed animals were found to exert disruption of pulmonary lipid homeostasis and immune impairment independent of nicotine in the aerosol.
S
Female mice were exposed (2 h/d, 6 weeks) to PG/VG aerosol with and without vanilla flavor (252). EC vehicle exposure was found to disrupt immune homeostasis, irrespective of the presence of vanilla flavor. No EC aerosol with nicotine was tested.
In an inhalation study with ApoE-deficient mice (3 h/d, 5 d/week, 6 months), L
C
M
Mice were exposed to EC aerosols with nicotine and various flavors as well as to a PG/VG aerosol (257). Exposure dose-dependent increases in total cells, macrophages and neutrophils in BAL were observed with all aerosol, irrespective of the nicotine content. Oxidative stress markers in blood (8-OHdG, MDA) were also found to be increased, dose-dependently and independent of nicotine. This was also true for some inflammatory response on the mRNA level.
Mice exposed to smoke (CC) or EC aerosol derived from e-liquid with 6 and 12 mg nicotine over 10 weeks showed the highest detrimental effects in terms of impaired lung function, elevated inflammation markers and severe inflammation proteome network perturbations after CC exposure (258). Effects (if any) of EC aerosol exposure were much smaller and independent of the nicotine level. The authors suggest that in this animal model, EC aerosol is less harmful to the respiratory system than cigarette smoke at the same dose of nicotine.
M
Based on the studies reviewed, the role of nicotine in the various effects of electronic cigarettes and HTPs on the lung can be summarized as follows:
Nicotine appears to be involved in airway hyper-reactivity, mucin production, cytokine and protease expression, and impairment of ciliary beat frequency and airway surface liquid volume; Nicotine may be implicated in proliferating and inflammatory effects on various lung cells, and can affect lung inflammation and repair responses; Nicotine may exacerbate or ameliorate lung damage, the evidence is inconclusive as observed in human studies; Nicotine-free electronic cigarette aerosols can also induce airway inflammation and affect lung function, suggesting that other constituents in the aerosol may also play a role.
EC aerosols with and without nicotine stimulated the expression of MUC5AC in human bronchial and nasal epithelial cells (205, 264), suggesting that aerosol constituents other than nicotine are involved in the impairment of the mucociliary transport system of users, which could lead to the various respiratory diseases, including COPD.
Studies with human alveolar macrophages revealed that EC aerosol is cytotoxic, proinflammatory and inhibits phagocytosis (265). These effects were found to be partly dependent on nicotine.
A study with EC aerosol derived from VG (no nicotine, no flavors) including human volunteers, animals (sheep) and
Nicotine was found to significantly contribute to the disruption of the lung epithelial barrier function both when present in condensate of CCs and ECs (268). The authors suggest that another constituent in EC aerosol causing this effect was acrolein.
M
Adverse pulmonary and systemic effects of a nicotine aerosol were shown in a rat (
Cinnamaldehyde, an EC flavor agent, was found to dose-dependently decrease the ciliary beat frequency in human bronchial epithelial cells via inhibition of mitochondrial energy supply (272). Addition of nicotine had no effect. The authors conclude that inhalation of cinnamaldehyde with EC vapor may increase the risk of respiratory infections. Diacetyl and 2,3-pentanedione, two EC flavor compounds, were shown by transcriptomic studies with normal human bronchial epithelial cells (NHBEC) to impair the cilia function and likely contribute to the adverse effects of ECs in the lung (273). The role of nicotine in this system was not investigated.
The EC aerosol matrix compounds PG/VG have been shown in
Human nasal epithelial cells derived from smokers and non-smokers were exposed to PG/VG without and with nicotine (as salt or free base) (275). Changes in MUC5AC and pro-inflammatory cytokines were used as biological endpoints. Observed effects were dependent on the type of nicotine as well as on the source of the cells (smokers or non-smokers). The authors conclude that it is important to understand that the biological effects of ECs use are likely dependent on prior cigarette smoke exposure.
The Exposure to electronic cigarette aerosols containing nicotine can disrupt the lung epithelial barrier function and induce goblet cell hyperplasia, potentially impacting airway physiology and susceptibility to respiratory diseases; While aerosol constituents other than nicotine appear to be involved in the impairment of the mucociliary transport system of users, nicotine is implicated in the stimulation of MUC5AC expression in human bronchial and nasal epithelial cells, which could contribute to respiratory diseases; The impact of electronic cigarettes on mitochondrial DNA copy number in lung biospecimen is less clear than the impact of cigarette smoking, but exposure to electronic cigarette aerosols may also lead to significant changes; The adverse effects of certain electronic cigarette flavor compounds, such as cinnamon aldehyde, diacetyl, and 2,3-pentanedione, on lung cells are likely independent of nicotine, but the role of nicotine in the impairment of cilia function by aerosol constituents is not yet clear.
Cigarette smoking (CC) is an established risk factor for non-malignant lung diseases such as chronic bronchitis, COPD, emphysema and asthma. Impairment of various lung defense systems including mucociliary clearance and innate immunity as well as activation of inflammatory processes are first steps in the smoking-related pathogenesis. Smoking is significantly associated with a decline in spirometrically determined lung function as well as FeNO.
Numerous studies with vapers (EC) (and to a much lower extent also with HTP users) have investigated acute effects of product use on the respiratory system with as yet inclusive results. A limited number of long-term studies (observation periods of > 1 year) with vapers suggest that detrimental effects on the respiratory system, if any, are much smaller than in smokers (CC). No involvement of nicotine in the pathogenesis can be deduced from human studies. A few studies reported a possible role of nicotine in the gene regulation of lung cells. Consequences of these observations in terms of risk for lung diseases are as yet unknown.
In conclusion, presently there is no sufficient evidence that nicotine in NGPs has any detrimental effects leading to an increase in non-malignant lung diseases for the users. Well-designed long-term studies are urgently required to fill this gap of knowledge.
The oral cavity is the primary target organ for all tobacco and nicotine product habits, particularly oral products such as SLTs (snus, oral snuff), nicotine pouches and nicotine gum, but also inhalable products such as CCs, ECs, HTPs and nicotine inhalers. This chapter discusses the available evidence in terms of pathogenesis for various non-malignant oral health issues upon using conventional tobacco products such as CCs and SLTs as well as human, animal and
The US Surgeon General Report on the health consequences of SLT use concluded that an early effect is leukoplakia formation with the possibility of transformation to dysplastic lesions and finally (after decades of use) to oral cancer (276). Suspected, but still not confirmed at that time, were detrimental effects of SLT use on gingivitis, periodontitis, damage of the salivary glands and negative effects on teeth. It should be mentioned, however, that the Surgeon General’s conclusions are based on findings from various countries including those where more harmful oral tobacco products were sold than for example in Scandinavia and the USA.
In general, the lack of dental hygiene is a potential confounder in oral health effects (277).
Delayed healing after oral surgery or tooth extraction is another negative health effect of tobacco use. Less a health effect but rather a social problem could be bad breath (278) and dental staining (279) which is frequently observed in chronic smokers.
Major oral diseases associated with tobacco use and smoking are periodontal diseases and oral cancer (280). Involved mechanisms for periodontal diseases are the promotion by the invasion of pathogenic bacteria, inhibiting auto-immune defense, aggravating the inflammatory reaction, and aggravating the marginal bone loss (MBL). According to the authors, the link between periodontal disease and oral cancer is limited and needs further research. Evidence is provided that nicotine has a damaging effect on periodontal cells and alveolar bone (alveolar process).
Indicators of periodontitis risk such as increased plaque index (PI), probing depth (PD), clinical attachment loss (CAL) and decreased bleeding on probing (BOP) are more frequently observed in smokers than NU (281).
The oral microbiome of smokers (CC) is significantly different from that of non-smokers, creating an “at-risk-for-harm” oral environment (282, 283). CC use was demonstrated to create greater abundance of
Medical investigations of the oral cavity and gum use a number of diagnostic measures to evaluate oral health, here are short definitions of the most important ones:
PI (plaque index): A measure of the amount of plaque on teeth and gums; PD (probing depth): The depth of the pocket between the tooth and gum, which can indicate gum disease; BOP (bleeding on probing): Bleeding that occurs when a dental instrument is used to measure PD, also indicating gum disease; MBL (marginal bone loss): The amount of bone that has been lost around a tooth, often due to gum disease. CAL (clinical attachment loss): The distance between the gum line and where the tooth is attached to the bone, which is another indicator of gum disease; Xerostomia: The medical term for dry mouth, which can be caused by impairment of the salivary glands.
A systematic review on the effects of EC use in the oral cavity comprising 8 studies was published in 2019 (285). The major lesions and markers of interest were plaque index (PI), clinical attachment loss (CAL), probing depth (PD), marginal bone loss (MBL), bleeding on probing (BOP) and pro-inflammatory cytokine levels. All parameters (except for BOP which decreased with exposure), were significantly elevated in EC users compared to NU, but lower than observed in smokers (CC). Additionally, 9 different types of lesions of the oral mucosa were detected, with nicotinic stomatitis, hairy tongue and angular cheilitis being more prevalent in vapers. The authors cite evidence that the decrease in BOP is a nicotine effect (vasoconstriction).
NASEM (6) reviewed 4 human and 5
In a recent systematic review by Y
In a large population-based cross-sectional questionnaire study in the USA with > 450,000 adults, daily EC use was associated with poor oral health (adjusted OR (CI) = 1.78 (1.39–2.30), daily EC users versus NU) (288).
From a systematic review of the literature on the impact of vaping on periodontitis (289), the authors conclude that the available results point to increased destruction of the periodontium leading to the development of the periodontitis. The authors cite evidence that nicotine might play a role in reduction of BOP by vasoconstriction in the gingival tissue. For a systematic review on vaping and periodontal indices (290), 5 studies with 512 subjects were identified. Smokers (CC) had the worst values for PD and PI, non-users (NU) the best. The BOP parameter was equally reduced in CC and EC compared to NU. The latter finding is consistent with a reduced microcirculation in gingival tissues caused by nicotine.
R
A systemic review comprising 14 studies evaluated xerostomia in vapers (EC) and smokers (CC) (293). The prevalence was 33 and 24% in users of ECs and CCs, respectively. The difference, however, was not significant. P
In a review of the literature about the effects of vaping on oral health, it was found the at EC use might be implicated with less marked detrimental effects on the buccal mucosa and gingival tissues than smoking (CC) (295). In terms of nicotine’s role in oral health, the authors conclude that the alkaloid may be involved in migration inhibition, cyto-skeleton alterations, and extracellular matrix remodeling in human gingival fibroblasts and increase the amount of pro-inflammatory cytokines secreted in cultured gingival keratinocytes and fibroblasts. Furthermore, e-liquids, irrespective of the presence of nicotine, may induce oxidative stress buccal mucosa cells.
M
In Table 4 (see page 76), 23 studies, 18 of the cross-sectional and 5 of the longitudinal type are briefly described and evaluated (281, 296,297,298,299,300,301,302,303,304,305,306,307,308,309,310,311,312,313,314,315,316,317). All longitudinal studies (281, 301, 305, 314, 315), that investigated the effects of ECs, comprised observation periods between 6 months and > 1 year and reported somewhat impaired oral health in vapers compared to NU. The effects were significantly lower than those found in smokers (CC). In one longitudinal study (315), acrolein-derived DNA adducts were reported to be elevated in buccal cells of EC users compared to NU, but lower than in smokers (CC).
Of special interest is also the finding that PCR-determined DNA lesions in special genes (e.g., HPRT) in vapers (EC) were similar to smokers (CC) but significantly elevated compared to NU (317).
In one study of Table 4, pro-inflammatory cytokines in saliva of snus (including nicotine pouches) users were investigated (316). Levels were reported to be higher in snus and nicotine pouch users than in smokers (CC) and vapers (EC), which in turn were higher than in NU.
8-OHdG adducts (a marker for oxidative stress) were not found to be different between buccal cells of NU, EC and CC users (308). In contrast, myeloperoxidase (MPO), another oxidative stress biomarker, was reported to be higher in EC, CC and dual users compared to NU (309).
In almost all studies of Table 4, inflammation markers were found to be highest in smokers (CC) and lowest in NU, with EC and snus users in between. The same is true for the oral/tooth health indicators PI, PD, BOP, MBL and CAL. BOP was consistently reported to decrease nicotine-dependently in several studies, which is interpreted as a nicotine-related vasoconstriction in the gingival tissue (281, 296, 299, 300, 303,304,305, 311). For other biological effects listed in Table 4, either no involvement of nicotine can be stated (0) or a participation of nicotine is not deducible from the reported data (?).
The oral microbiome was found to differ significantly between users of CCs, ECs and NU, with only some overlap (312, 314). Consequences in terms of oral health risk can, as yet, not be inferred.
The same might be true for the reported dysregulation of genes in the oral cavity (306, 317), although the authors interpret the changes as indication for a higher oral health risk.
Taken together, there is (although as yet) limited evidence from human studies showing that use of NGPs can deteriorate oral health markers such as PI, PD, BOP, MBL, CAL and inflammation markers compared to NU. The reported effects are in general, however, significantly lower than in smokers (CC). The oral microbiome as well as the gene regulation in buccal cells was found to be different between smokers (CC), vapers (EC) and NU. The impact or changes in the oral microbiome for oral health is as yet unknown. Of interest is the vaping-dependent increase in acrolein-derived DNA adducts in buccal cells, which certainly requires further investigations. For most of the reported effects there is no, or only questionable evidence, for an involvement of nicotine. An exception is the oral health marker BOP, which is consistently found to be decreased in users of nicotine-containing products, most probably due to the vasoconstriction effect of nicotine in gingival tissue.
No
An
The oral cavity is the primary target for all tobacco and nicotine product habits. The use of conventional tobacco products can lead to non-malignant disorders such as leukoplakia, gingivitis, periodontitis, salivary gland and teeth damage, delayed healing, bad breath, and dental staining.
Most human studies in this field investigated EC use and reported impairments in the clinical oral health indicators PI, BOP, CAL, PD, MBL, as well as in pro-inflammatory cytokine levels. Effects are usually slightly higher than in NU, but significantly lower than in smokers (CC). The oral microbiome and gene regulation in buccal cells is found to significantly differ between EC and CC users and NU. Whether this has implications for oral health risk is not yet known. DNA lesions in buccal mucosa cells, as found to be elevated in smokers (CC), were not increased in vapers (EC). In a very recent study, EC use was reported to increase acrolein-derived DNA adducts in buccal cells.
A participation of nicotine in the development of the reported oral health disorders was not unequivocally observed with the exception of BOP. The decrease in BOP was found to be dependent on the presence of nicotine, most probably through its vasoconstriction effect in the gum. Whether this has detrimental effects upon chronic use of NGP is not known.
Oxidative stress and inflammation are crucial processes in the pathogenesis for many diseases. Smoking is causally related to both processes. There are a series of BOBEs for oxidative stress and inflammation which are applied in many human studies as early indicator for detrimental effects of smoking in various organs, tissues and cell systems (1, 22, 25).
Therefore, results for these biomarkers in users of NGPs are presented in the context of almost all diseases and disorders. In this chapter, oxidative stress and inflammatory processes are described in a more general context.
Smoking is associated with an increase in oxidative stress, which is thought to be a major mechanism underlying the pathogenesis of smoking-related diseases (25, 319).
Oxidative stress occurs when there is an imbalance between the production of reactive oxygen species (ROS), which are formed by subsequent addition of electrons to molecular oxygen (O2), yielding: superoxide radical anions (O2•−), hydrogen peroxide (H2O2), hydroxyl radicals (OH•) and water (H2O). The highly reactive superoxide radical anion and the hydroxyl radical can initiate lipid peroxidation to form lipid peroxides (ROO•). The body has the ability to detoxify these molecules by various processes, including:
Antioxidant enzymes (superoxide dismutase (SOD), catalase, glutathione peroxidase) Endogenous antioxidants (glutathione, thiols, ureate) Exogenous antioxidants (ascorbate, tocopherols, ubiquinol, flavonoids, carotinoids)
Smoking disturbs the oxidant/antioxidant balance so that ROS can cause damage to cellular components, including DNA, proteins, and lipids.
Cigarette smoke contains a complex mixture of more than 7,000 chemicals, including free radicals and other ROS. These ROS can directly damage cellular components, including DNA, proteins, and lipids, leading to oxidative stress. In addition, cigarette smoke can also activate immune cells, such as neutrophils and macrophages, which produce additional ROS and other inflammatory molecules. This creates a cycle of oxidative stress and inflammation that can contribute to the pathogenesis of smoking-related diseases.
One of the key mechanisms by which smoking causes oxidative stress is through the activation of the nicotin-amide adenine dinucleotide phosphate (NADPH) oxidase system. NADPH oxidase is an enzyme complex that produces ROS as part of the normal immune response. However, cigarette smoke can activate this system in a way that leads to excessive production of ROS, contributing to oxidative stress. In addition, cigarette smoke can also impair the function of SOD and other antioxidant enzymes, further exacerbating oxidative stress.
Finally, smoking can also lead to oxidative stress through the depletion of antioxidants. Cigarette smoke contains a number of chemicals that can deplete antioxidants, including ascorbate and glutathione (GSH). As a physiological response (compensation), GSH in various cells and tissues of smokers is elevated compared to that of non-smokers.
In summary, smoking is associated with an increase in oxidative stress, which is thought to be a major mechanism underlying the pathogenesis of smoking-related diseases. Smoking can cause oxidative stress through a number of mechanisms, including the activation of the NADPH oxidase system.
Nicotine has not been reported to be a cause or otherwise involved in the smoking-related oxidative stress, for which a number of chemicals in tobacco including aldehydes, radicals, quinones and many others were found to be responsible (320). It is also probable that nicotine is not causally involved in inflammatory processes (321).
Another important process how smoking is causally involved in the development of various diseases is the stimulation of inflammatory processes (25, 193). Inflammation is a complex process involving the immune system, which aims to protect the body from harmful stimuli, including pathogens, damaged cells, and irritants. When the immune system detects such stimuli, it triggers a cascade of molecular and cellular events, including the release of cytokines, chemokines, and reactive oxygen species (ROS), the recruitment of immune cells such as neutrophils and macrophages, as well as the activation of inflammatory signaling pathways. Smoking can trigger inflammation through several mechanisms.
Firstly, cigarette smoke contains numerous harmful chemicals, including “tar”, carbon monoxide, and nicotine, which can directly damage cells and tissues and trigger an immune response. For example, “tar” can induce DNA damage and oxidative stress, which can activate the nuclear factor kappa B (NF-κB) pathway, a key regulator of inflammation. Additionally, cigarette smoke can increase the production of ROS, which can cause oxidative damage and trigger inflammation by activating redox-sensitive signaling pathways.
Secondly, smoking can alter the composition of the microbiome in the respiratory tract or oral cavity, leading to dysbiosis and inflammation. The respiratory tract is normally colonized by a diverse community of microbes, which can play a role in immune regulation and protection against pathogens. However, smoking can disrupt this balance by reducing the diversity of the microbiome and promoting the growth of pathogenic bacteria, thus initiating inflammatory processes.
Thirdly, smoking can activate immune cells and promote the release of pro-inflammatory mediators. For example, smoking can stimulate neutrophil activation and recruitment, leading to the release of cytokines such as interleukin-8 (IL-8) and tumor necrosis factor alpha (TNF-α). Additionally, smoking can activate macrophages and dendritic cells, which can present antigens to T cells and trigger an adaptive immune response.
Fourthly, smoking can alter epigenetic modifications, which can lead to persistent changes in gene expression and inflammation. Epigenetic modifications, such as DNA methylation and histone acetylation, can regulate gene expression by altering the accessibility of chromatin to transcription factors. Smoking has been shown to alter DNA methylation patterns in immune cells, leading to changes in the expression of genes involved in inflammation and immunity.
Overall, smoking can trigger inflammation through multiple mechanisms, including direct damage to cells and tissues, dysbiosis of the microbiome, activation of immune cells, and alterations in epigenetic modifications. These inflammatory processes can contribute to the development and progression of smoking-related diseases, such as cardiovascular disease, chronic obstructive pulmonary disease, and cancer.
E
A cross-sectional study by C
Overall, the studies listed in Table 5 suggest that use of NGPs (mostly EC use was investigated) leads to no change or to an increase in the markers for oxidative stress or inflammation compared to NU. Increases, however, were mostly found to be significantly lower than in smokers. Principal weaknesses in terms of current and former use of CCs in cross-sectional studies have to be considered (see comments in Table 5). Another general issue is that the duration of use of NGPs is too short for evaluating the long-term effects of NGP use.
The role of nicotine in oxidative stress or inflammation in general was not deducible from the study data. A study with long-term nicotine pouch or snus users showed no significant increase in oxidative stress or inflammation markers, suggesting that nicotine might play no role (0) in these processes (333).
NASEM stated that comparisons between cell studies were difficult due to different cell cultures used, varying exposure methods (for example, cells were exposed to vaping e-liquids, aerosol extract or aerosol generated directly by vaping products), and different lengths of exposure (6). Based mainly on findings from cell and animal studies, NASEM concluded that “
Rats exposed to nicotine-free EC aerosols showed increased oxidative stress (ROS, lipid peroxidation, protein carbonylation) in the testis (334). The authors suggested that human vapers may also develop gonads dysfunction. K
The cytotoxic, oxidative stress and inflammatory effects (release of IL-8) of the e-liquid flavors diacetyl, cinnamon aldehyde, acetoin, pentanedione,
In an
S
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Smoking cigarettes is causally associated with oxidative stress and inflammation. Both processes are first steps in the pathogenesis of many smoking-related diseases.
Human studies on users of electronic cigarettes (ECs, other NGPs have been investigated distinctly less frequently) showed mixed results. Some studies suggest that ECs and other new nicotine products may also contribute to oxidative stress and inflammation. The extent of both effects, if any, was found to be significantly smaller than in smokers (CC). The role of nicotine in these processes is unclear. In general, cross-sectional studies may suffer from bias and confounding factors, which have to be considered when the results are interpreted.
Animal studies showed that exposure to releases of ECs and other new nicotine products can lead to oxidative stress and inflammation. Nicotine seems to play a role in this process, as animal studies have shown that nicotine alone or EC aerosols with nicotine compared to those without can cause oxidative stress and inflammation.
Overall, there is evidence to suggest that using ECs and other NGPs can contribute to oxidative stress and inflammation but to a much smaller extent than smoking (CC). There is insufficient evidence that nicotine may play a role in this process, but further research is needed to fully understand the mechanisms involved. In particular, long-term human studies are required to find out whether NGP use is associated with oxidative stress and inflammation in various organ systems.
Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of developing heart disease, stroke, and diabetes. The syndrome is characterized by a combination of high blood pressure, high blood sugar, excess body fat, and abnormal cholesterol or triglyceride levels.
Cigarette smoking is a known risk factor for metabolic syndrome. Smoking increases insulin resistance, a condition in which the body becomes less responsive to the hormone insulin, which regulates blood sugar levels. Insulin resistance can lead to high blood sugar levels and eventually to type 2 diabetes (25).
Smoking also increases the risk of developing abdominal obesity, one of the key components of metabolic syndrome. The toxins in cigarette smoke promote the accumulation of fat in the abdomen, which increases the risk of developing insulin resistance, high blood pressure, and abnormal cholesterol or triglyceride levels.
There are several biomarkers that can be used to early detect metabolic syndrome, including:
Fasting glucose: A blood test that measures the amount of glucose in blood after an overnight fast. Elevated levels of fasting glucose can indicate insulin resistance and prediabetes, both of which are risk factors for metabolic syndrome; Hemoglobin AC1 (HbA1c): HbA1c is a long-term biomarker for elevated glucose levels in blood; Triglycerides (TG): High levels of TG are often seen in people with metabolic syndrome; HDL cholesterol: A blood test that measures the amount of high-density lipoprotein (HDL) cholesterol, often referred to as “good” cholesterol. Low levels of HDL cholesterol are also a risk factor for metabolic syndrome; Waist circumference: Abdominal obesity, or excess body fat around the waist, is a key component of metabolic syndrome; Insulin resistance: A blood test that measures the amount of insulin in blood. Elevated insulin in blood is a risk factor for metabolic syndrome and indicates lower insulin sensitivity; C-Peptide in blood: C-peptide is released from pro-insulin upon formation of insulin the pancreas. It is used as marker for physiological insulin generation.
Overall, a combination of these biomarkers can be used to early detect metabolic syndrome.
T
In an acute intravenous nicotine infusion study, A
H
Table 6 (see page 85) summarizes 7 studies on the association between nicotine product use and the risk for metabolic syndrome (determined by various biomarkers or self-reported pre-diabetes), including 5 cross-sectional (113, 121, 334,335,336), one cross-over (347) and one pooled study consisting of 5 cohort studies (348). The nicotine products investigated included NRTs (gum (345), patch (347)), SLT products (113, 348), ECs (344, 346) and dual use of EC + CC (121).
All but one study (346) showed at least some evidence that product use might be associated with insulin resistance (Table 6). The risk for metabolic syndrome, however, was lower than observed for smokers (CC).
Three studies (345, 347, 348) provide evidence that nicotine might be involved in the development of metabolic syndrome, while one study (346) suggests that an involvement of nicotine is unlikely.
There have been animal studies that suggest nicotine may have an impact on metabolic syndrome, although the exact mechanisms are not yet fully understood.
In a recent study, D
Long-term oral nicotine exposure of obese rats was found to reduce insulin resistance through reduced hepatic glucose release and thus contributes to lowering the blood glucose level (350).
In another rat study, 6 weeks of nicotine exposure resulted in reduced weight gain, blood insulin and TG (351). No effect was observed on blood glucose. Further experiments with antagonists suggest that the nicotine-related enhanced insulin sensitivity is mediated via the α-nAChR.
Mice exposed for 12 weeks to EC aerosol, smoke from CCs or fresh air were not reported to differ in terms of insulin resistance and glucose tolerance (346).
Experiments with white adipose tissues of smokers and non-smokers showed that nicotine increases lipolysis, which results in body weight reduction (a typical effect of CC use), but this increase also elevates the levels of circulating FFA and thus causes insulin resistance in insulin-sensitive tissues (352). These mechanisms would explain the controversial effects of nicotine in smokers: reduction in weight gain and increase in insulin resistance. Nicotine was shown to induce insulin resistance in cardiomyocytes of mice via downregulation of Nrf2 (353).
Smoking cigarettes is a well-established risk factor for metabolic syndrome, which is a cluster of conditions including high blood pressure, high blood sugar, excess body fat, and abnormal cholesterol and/or triglyceride levels. Studies have shown that smoking cigarettes is associated with an increased risk of metabolic syndrome and its individual components, even after accounting for other risk factors such as age, sex, and body mass index (BMI). The mechanisms underlying this association are not fully understood, but it is thought that smoking may contribute to metabolic dysfunction through inflammation, oxidative stress, and impaired insulin sensitivity.
There is limited research on the association between NGP use and metabolic syndrome, and the available studies have produced mixed results. Some studies have suggested that NGP use may be associated with metabolic dysfunction, such as increased insulin resistance and impaired glucose tolerance, while others have found no significant association. The role of nicotine in these effects is unclear, as some studies have suggested that nicotine alone may have metabolic effects similar to those of smoking, while others suggested that the effects of ECs on metabolism may be due to other factors such as flavorings or other additives.
Animal studies have provided evidence that chronic exposure to nicotine has no or even beneficial effects in terms of insulin resistance and glucose tolerance. These observations would be in disagreement with most of the human studies.
On the other hand, evidence from
Overall, the available evidence suggests that smoking cigarettes and using NGPs can contribute to the development of metabolic syndrome. While there is still limited research on the specific effects of ECs and other NGPs on metabolism, some studies suggested that these products may have similar effects to smoking, although to a significantly lower extent. The effects may be due, in part, to nicotine. Further research, in particular long-term studies with human NGP users is needed to prove or disprove an association between NGP use and metabolic syndrome.
Smoking cigarettes can negatively affect both male and female fertility. Also the offspring of smoking parents have been found to suffer from deficits as neonates but also later in their life (24)
The US Surgeon General Reports of 2010 (25) and of 2014 (24) gave overviews of the detrimental effects of smoking during pregnancy and the possible effects on the offspring. Accordingly, in males, smoking can lead to a decrease in sperm count, motility, and morphology. In females, it can affect ovulation and reduce the chances of conception. Smoking during pregnancy can increase the risk of miscarriage, premature birth, and low birthweight. It can also increase the risk of stillbirth and sudden infant death syndrome (SIDS). Smoking can accelerate the loss of fertility in women, leading to earlier menopause. It can also decrease the effectiveness of assisted reproductive technologies, such as
The Report of the US Surgeon General of 2016 on EC use among youth and young adults (354) concludes that nicotine can cross the placenta and has known effects on fetal and postnatal development. Nicotine exposure during pregnancy can result in multiple adverse consequences, including SIDS, altered corpus callosum, deficits in auditory processing, and obesity.
The EU-based S
There were only few human studies on the use of NGPs during pregnancy and its impact on mother and baby. Previous reviews came to the conclusion that, in particular, vaping during pregnancy does not reduce the birthweight and that there is insufficient evidence for detrimental effects on fetal development (6, 7, 355). Also, no particular involvement of nicotine was identified. Based on animal studies, the COT (7) concluded with respect to effects on the developing lungs, there “
In a review on vaping during pregnancy, C
Another review on possible detrimental effects of vaping on reproduction came to the conclusion that human studies are scarce and that the effects observed in animal models suggest that caution should be taken when vaping and that more research is required to identify its potential adverse effects on fertility (357).
M
In Table 7 (see page 87), five studies with users of NGPs are summarized (359,360,361,362,363). All studies were of the cross-sectional type and included ECs as NGP, in one study snuff use was investigated (360), in two studies (359, 361) also dual users (CC + EC) were evaluated.
Results for EC users were inconsistent: No impact of vaping during pregnancy on birthweight was found in one study (361), whereas decreased birthweight was reported in daily EC users in another (363). Reduced birthweights in offspring were, however, observed for women who were dual or CC users during pregnancy (361). Surprisingly, smallness for gestational age (SGA) in offspring was observed when mothers vaped during pregnancy, but not for CC and dual users (359). Fertility was not found to be diminished by either vaping (EC) or smoking (CC) (362). Total sperm count was found to be significantly decreased in daily users of CC or EC, not so in snuff users (360). The authors concede that dual use (CC + EC) could not be excluded in their study population.
In a large study with 24,904 reproductive-aged women, a significantly elevated risk for disability in reproduction was reported for vapers (similar to smokers and dual users) compared to NU (364).
None of the study results in Table 7 shows evidence for a contribution of nicotine on detrimental effects of human reproduction.
Taken together, inconsistent results were found for electronic cigarette (EC) users during pregnancy, with some studies reporting no impact on birthweight and others reporting decreased birthweight or smallness for gestational age in offspring. None of the study results show evidence for a contribution of nicotine on detrimental effects of human reproduction.
Gravid rats were exposed to an aerosol derived from ECs with 0 and 18 mg/mL nicotine in the liquid as well as to fresh air (365). Weight at birth was not different between the groups. However, cerebrovascular dysfunction was observed in the offspring of EC-exposed rats, which was independent of nicotine content. The authors state that their data show some evidence for an effect of nicotine in the very early phase of life (1 month old offspring).
Gravid mice were exposed to EC aerosol with and without nicotine (366). Since the exposure was detrimental to maternal and offspring lung health, irrespective of the presence of nicotine, the authors concluded that the effects are likely due to by-products of vaporization rather than nicotine.
W
Offspring of mice exposed to EC aerosol with and without nicotine during gravity showed, regardless of nicotine presence, lung dysfunction and structural impairments that persists to adulthood (368).
R
Smoking cigarettes (CC) is an established risk factor for impairing female and male fertility. Smoking during pregnancy also increases the risk for low birthweight and has detrimental effects on the offspring.
Studies on new NGPs, particularly ECs, are limited, but previous reviews suggest that vaping during pregnancy does not reduce birthweight, nor is there sufficient evidence for detrimental effects on fetal development. Animal studies suggest that nicotine can have an effect on lung development, but it is unclear if this can be translated to humans. Gravid rats exposed to an aerosol derived from electronic cigarettes with nicotine showed a decreased number of offspring and a delay in fetal development.
Overall, inconsistent results were found for electronic cigarette (EC) users during pregnancy, with some studies reporting no impact on birthweight and others reporting decreased birthweight or smallness for gestational age (SGA) in offspring. None of the study results show convincing evidence for a contribution of nicotine on detrimental effects of human reproduction. Some animal studies suggest that nicotine exposure can affect reproduction. Further research is certainly needed, in particular human long-term studies, to clarify the somewhat controversial results between human and animal studies with respect to the role of nicotine.
In the following subchapters some other roles of cigarette smoking, NGP use and the potential participation of nicotine are briefly discussed. The disorders comprise (Table 8, see page 88):
Ocular disorders Bone disorders Impaired physical performance Mental disorders
Cigarette smoking can have several detrimental effects on the eyes (370), including:
Increased risk of age-related macular degeneration (AMD). Smoking was found to increase the risk of developing AMD by up to four times; Increased risk of cataracts: Cataracts are a clouding of the eye’s lens that can cause vision loss. Smoking increases the risk of cataracts and can also cause them to develop at an earlier age; Increased risk of dry eye syndrome, which can lead to eye irritation, redness, and blurred vision; Increased risk of diabetic retinopathy: Smoking can worsen diabetic retinopathy, a condition that affects people with diabetes and can lead to vision loss.
The exact mechanisms by which smoking causes these detrimental effects are not fully understood. However, it is thought that smoking may cause oxidative stress and inflammation in the eyes, leading to damage to the ocular cells and tissues.
Nicotine is known to constrict blood vessels, which can decrease blood flow to the eyes and other parts of the body. This can contribute to the development of AMD and other eye diseases. Additionally, nicotine has been shown to have a detrimental effect on the tear film, which can contribute to the development of dry eye syndrome.
In Table 8, four studies on EC use and detrimental ocular effects are briefly described (371,372,373,374). The rather small studies investigated both acute (371, 374) and chronic effects (1 to > 3 years of EC use) (372, 373). No acute effects on tear film quality (371) or on choroid thickness (CT) and centralfoveal thickness (CFT) (374) were reported. Long-term use (a few years) was found to be associated with detrimental effects on tear film quality (372) and foveal vision (373). In the latter study, nicotine-related vasoconstriction in the retina was suggested. From all other studies no involvement of nicotine can be deduced. The chronic studies were cross-sectional studies and may suffer from misclassification of product use.
Cigarette smoking can have several detrimental effects on the bones (375), including:
Increased risk of osteoporosis, which causes bones to become weak and brittle, making them more susceptible to fractures. Smoking can contribute to osteoporosis by reducing bone density and interfering with the body’s ability to absorb calcium. Smoking can slow down the process of bone healing, e.g., after a fracture or surgery. This is because smoking can reduce blood flow to the bones, which is necessary for proper healing. Smoking can increase the risk of bone infections, such as osteomyelitis, which can lead to bone loss and other complications.
The exact mechanisms by which smoking causes these detrimental effects are not fully understood. However, it is thought that smoking may cause oxidative stress and inflammation in the bones, leading to damage to the cells and tissues that make up the bones.
Nicotine may have detrimental effects on bone health, for example by interfering with the body's ability to absorb calcium, which is essential for healthy bones. Additionally, nicotine has been shown to reduce bone density and bone mineral content, which can contribute to the development of osteoporosis (376).
N
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In Table 8, two cross-sectional studies were briefly reviewed, one suggested that vaping (EC) could increase the risk of bone fragility (381), the other (382) implies that EC use is a risk factor for arthritis. An involvement of nicotine in inflammatory processes such as arthritis cannot be excluded. The weaknesses of cross-sectional studies have to be considered when these results are interpreted.
Cigarette smoking can have impairing effects on physical performance (383, 384), including:
Decreased lung function: Smoking can damage the lungs and reduce lung capacity, making it more difficult to breathe during exercise. This can result in reduced endurance and performance. Smoking can damage blood vessels and increase the risk of heart disease, which can affect cardiovascular function and reduce physical performance. Smoking can reduce oxygen levels in the blood, making it more difficult for the body to produce energy. Smoking can reduce muscle strength and endurance, making it more difficult to perform physical tasks.
Smoking-related oxidative stress and inflammation in the body lead to damage of lung cells and tissues as well as blood vessels and muscles.
Nicotine can have a stimulant (sympathomimetic) effect on the body, which can increase heart rate and blood pressure. However, nicotine can also constrict blood vessels, thus reducing blood flow to the muscles and impairing physical performance. Additionally, nicotine can interfere with the body’s ability to transport and use oxygen, which can contribute to reduced endurance. Overall, it has to be assumed that the negative effects of smoking on physical performance outweigh any potential benefits from nicotine’s stimulant effects.
Physical performance in EC-exposed female mice (measured by the grip strength, swimming time and glycogen content in liver and muscles) decreased with increasing nicotine content in the e-liquid (385). The authors do not provide a plausible explanation for this observation.
Impairment of skeleton muscle force and regeneration was compared in male mice exposed to air, PG/VG +/− nicotine aerosols (386). Impairment was found after exposure to sole PG/VG aerosol, however, effects were stronger with the nicotine-containing aerosol. The nicotine aerosol also decreased the adrenal and increased the blood epinephrine and norepinephrine levels. Furthermore, the glycogen stores in the muscles and the liver were elevated after exposure to nicotine aerosol.
In Table 8, a short description of a study is listed, which investigated the physical performance of long-term smokers (CC, 28 years use duration) and SLT users (25 years of use) in comparison to NU (387). While for smokers a significantly lower VO2max and workload was found, no decrease was seen in SLT users. The results suggest that nicotine might not be responsible for an impairment of physical performance.
Cigarette smoking was reported to have a range of detrimental effects on brain and the mood, including depression, anxiety disorders, schizophrenia, and substance use disorders (388, 389).
Studies have shown that cigarette smoking can increase the risk of developing depression and anxiety disorders, and can worsen the symptoms of these disorders in people who are already affected. Observations are controversial, while smoking was found to worsen the symptoms of schizophrenia and impair cognition and memory, other studies reported improving effects of smoking on these traits (see also next chapter).
Several hypotheses have been proposed with respect to the mechanism how smoking may affect the brain (390). One possibility is that the nicotine in cigarettes can affect the release of various neurotransmitters in the brain, including dopamine and serotonin, which are involved in mood regulation. Nicotine can also activate the hypothalamic-pituitary-adrenal (HPA) axis, leading to increased levels of stress hormones, which can exacerbate anxiety and other mental health problems.
Additionally, smoking is associated with chronic inflammation, which may play a role in the development of mental disorders. Studies have shown that people with mental illnesses often have higher levels of inflammation biomarkers in their bodies, and smoking may contribute to this by increasing levels of pro-inflammatory cytokines.
Overall, while nicotine may play a role in both detrimental and beneficial effects of cigarette smoking on mental health, the exact mechanisms are likely complex and multifaceted.
The C
In a state-of-the-art review, R
A vast amount of literature shows that smoking-derived nicotine exacerbates ischemic brain damage and induction of stroke (392). S inhibition of aromatase enzyme activation thus abolishing the an alteration in metabolism of histamine and γ-aminobutyric acid (GABA), which leads to hypoperfusion that subsequently can reduce glucose uptake resulting in impairment of the energy production as well as the functionality of the blood–brain barrier (BBB), and inducing edema; induction of inflammatory processes; as a consequence of systemic inflammation: vascular injury, endothelial dysfunction, and thrombus formation. The authors suggest that vaping (EC), similar to smoking (CC) may have the same detrimental effects in the brain, however, long-term studies to approve this, are as yet lacking.
In a literature review, R
R
Nicotine exposure during adolescence may enhance susceptibility to addiction, impulsivity, and mood disorders, while during adulthood nicotine may not have the apparent adverse consequences on the brain. The authors finally point to potential neuroprotective effects (in e.g., Alzheimer’s and Parkinson’s diseases, see also chapter on beneficial effects of this review) of nicotine in senescence, which might comprise an interesting field of research to explore further.
In a recent review, L
The Report of the US Surgeon General of 2016 on EC use among youth and young adults (354) concludes that nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain.
In
In Table 8, two relatively large cross-sectional studies on the use NGPs and mental disorders/mood are listed (397, 398). In both studies, an association between EC use and depression as well as suicidality was observed. An involvement of nicotine cannot directly be deduced from the results, but is supposed by the authors (397, 398).
In the same section of Table 8, a meta-analysis comprising 31 placebo-controlled clinical trials with nicotine patches and their acute impact on cognitive functions, attention and memory is reviewed (399). A significant improvement in cognitive function and attention was observed upon nicotine patch use.
Apart from the role nicotine might play in diseases and disorders discussed in the previous chapters, nicotine has been found to have some beneficial effects, meaning that traits are improved (e.g., cognitive function), disease symptoms are suppressed (e.g., tics in Tourette syndrome), or the risk for development of a disease may be reduced (e.g., Parkinson’s disease) (400, 401). Not all researchers, however, would agree that nicotine has any beneficial effects (402). Nicotine, of course, is not primarily used for therapy and prevention of these diseases. However, if adult users of nicotine products want to benefit from these positive properties, they most likely would not increase their risk for many diseases discussed in previous sections when using NGPs in contrast to cigarette smoking.
In the following, the evidence for beneficial nicotine effects is summarized. If available, studies with NGPs are included in the evaluations for the following traits and disorders:
Cognitive function Schizophrenia and other mental diseases Ulcerative colitis Parkinson’s disease Alzheimer’s disease Tourette’s syndrome Weight gain
There is some evidence to suggest that nicotine may have some cognitive benefits. Research suggests that nicotine can improve attention, working memory, and other cognitive functions, particularly in people who are abstinent from smoking or have a genetic predisposition to cognitive deficits. The former observation would suggest that nicotine acts primarily by eliminating withdrawal effects of abstinence, which has impaired cognitive capabilities. Nicotine appears to work by increasing the release of neurotransmitters such as dopamine and norepinephrine, which are involved in attention and memory processes.
In a nicotine replacement study (abstinent smokers used nicotine lozenges), it was shown by EEC measurement that the treatment directly affected brain neuronal activity modulating the cognitive network (403).
Comparing the cognitive performance in subjects smoking nicotine-containing and de-nicotinized (placebo) cigarettes suggests that response expectancies can be experimentally manipulated and can influence perceived rewarding effects of smoking, but do not affect the actual cognitive performance when smoking nicotine cigarettes (404).
N
A meta-analysis comprising 31 studies revealed that transdermal nicotine had statistically significant positive effects on attention, and non-significant effects on memory, in healthy non-smoking adults (399).
Nicotine can improve some of the cognitive deficits associated with schizophrenia, such as attention, working memory, and sensory processing. The same mechanisms as described in the previous section are involved.
In addition, some studies have found that smoking may have a protective effect against the development of schizophrenia, and that people with schizophrenia who smoke may have better cognitive function and fewer negative symptoms than those who do not smoke. Smoking rate in schizophrenic patients is significantly higher than in the general population, suggesting that schizophrenics may use nicotine products for self-medication (406, 407).
It was suggested that also other patients with psychiatric disorders may benefit from the pharmacological effects of nicotine on cognitive functions (408). Therefore, various groups of patients with psychiatric diseases may particularly benefit from harm-reduced NGPs.
In a review of 2017 (409), 9 relevant studies were identified which investigated the replacement of CC with EC in patients with mental illnesses. It was found that some studies suggest that combustible tobacco product use is decreased among these patients after initiating EC use, other studies imply that rates of dual use are higher than in the general population. The authors conclude that more research is required on the potential benefit or harm for subjects with mental illness when they switch from CC to EC.
Another review on EC use in mentally ill adolescents and young adults (12–26 years old) identified 40 (mostly) studies and found a significant relationship between vaping and mental illness compared with NU. The mental illness included depression, anxiety, suicidality, eating disorders, post-traumatic stress disorder, externalizing disorders (attention-deficit/hyperactivity disorder and conduct disorder), and transdiagnostic concepts (impulsivity and perceived stress). Notably, the authors name the association between the illnesses and EC use ‘comorbidities’. However, they concede significant methodological limitations, e.g., directionality in cross-sectional studies.
There is some evidence to suggest that smoking and nicotine may have beneficial effects for people with ulcerative colitis (UC), a type of inflammatory bowel disease. Research suggests that smoking may decrease the risk of developing UC, and that people with UC who smoke may have less severe symptoms and a lower risk of requiring surgery than non-smokers with UC (410, 411).
Possible mechanisms responsible for this remain purely speculative but may involve mucosal eicosanoids and intestinal mucus. It is also not clear whether nicotine by binding to the nACHR is the major component in smoke responsible for the beneficial effects in UC (412, 413).
As to the role for nicotine, some studies have found that nicotine replacement therapy (NRT, usually nicotine patches) may improve symptoms in people with UC who do not smoke. A review comprising 22 studies came to the conclusion that transdermal nicotine in combination with conventional therapy was more beneficial than individual treatment with either (414).
In a case control study, no association between vaping (EC) and the treatment outcome of UC was observed compared to NU (415). However, the study was rather small (47 UC cases using ECs).
Taken together, there is supportive evidence that smoking (CC) could be beneficial for UC, but there is as yet inconclusive evidence that nicotine and NGPs can have such a beneficial effect.
There is epidemiological evidence to suggest that smoking (CC) may have beneficial effects on the development and severity of Parkinson’s disease (PD) (416). The author states that the frequently discussed ‘pre-Parkinson’s personality’ appears unlikely as an explanation for the association. Research suggests that nicotine can improve some of the motor and cognitive symptoms associated with PD, such as tremors, rigidity, and attention. Nicotine appears to work by increasing the release of dopamine and other neurotransmitters that are involved in motor and cognitive processes. A recent investigation with neurons of
Q protective action against nigrostriatal damage; a symptomatic effect in PD; attenuation of L-dopa-induced dyskinesias, a debilitating side effect of L-dopa therapy. Stimulation of the release of dopamine, thus compensating the deficit of this neurotransmitter in PD appears to be the most probable mechanism.
It was suggested that nicotine gum could be a promising tool against various brain disorders, including PD and Alzheimer’s disease (AD).
Various research suggests that nicotine may have beneficial effects for people with Alzheimer’s disease (AD) by improving memory performance and cognitive deficits (419, 420). Nicotine appears to work by increasing the release of dopamine that is involved in cognitive processes. In addition, some studies have found that smoking may have a protective effect against the development of AD, and that people with AD who smoke may have slower cognitive decline than non-smokers with AD.
Possible mechanisms for the beneficial effects of nicotine in AD but also in PD and in cognitive function in healthy individuals have recently been reviewed (421). The mechanisms involved are not yet clear. Stimulation of the nicotinic receptors in the brain is hypothesized. However, anti-inflammatory, anti-oxidant effects as well as neuro-protective effects by enhancing the survival of certain types of neurons are also discussed.
Tourette’s syndrome (TS) is a neuropsychiatric disorder characterized by motor and vocal tics, obsessions, compulsions and visual-motor deficits (422). It has been shown that administration of nicotine (patches or gums) can potentiate the efficacy of treatment with neuroleptics (422, 423). The effect was observed to persist for days, weeks or even months without further nicotine administration.
It has been proposed that TS is caused by excessive striatal dopamine release and/or dopamine receptor hypersensitivity. Nicotine is known to pre-synaptically rapid release of several neurotransmitters, such as acetylcholine, γ-aminobutyric acid, norepinephrine, dopamine, and serotonin, followed by a prolonged desensitization of the receptors. The latter effect might be responsible for the persistent effect of nicotine in TS (422).
It is well established that smoking cessation is associated with a significant weight gain (424,425,426,427).
The mechanism of this phenomenon is not exactly known, various possibilities are discussed:
increased food intake; alteration in physical activity, reduced basal metabolic rate (347).
The role of nicotine is discussed controversially. In a long-term smoking cessation study, nicotine gum users gained significantly less weight than NU (428). A similar effect was observed, when nasal nicotine spray was applied as smoking cessation aid (429). In a smoking cessation study over 12 months in Japan, it was found that when Varenicline was used as a quitting aid, weight gain was lower than when using nicotine patches (0.94
Another nicotine patch study compared standard treatment duration (8 weeks)
Nicotine can act as an appetite suppressant, reducing feelings of hunger and increasing basic metabolism. Nicotine appears to work by stimulating the release of adrenaline and other neurotransmitters that increase energy expenditure and reduce food intake (433).
The purpose of this review was to elucidate the role of nicotine in potential health risks associated with the long-term (chronic use) of NGPs. Evidence was presented from human, animal and
The presented data will be discussed with the following aspects in focus:
Chronic human studies with NGPs (strengths and limitations) Diseases and disorders in which nicotine might play a role Gaps in knowledge and possible research to fill them
Long-term epidemiological studies, which investigate chronic effects of NGP use for 10 or more years are by now virtually available only for products such as SLT (e.g., snus) or NRT products by which the class of NGPs was extended. Endpoints include myocardial infarction (MI) (39,40,41,42), heart failure (43), stroke (42, 48), cardiovascular diseases (CVD) (56), hypertension (HT) (87, 88), various cancers (56, 161,162,163), type 2 diabetes (348).
In a series of human studies the long-term use of ECs were investigated. The duration of use is frequently not well defined, but can be assumed to be less than 10 years, due to the market availability of these products since about 2006. Endpoints of these studies include stroke (52), hypertension (89, 90), asthma (212, 231, 232), COPD and various respiratory impairments (119, 198, 199, 213, 216, 223), oral health risks (301), metabolic syndrome and diabetes (344, 346), arthritis and bone impairments (381, 382), low birthweight delivery (363), mental health symptoms and depression (397, 398).
Brief study descriptions, results, role of nicotine and limitations of these long-term studies are presented in Tables 1–4 and 6–8.
Results of the long-term studies cited above are very inconsistent. Chronic use of NGPs ranged from lowering the risk to levels comparable to NU risk to increasing the risk close to or even higher than that of cigarette smoking (CC).
All studies have a number of weaknesses and limitations noted in the summary tables. Apart from the fact that all chronic EC studies presently available, cover by far a too short time period of EC use (significantly lower than 10 years) in order to draw any firm conclusions with respect to causing chronic detrimental effects or diseases, there are at least two major issues, which could erroneously increase the risk of NGP use determined in long-term studies, particularly cross-sectional studies:
Misclassification of NGP use: It is highly likely that subjects defined as NGP only users are actually, at least for some time periods, dual users of NGPs with most frequently combustible cigarettes (CC). Questionnaires and short-term biomarkers of exposure to CC (e.g., COHb/COex, but also cotinine) are in general not suitable to eliminate this confounder (16, 434). Almost all studies have shown that dual use is implicated with health risks similar or close to that of CC only use (see Tables 1–8 in this review). A suitable measure to avoid or at least reduce the confounder of misclassification would be to apply specific long-term biomarkers of exposure to CC, such as 2-cyanoethyl-valine hemoglobin adducts (CEVal), which can indicate CC use of the last 3–4 months (123, 333, 435). An issue with cross-sectional studies is that this type of study cannot, in principle, prove causality, because of temporality (234): it is not known whether the observed disorder or disease is a result of using the NGP or whether the subject switches to an NGP because of early symptoms of a disorder or disease. Temporality is obviously inversed in mental disorders such as schizophrenia where patients are supposed to use nicotine products as a kind of self-medication (406). It may, however, also play a role in diseases/disorders with readily identifiable early symptoms such as respiratory diseases, hypertension and CVD, which would induce users of a harmful product (e.g., CC) to switch to a presumably less harmful product (e.g., EC).
The possible involvement or non-involvement of nicotine in the pathogenesis of the investigated diseases or disorders would also have to be evaluated by considering the general study limitations described above.
On the other hand, the evaluation ‘0’ (meaning that nicotine is not involved, e.g., in (39, 40, 161, 163, 199)) could also be wrong for reasons discussed in the following.
First, the duration of EC use could be too short for a profound statement in the implicated risk. Second, other weaknesses might be too small group sizes and very heterogeneous product designs preventing clear study outcomes. Third, nicotine delivery of the first generation of ECs was rather low compared to CCs and the newer generations of ECs (97, 105, 209), so that the alkaloid could not unfold an effect. Forth, the same could be true with the low nicotine deliveries of NRT products investigated in long-term (163).
The involvement of nicotine in the pathogenesis of various diseases, disorders or any physiological changes upon chronic and acute use of NGPs has been evaluated in the presented human studies (Tables 1–8) as described in the methodological sections 2.3 and 2.4. The results of this evaluation were further condensed to an even simpler system, comprising 3 classes for describing the probability of an involvement of nicotine in detrimental effects in NGP users:
Nicotine is unlikely to be involved in the pathogenesis. Class I comprises the codes 0 and 0/? used in Tables 1–8). An involvement of nicotine cannot be deduced from the study data. However, a participation of nicotine cannot be completely ruled out. Class II is equivalent to the code ? (only) in Tables 1–8. There is some evidence from the study data, the article authors’ as well as the review authors’s interpretation that nicotine is at least partly involved in the pathogenesis of the observed effects. Class III includes the codes 0–0.5, 0.5, 0.5–1.0 and 1.0 used in Tables 1–8).
Table 9 summarizes the results of Tables 1–8 according to this classification system (see page 90).
From the number of evaluable observations in human studies, it is obvious that for most of the single diseases of disorders the number of studies is too low for any strong conclusions. For all disorders, Class II (involvement of nicotine cannot be deduced, but can also not be ruled out) is found to have the highest frequency (50%). In disorders with at least 10 observations, Class I (involvement of nicotine rather unlikely), cancer shows the highest frequency (40%).
CVD-related endpoints were most frequently investigated in our review (75 observations), followed by RD-related (43 observations) and oral health-related endpoints (23 observations). Although we are well aware of the fact that the relative distributions cannot be representative for any disease or product investigated, the described classification for the role of nicotine may provide some valid indications in which diseases or detrimental effects the participation of nicotine is possible or unlikely.
In all CVD-related effects in NGP users presented in Table 1, 49% were assigned to Class III (evidence for participation of nicotine). Some disorders in the CVD category showed exceptionally high percentages for Class III, namely risk for hypertension (100%), acute increase in heart rate and blood pressure (72%) and arterial stiffness (47%) (Table 9). An involvement of nicotine in CVD-related disorders was also reported in long-term animal studies (most frequently using mice as a model) (127,128,129,130,131). As possible mechanisms for the involvement of nicotine in CVD development in mice the stimulation of oxidative stress, inflammatory processes in the vascular endothelium, lipid accumulation and sympathetic dominance were discussed (132).
The role of nicotine in respiratory disease- (RD) related endpoints was evaluated in 43 human studies with NGPs (Table 3). A participation of nicotine could not be deduced from the presented study data (but also not excluded) in 65% or the observations (Class II), while the percentages for an unlikely (Class I) and a possible involvement of nicotine (Class II) in the pathogenesis was 16 and 19%, respectively (Table 9). In other words, for this category of disorders, the uncertainty of the role of nicotine is higher compared to CVD-related disorders. In considering the literature on human studies with NGPs and the effects on the respiratory tract (see Section 5.2), the overall conclusion with respect to the role of nicotine was that there is inconsistent evidence for a participation of nicotine in the development of RD. A controversial picture of the participation of nicotine in RD-related effects of EC and HTP aerosols must be also deduced from animal and
Damaging effects on the oral cavity and buccal cells were investigated in 23 human studies (Table 4). In the majority of observations (57%) a participation of nicotine cannot be deduced from the data, but also not completely ruled out (Class II). A participation of nicotine in the observed effect of NGP use was unlikely in 9% of the studies (Class I), whereas a contribution of nicotine to detrimental effect appears possible in 35% of the observations (Class III). A similar conclusion in terms of the participation of nicotine in oral health risks can be drawn from various reviews considered in Section 6.2. A consistent finding is that nicotine is causally associated with a decrease in BOP, due to its vasoconstriction effect in gingival tissue. No animal studies on the role of nicotine in oral mucosa damage are available. An
Not unexpectedly (chemical carcinogenesis typically requires decades in humans), there are only a limited number of human cancer studies available which allow an evaluation of the role of nicotine in the development of this class of disease (10 studies are summarized in Table 2). The Class I/II/III distribution for the probability of a participation of nicotine in cancer induction was found to be 40/50/10% (Table 9), with a high degree of uncertainty, given the low number of studies and the extent of bias and confounding factors in human long-term studies, as discussed earlier in this review. The role of nicotine in carcinogenesis is discussed controversially since at least the first US Surgeon General Report on Smoking and Health (8). In none of the recent evaluations of the cancer risk in NGP users (particularly vapers) presented in Section 4.2, nicotine is genuinely considered as a product constituent responsible for increasing the cancer risk (6), although the possibility that nicotine can be a precursor for the human carcinogens NNN and also (much less likely) NNK has to be kept in mind (184, 185). In long-term animal studies, nicotine was not found to increase the lung cancer rate in mice (179, 180). On the other hand, EC aerosol without nicotine was reported to increase the lung and bladder tumor rate in mice (30, 181, 182). To sum up the potential role of nicotine in cancer risk of NGP users, it appears safe to state that there is presently no evidence that nicotine might increase the cancer risk compared to NU. The data available rather give cause to assume that cancer risk in NGP users is reduced compared to smokers of CC.
There is at least some evidence that nicotine might be involved in the development of a metabolic syndrome in NGP users (7 studies, Tables 6 and 9). Evidence from animal studies (Section 8.3) and
Five human studies on use of NGPs and reproduction were evaluated for a possible role of nicotine (Table 7). None of the studies shows evidence for a participation of nicotine in generation of detrimental effects to the offspring. A rat study (reviewed in Section 9.3) suggests that nicotine may have detrimental effects in lung and CNS development in the offspring (367). However, no nicotine-dependency of these endpoints were reported in other studies (365, 366, 368).
Too few observations for a meaningful evaluation of the role of nicotine in other disorders such as detrimental effects on the eyes, bones, brain or physical performance are available (Table 9). In terms of mental disorders, the considerations provided in Section 10.4 suggest that nicotine may have both detrimental effects as well as beneficial effects on the brain. For the developing brain (up to 25 years of age in humans), the C
In Tables 1–8, which review potential risks for diseases and disorders of NGP users, gaps (“G”), limitations (“L”), potential bias and confounding factors are briefly mentioned. Also, for promising approaches, possible research proposals (“P”) are mentioned, which we think would broaden our knowledge in the field of NGPs and health risks. Further valuable information on nicotine effects could be gained from medium- to long-term studies with NRT products such as nicotine nasal spray, gum or patches.
Almost all studies reviewed in Tables 1–8 have similar limitations, weaknesses and gaps, which are compiled together with suggestions for avoidance and study improvements in Table 10 (see page 90).
In order to improve and extent knowledge on possible detrimental effects of NGPs and the role of nicotine in any pathogenic processes, it is obvious that future research has to avoid the limitations and weaknesses listed in Table 10. Some of these (e.g., numbers 1, 4, 5, 6, 11) are inherent to the present market situation of NGPs and can be improved in probably only a decade from now.
It appears that the number of human studies on the association between NGP use and diseases/disorders summarized in Tables 1–8 correctly reflects the importance of the research areas by now and also for the future. These include (without preempting a rank order for the importance):
CVD Cancer Respiratory diseases Oral health Metabolic syndrome
Classical epidemiological studies (preferably of prospective type) with suitable morbidity and mortality endpoints would represent the gold standard. For reasons given above, it would require another one to two decades from now before suitable epidemiological studies can get off the ground.
Till then, application of suitable BOBEs embedded in well-designed studies would represent an acceptable alternative. Suggestions for suitable study designs are provided in Table 10. There are a multitude of BOBEs listed in Tables 1–8, many of them have been successfully applied in short-, mid-term and (rarely) long-term studies. However, their prediction power for a disease has most frequently not been evaluated sufficiently. Future research will (hopefully) resolve some of these deficiencies. In the last column of Tables 1–8, promising study designs and endpoints are indicated with “of interest” under the caption “P” (= Proposal for research project). In general, effects of long-term (> 1 year) use of NGPs (preferable of one class or NGP only) would be of highest relevance.
Apart from these more general considerations for future research in the field of NGP use and health risks, in the following we provide two examples for specific studies, which, in our view, could be of relevance for evaluating the potential health risks for NGP users.
It was pointed out at various passages in this review that it is of eminent importance for NGP risk evaluation to differentiate between NGP only use and dual (or even multi) product use. In present time, for NGP users, dual use (most frequently in combination with CC) is the rule rather than the exception. Many studies in Tables 1–8 have shown that health risks associated with dual use are commonly closer to CC use than to NGP only use, depending on the substitution of CC with NGPs. Insufficient separation of NGP only and dual user groups (misclassification), therefore, is a severe source of confounding and bias, particularly in cross-sectional studies. A recent review (16) showed that there are many possibilities to differentiate CC users from NGP users by suitable biomarkers of exposure. Differentiation of dual from NGP only and CC only use becomes more complex. This is also evident from the biomarker results of a controlled clinical study with users of CCs, ECs, HTPs, snus, NRT products and NU (15, 155,156,157,158). We suggest to assess levels of suitable biomarkers in exclusive and dual- (or poly-)users of nicotine/tobacco products in long-term studies for the differentiation of these groups. In particular, CEVal (2-cyanoethylvaline) as a specific marker for chronic smoking (CC) should be also included (123, 333, 435). This long-term biomarker of exposure to acrylonitrile reflects the use of CC in the last 3–4 months.
The human carcinogens NNN and (much less likely) NNK may be formed under special chemical conditions from nicotine (184, 185). NNN can also be formed by nitrosation of the nornicotine, which is a minor nicotine metabolite and, therefore, present in all NGP users. There is evidence that endogenous NNN formation in EC users is possible in saliva, catalytically accelerated by thiocyanate (157) and in urine under acidic conditions (436, 437). To further clarify the possibility of endogenous formation of NNN and NNK from nicotine in NGP users, we suggest to perform controlled clinical studies, in which this issue is investigated.
From the evaluated literature the following conclusions can be drawn:
The market availability of potentially harm-reduced NGPs (ECs, HTPs, NPs) is too short (< 10 years) to allow epidemiological studies with morbidities and mortalities as endpoints. Therefore, the assortment of NGPs was extended by snus and NRT products as well as study endpoints were broadened to BOBEs indicating acute, mid- and long-term physiological changes in order to predict a disease risk later in life; Use of NGPs was reported to have detrimental effects thus increasing the risk for a broad range of diseases, including CVD, cancer (various organs), respiratory/lung diseases, buccal mucosa and gingival tissue changes, metabolic syndrome and many other disorders, particularly in switchers from CC. Previous use of CCs over a long time period may certainly have an impact on the health risks in switchers. It is, therefore, of high importance that the history of previous smoking is accurately assessed when studying the risks of NGP use. Furthermore, a number of limitations in study design and user group misclassifications could have erroneously increased the risk. The evaluation of the role of nicotine suffers from the same shortcoming. However, the involvement of nicotine was judged to be not unlikely in a number of primarily acute changes upon NGP use such as cardiovascular effects (heart rate, blood pressure, arterial stiffness), metabolic syndrome and mental disorders. Results of animal and In the majority of human studies, the study design does not allow to deduce the role of nicotine in the observed biological endpoints, leaving open the question, whether nicotine is at least partly responsible for the observed effects or not involved at all. Nicotine appears to have controversial effects to the brain. While the alkaloid is suggested to have adverse effect to the developing brain, it is reported to improve cognitive performance. Nicotine is also suggested to have beneficial effects in terms of alleviation of symptoms, delaying or preventing the outbreak of a number of diseases. Beneficial effects of nicotine, however are not in the focus of this review and, therefore, only briefly discussed. Suggestions for improvements in study design in order to avoid or minimize falsified risk estimates for NGP users are provided. Also, two examples for research proposals are briefly presented.
CVD and CVD-related biomarkers of potential harm (BOPH).
Author, year, country (Ref) | Study type | User groups / duration of product use | Endpoints and findings | Comments (bias, compliance, etc.) | Conclusions regarding nicotine's ( |
Limitations (L) / Gaps (G) / Proposals (P) |
---|---|---|---|---|---|---|
H |
Case-control |
35–64 y old men: • 585 Cases with MI • 589 Controls Duration of SLT use: 10–30 y |
ORs (CI) • CC: 1.87 (1.40–2.48) • SLT: 0.89 (0.62–1.29) |
AO: Snuff dipping for middle aged men is associated with a lower risk for MI than smoking (CC). ARO: No verification of SLT use. |
The authors suggest that CO and PAH, rather than |
L: Relative low number of cases/controls using SLT (10–15%). G: Dual use (SLT+CC) not assessed. P: Larger study which avoids these weaknesses would be of interest. |
0 / ? | ||||||
H |
Case-control |
WHO MONICA study, 25–64 y old men: • 687 MI cases • 687 Controls Duration of SLT use: 5–30 y |
ORs (CI) for first • SLT only (N=59): 0.96 (0.65–1.41) • CC only (N=248): 3.65 (2.67–4.99) SLT risk slightly (not sign.) higher for fatal MI (OR=1.50) |
AO: MI is not increased in snuff dippers. ARO: Dual use was evaluated separately, but no verification for SLT only users. |
The authors conclude that |
L: Small group sizes; only men, relatively young population. G: No other NGPs; no N-free ECs. |
0 | ||||||
H |
Prospective | 118,395 healthy, never-smoking men (construction workers), 19 years (mean) of follow-up |
• Non-fatal: 0.91 (0.81–1.02) • Fatal: 1.28 (1.06–1.55) • Fatal, highest consumption: 1.96 (1.08–3.58) |
AO: Snuff use increases the risk of fatal MI. ARO: Tobacco use information was obtained from questionnaires at entry. |
The authors cite evidence that Participation of |
L: RR are very low and only sign. for fatal MIs; no clear dose-response; tobacco habits rely on self-reports; changes in habits are not assessed. |
0.5 / ? | ||||||
B |
Case-control and Prospective (meta-analysis) |
9 Epi studies on MI 6 Epi studies on stroke in Sweden (Swe) and USA Duration of use: 20 y (estimate) |
RR (CI) of current SLT users (number of studies): Any • Swe (6): 0.87 (0.75–1.02) • USA (3): 1.11 (1.04–1.19) Fatal MI: • Swe (5): 1.27 (1.07–1.52) • USA (3): 1.11 (1.04–1.19) Any • Swe (3): 1.02 (0.93–1.13) • USA (3): 1.39 (1.22–1.60) • Swe (3): 1.25 (0.91–1.70) • USA (3): 1.39 (1.22–1.60) |
AO: Use of SLT increases the risk of fatal MI and stroke, which does not seem to be explained by chance. ARO: Dual use (SLT + CC) is a general issue. |
The authors cite evidence that ARO: From the data, the role of |
L: Heterogeneity; SLT products in USA and Sweden are different, limited or no dose-response shown. G: No other NGPs. |
0.5 / ? | ||||||
A |
Prospective (2 studies) |
• ULSAM: 1,056 elderly men, never smoking, median FU 8.9 y • CWC: 118,425 construction workers, never smoking, median FU 18 y Duration of snus use: 50 y (estimate) |
• ULSAM: 2.08 (1.03–4.22) • CWC: 1.28 (1.00–1.64) |
AO: Use of snus increases the risk of heart failure. ARO: Snus only use was not verified. |
The authors assume that ARO: |
L: Low case numbers (particularly in ULSAM study); no reliable information on tobacco use habits (misclassification possible); no dose-response observed; men only. |
0.5 / ? | ||||||
A |
Cross-sectional (NHIS = National Health Interview Survey) |
Survey of 2014 and 2016 • 60,100 NU, 51.9 y, 2,309 MIs • 7,093 Former EC users, 39.9 y, 225 MIs • 1,483 EC some days, 41.4 y, 61 MIs • 776 EC daily (41 never smoked), 44.2 y, 47 MIs Duration of EC use: < 10 y (?) |
Adjusted ORs (CI) for • Former EC: 1.06 (0.86–1.30) • EC some days: 1.16 (0.83–1.62) • EC daily: 1.79 (1.20–2.16) |
AO: Daily use of EC increases the MI risk. ARO: Dual use was adjusted in the ORs, no verification. |
ARO: |
L: All data rely on self-reports. G: No N-free EC group. Causality between EC use and MI was questioned in a letter to the editor (47). |
? | ||||||
V |
Cross-sectional |
National Health Interview Survey, 2014, 2016, 2017, 2018; 16,855 participants: • 2,848 NU, 30.3 y • 401 Vapers (EC), 26.7 y • 7,291 Tobacco users (mostly CC), 44.0 y • 2,240 Dual, 42.2 y Duration of EC use: < 10 y (estimate) |
Adjusted ORs (CI) • EC: 4.09 (1.29–12.98) • CC: 4.52 (2.49–8.21) • Dual: 5.44 (2.90–10.22) • EC: 1.22 (0.36–4.18) • CC: 2.15 (1.38–3.35) • Dual: 2.32 (1.44–3.74) • EC: 0.67 (0.18–2.44) • CC: 1.90 (1.20–3.11) • Dual: 2.27 (1.37–3.77) |
AO: EC users have an increased risk for MI. The highest risk for MI, stroke and CHD were observed for dual users. ARO: Grouping relies on self-reports (danger of misclassification). |
ARO: |
L: All data rely on self-reports (misclassification of product use is possible). G: No N-free EC group. |
? | ||||||
H |
Prospective |
118,395 healthy, never-smoking men (construction workers), enrolled 1978–1993, follow-up 2003 • 3,248 cases of stroke Duration of snuff use: 10–30 y (estimate) |
RR for ever snuff users: • All • • Fatal |
AO: Snuff use increases the risk of fatal ischemic stroke. ARO: Tobacco use information was obtained from questionnaires at entry. |
The authors cite evidence that ARO: Participation of |
L: RR are very low and only sign. for fatal ischemic strokes; no clear dose-response; tobacco habits rely on self-reports; changes in habits are not assessed. |
0.5 / ? | ||||||
P |
Cross-sectional |
Telephone survey, 161,529 young adults (18–44 y): • 13,3077 NU • 13,318 CC only • 3,437 EC only • 4,204 EC/exCC • 7,493 Dual Duration of EC use: < 10 y (estimate) |
OR (CI) for • CC only: 1.59 (1.14–2.22) • EC only: 0.69 (0.34–1.42) • EC/exCC): 2.54 (1.16–5.56) • Dual: 2.91 (1.62–5.25) |
AO: Sole EC use is not a risk factor for stroke. ARO: All data rely on self-reports (no verification of product use). |
The authors cite evidence that ARO: Absence of risk in EC only would suggest no role of |
L: Misclassification due to self-report is possible; switching to EC due to early symptoms possible. G: No N-free EC group. |
0 / ? | ||||||
B |
Cross-sectional |
Behavior and risk factor survey (BRFSS), 2016, 486,303 participants: • G1: EC every day, m/f: 2,778/2,229 • G2: EC some day, m/f: 5,018/5,151 • G3: Former EC, m/f: 29,014/29,815 • G4: NU, m/f:164,605/226,937, older than G1–G3 Duration of EC use: < 10 y (estimate) |
Adjusted OR (CI) for • G1: 1.62 (1.18–2.31) • G2: 1.28 (1.02–1.61) • G3: 1.09 (0.98–1.23) |
AO: EC use is of potential concern for CVD. Self-reports and cross-sectional design can lead to confounding and bias. |
ARO: |
L: Only short use of EC (2007–2016); most participants were former CC users; dual use possible; temporality (due to cross-sectional design) not determined. |
? | ||||||
Z |
6 Cross-sectional studies (meta-analysis) |
1,134,896 Subjects, groups used for meta-analysis: • EC1: EC users (all, including only, dual, former CC) • EC2: EC only users • EC3: Current dual users • EC4: EC only users, former CC users • CC: CC only users • NU: no EC, no CC Duration of EC use: ? |
OR for prevalence of • EC1 • EC2 • EC3 • EC4 Subgroup analysis had lower heterogeneity |
AO: The role of EC use in stroke development is inconclusive due to the strong effect of former CC use. ARO: General problems with misreports of product use. |
L: Partly low quality studies; stroke types not differentiated; misclassification of product use possible; temporality unclear in cross-sectional studies. G: No prospective studies available; no N-free EC groups available. |
|
? | ||||||
P |
Cross-sectional |
NHANES 2015–2018, 79,825 users: • 7,756 EC users, 48y • - EC1: EC use in last 30d • - EC2: No EC use in last 30d • 23,444 Dual users, 50y • 48,625 CC users, 59y EC users are sign. younger |
Adjusted ORs (CI) for • EC • Dual • EC1 * discrepant to the text!? |
AO: Stroke in EC users was earlier in onset than in smokers. ARO: Usual problems with cross-sectional approach (temporality, recall bias). |
The authors cited evidence that |
L: Temporality in cross-sectional studies; misreports in product use; stroke not further classified. G: No N-free EC group. |
0.5 | ||||||
W |
Cross-sectional |
577 young men (18–19 y): • 377 NU • 43 CC only • 127 Snuff only • 30 Dual (Snuff + CC) |
Sign. diff. in CVD-related BMs in urine: • Tx-M: CC > NU, Dual > NU |
AO: CC but not snuff use facilitates TBX-A2 formation, reflecting platelet activation and potential CVD development. ARO: No verification of snuff only use. |
The authors cite evidence that ARO: |
L: Small user group sizes; young men only. G: No other NGPs (EC, HTP), N-free EC. P: Larger study with older subjects, including additional NGPs would be of interest. |
? | ||||||
B |
Prospective |
Male construction workers, up to 65 y (1970/71), follow-up after 12 years for mortalities: • 32,546 NU • 6,297 SLT users • 14,983 Smokers (CC1), < 15 cig/d • 13,518 Smokers (CC2), ≥ 15 cig/d Duration of SLT use: 10–40 y (estimate) |
RR (CI) compared to NU: • – SLT: 1.4 (1.2–1.6) – CC1: 1.8 (1.6–2.0) – CC2: 1.9 (1.7–2.2) • – SLT: 1.1 (0.9–1.4) – CC1: 1.5 (1.3–1.8) – CC2: 2.5 (2.2–2.0) • – SLT: 1.4 (1.3–1.8) – CC1: 1.7 (1.6–1.9) – CC2: 2.2 (2.0–2.4) |
AO: Both CC and SLT users have an increased risk for CVD, risk for SLT is lower. ARO: SLT (only) use was not verified, dual use is not unlikely. |
The authors cite evidence that ARO: |
L: Only male workers (healthy-worker effect?); dual use (SLT+CC) is possible. G: Other NGPs; ECs without |
0–0.5 | ||||||
B |
Cross-sectional |
143 Men, 35–60 y: • 40 NU, 43.1 y, CotP: 3.8 ng/mL • 28 SLT users, 44.4y, median 25y of SLT use, CotP: 338 ng/mL • 29 Smokers (CC), 48.0y, median 30y of CC use, CotP: 248 mg/mL |
Markers for • • • • • • • • • Alcohol consumption: ↑ |
AO: The increased occurrence of atherosclerosis in smokers is caused by other components of tobacco smoke than nicotine. ARO: SLT only use not verified. |
The authors state that, while |
L: Small group sizes; SLT group might contain dual users. G: No other NGPs included. P: A study avoiding these weaknesses would be worthwhile. |
0 | ||||||
W |
Cross-sectional |
391 Healthy men, 58 y • 139 NU (never SLT, never CC) • 48 SLT users (29% also smoked) • 96 CC users |
Risk factors for • SLT: • CC: |
AO: Smoking, but not SLT is an import risk for atherosclerosis. ARO: No exclusive SLT group evaluated. |
The authors conclude that the data clearly indicate that |
L: Only men, only one age. G: No exclusive SLT group, no other NGPs. |
0 | ||||||
Y |
Prospective (1987/89, FU: median 16.7 y later) |
• NU (no SLT, no CC): Total: 9,906; 1,510 CVD cases • SLT (no CC): Total: 354; 102 CVD cases; SLT = Snuff + chewing tobacco |
Harm ratio (CI) for • SLT: 1.31 (1.06–1.61) • CC (only): lower CVD risk than SLT!? |
AO: SLT use increases the risk CVD and is no alternative to CC use. ARO: SLT use only was not verified. |
No statement on role of ARO: A role of |
L: Misclassification of SLT (and CC) is possible (also conceded by the authors). |
? | ||||||
N |
Cross-over |
40 Subjects (20 S and 20 NS) were investigated under 2 conditions, separated by 1 week: • C1: Vaping, 9 puffs, EC with 16 mg N/mL • C2: Smoking, 1 CC (0.6 mg N/cig); Blood samples for BM analysis were taken right before and 5 min after product use |
Sign. diff. between S and NS at baseline: • sCD40L: higher in S • sP-Selectin: higher in S Changes pre/post: Elevation in NS and S under both conditions (C1, C2) for the 3 BMs • • • |
AO: Both CC and EC use acutely increase platelet activation. |
ARO: Involvement of |
L: Low number of subjects. G: No ECs without P: Results suggest a chronic effect of smoking on sCD40L, sP-Selectin. Therefore a larger study with long-term (> 12 months) use of CC and EC would be worthwhile. |
? | ||||||
M |
Cross-over |
17 occasional smokers were assigned to 2 conditions, separated by 1 week: • C1: EC with • C2: EC without BM measurements at 0, 2, 4, 6 h post vaping |
C1: sign. increase in: • • • • C2: sign. increase only in • BM4 (smaller than in C1) |
AO: As few as 30 puffs of nicotine-containing EC vapor caused an increase in levels of circulating E |
ARO: Nicotine likely to be involved in the acute increase of all 4 BMs. |
L: Low number of subjects. G: BM levels after chronic use of EC and other NGP use. |
1 | ||||||
S |
Cross-sectional |
Young adults: • 20 Smokers (CC), 27.0 y • 20 EC users (EC use only for the past 3 months, 80 % were previous smokers), 25.7 y, • 20 NS, 24.6 y |
|
AO: CC and EC users had significantly more carotid plaque burden compared to NU. Results further indicate that vaping does not cause an increase in vascular inflammation. ARO: Product use was self-reported (no biochemical validation). |
ARO: Role of |
L: Small sample sizes; EC use probably too short and compliance not approved. G: No N-free EC group. |
? | ||||||
G |
Cross-sectional |
17 Men, 18–75 y • 7 NU, 25.6 y, ≥2 containers SLT/week, CotP: < 10 ng/mL • 5 SLT users, 28.2 y, CotP: 226 ng/mL • 5 CC users, 21.2 y, ≥10 cig/d, CotP: 170 ng/mL |
Sign. differences (>/<): • • FMD (nitroglycerine-dependent): NU ≈ SLT ≈ CC |
AO: Endothelial function is sign. impaired by CC and SLT. ARO: SLT only use not verified. |
The authors cite evidence (including their results) that |
L: Small sample size; only men; low average age (short product use period); dual use possible. G: No other NGPs, no N-free EC group. |
1 / ? | ||||||
R |
Cross-over |
20 Snus users (m/f=18/2), mean age: 34 y: • All 20 performed a session with 1 g snus • 10 performed a similar session with placebo Measurements at 0 (BL), 20 and 35 min |
Sign. changes: • • • • |
AO: Oral moist snuff significantly impaired FMD of the brachial artery, predicting an increased CVD risk. |
The authors cite evidence that |
L: Small group size; mostly men, relatively young, only acute effects detected. G: No other NGPs, no N-free EC group. P: A study on chronic FMD impairment would be of interest. |
1 | ||||||
S |
Cross-sectional |
1,592 Healthy men (from HUNT3 Study): • 886 NU, 47.4 y • 238 Snuff only users, 42.8 y • 447 Smokers (CC), 47.4 y • 21 Dual users, 44.0 y |
The diff. in FMD was larger in SLT users with low fitness. Sign. changes: • • • • |
The authors conclude that snus acutely impairs FMD and is a risk factor for CVD. |
AO: The possible role of ARO: Role of |
L: Partly small group sizes; only men; duration of SLT use not provided. |
? | ||||||
F |
Cross-over |
15 Smokers, 22.9 y, were randomly allocated to 3 conditions: • EC(+) with • EC(−) without • CC: 1 CC 48 h washout period between conditions; measurements before and every 15 min after vaping/smoking up to 2 h |
Sign. changes in CC and EC(+) conditions between 15 and 60 min: No change in EC(−) |
AO: Speculate that long-term EC(+) use may increase the risk for CVD. |
ARO: The results suggest the CV effects were caused by |
L: Very small number of subjects; changes after only one use of product was investigated. G: Data allow no deduction of a dose-response relationship for P: A study with long-term EC users avoiding the weaknesses would be of interest. |
1 | ||||||
I |
Cross-over |
70 Smokers (CC) in cessation clinic: Acute study: • G1: 35 vaped ECs with • G2: 35 vaped ECs without Chronic study (1 month): • G3: 24 were dual users (CC/EC) • G4: 42 only used EC • G5: 20 only used CC (control) |
Acute study: • • • Chronic study: • PWV, AIX75, MDA: decrease in G3 and G4 (larger in G4), unchanged in G5 |
AO: The findings suggest that ECs may be used in a medically supervised smoking-cessation program. |
AO: EC use can reduce effect of smoking on arterial stiffness and oxidative stress (acute and chronic). ARO: Effect of |
L: Small group sizes, short duration. P: Perform larger and longer studies. |
0.5 | ||||||
C |
Cross-over |
25 Occasional smokers, 24 y, were allocated to 3 conditions: • Vaping (EC) without • Vaping (EC) with • Sham vaping (EC switched off) Vaping session: 25 puffs (4 s, 30 s intervals). Measurements before (BL) and up to 120 min after vaping |
Changes when vaping with • Impaired • Increased arterial stiffness ( • Increase in • Increase in These parameters did not change upon vaping without |
AO: The observed effects were solely attributable to |
ARO: Measured (acute) effects are caused by |
L: Only acute effects were measured, small group size. P: Similar but larger study with long-term users would be of interest. |
1 | ||||||
G |
RCT |
• G1: 40 CC (> 2 years) • G2: 37 CC switched to EC with • G3: 37 CC switched to EC without |
• • • • • • |
AO: Improvements in women higher than in men. ARO: More compliant groups G2 and G3 (COex < 6 ppm) show higher effect of switching to EC. |
ARO: No evidence that nicotine is measurably involved in the observed effects. |
L: Too short use of ECs; low numbers of subjects in all groups. P: Long-term study (> 12 months) with larger group sizes (> 100/group). |
0 | ||||||
I |
Cross-over | 40 S were switched to EC (12 mg N/mL) for 4 months, |
Sign. changes by condition: • • • • |
AO: Switching to ECs for 4 months has a neutral effect on platelet function while it reduces arterial stiffness and oxidative stress compared to CC smoking. |
ARO: Role of |
L: Small sample size, 4 month probably too short to assess long-term effects. G: N-free EC would be of interest. P: Perform study which overcomes the deficiencies (L, G). |
? | ||||||
C |
Cross-over |
16 NU (no nicotine products in the last 6 months) were assigned to 3 vaping conditions: • V1: 18 puffs, 5.4 % nicotine • V2: 18 puffs, no nicotine • V3: 18 sham puffs Measurements 0, 1 and 2 h after vaping |
Biomarkers: |
AO: Vaping ECs regardless of nicotine content are not significantly different from each other and do not produce lasting effects over the course of a 2-hour trial. |
ARO: No involvement of nicotine can be deduced, since no effects were observed. |
L: Study duration too short (single use of product), too few subjects/conditions. P: Long-term study (> 12 months) with larger group sizes (> 100/group). |
? | ||||||
H |
Cross-over |
• G1:49 Vapers (EC for > 1 year) • G2: 40 Smokers (CC for > 1 year) • G3: 47 NU (non-smokers or ex-smokers for > 1 year) |
• Baseline FMD not sign. diff. between G1, G2 and G3 • Acute CC use of G2: FMD sign. lower (impaired) • Acute EC use of G1 (with/without nicotine, N-inhaler, sham): no sign. diff. • Acute EC use of G3 (NU) (with/without nicotine, N-inhaler, sham): no sign. diff. • Acute use of CC (in G2): sign. increase of all three • Acute use of EC with nicotine, N-inhaler (in G1 and G3: sign. increases • Acute use of EC without nicotine, sham (in G1 and G3: partly decreases, mostly not sign. |
AO: Although it is reassuring that acute EC vaping did not acutely impair FMD, it would be premature and dangerous to conclude that ECs do not lead to atherosclerosis or increase cardiovascular risk. |
ARO: Nicotine is not involved in the acute decrease (impairment) of FMD. |
L: Small group sizes. P: Perform study with larger and well defined (in terms of product use) groups. |
0 | ||||||
Nicotine caused acute increases of HR, SBP and DBP. | ||||||
1 | ||||||
Chronic use of nicotine (with CC or EC) does not lead to permanent changes in FMD, HR, SBP and DBP (at least in the population investigated). | ||||||
0 | ||||||
K |
Cross-over | 20 Smokers vaped 1 EC (18 mg N/mL) with 40 puffs at 30 s intervals over 20 min, measurements for BMs were performed pre and post vaping |
Changes in vapers (pre/post): • • • • |
AO: EC vapour exposure increases vascular, cerebral, and pulmonary oxidative stress via a NOX-2-dependent mechanism. Our study identifies the toxic aldehyde acrolein as a key mediator of the observed adverse vascular consequences. |
Experiments with mice show that: • EC without • acrolein is mostly responsible for the effects of ECs. |
L: (Human study): low subject number, too short. G: (Human study): No condition without |
? (human) / 0 (mice) | ||||||
F |
Cross-sectional |
• 94 NS, 29 y • 285 CC, 32 y • 36 EC, 29 y • 52 Dual, 33 y |
Vascular measures sign. diff. between groups: • Carotid-femoral • Carotid-radial • • • No sign. diff.: • • |
AO: EC use is not associated with a more favorable vascular profile. ARO: No information on EC use duration. |
ARO: |
L: Most groups too small. G: No information on EC use duration; EC without |
0.5 / ? | ||||||
P |
Cross-sectional |
• 51 Smokers (CC), 21.3 y, CC duration 3 y, 3 cig/d • 22 Vapers (EC), 21.4 y, EC duration 4 y (2–6 y), 1 (0.8–1.6)mg N/mL • 197 NU, 21.1 y |
Sign. diff. in BMs: • Albuminuria: EC > CC > NU • – No sign. diff. in |
AO: No association of BMs with ARO: Albuminuria measured with dipstick only. Compliance of EC group not approved. |
ARO: |
L: Only very young subjects; EC use somewhat questionable; albumin method doubtful. G: No N-free EC group. P: Larger study without the weaknesses would be of interest. |
? / 0 | ||||||
C |
Cross-over |
31 NS vaped 1 EC without Blood samples were drawn for BM analysis pre and post vaping |
Sign. changes (post Increases: • • • • • Decreases: • • • |
AO: The findings indicate that a single episode of vaping has adverse impacts on vascular inflammation and function. |
ARO: No statement on the role of |
L: Sample size is low, only acute effects investigated. G: No condition with P: Larger study including ECs with |
? | ||||||
A |
Cross-sectional |
• 24 Snus users (males, healthy), 44.8 y; ≥15 y snus, < 1 y CC use • 26 NU (males, healthy), 43.4 y |
• • Snus users reported sign. higher alcohol consumption at BL. |
AO: Long-term snus use may alter endothelial function and increase CVD risk. |
The authors cite (convincing) evidence that |
L: Snus only use not verified; small group sizes; only males (women could have different CVD risks). P: Larger study with both sexes and product use verification would be of interest. |
1 | ||||||
M |
Meta-analysis (8 studies) |
372 Subjects, conditions compared: • Vaping without • Vaping with • Smoking (CC) |
Endothelial function, acute changes: EC+ • • • EC+ • FMD: no sign. change • PWV: sign. decrease • AI: sign. decrease |
AO: EC use negatively changes the endothelial function. |
ARO: Observed effects with EC+ are caused by |
L: Relatively small number of studies and subjects; only acute effects evaluated (long-term use would be of interest). |
1 | ||||||
M |
Cross-sectional |
Subjects with chronic product use: • 42 Vapers (EC), 29 y, mean duration of EC use: 1.7 y, CotU: 923 ng/mL • 28 Smokers (CC), 34 y, mean duration of CC use: 10.2 y, CotU: 1,735 ng/mL • 50 NU, 28 y, CotU: 2 ng/mL |
Endothelial function (≈: not sign.) • • • Endothelial cell permeability in user sera: EC < CC ≈ NU |
AO: EC use can increase CVD risk and dual use can further increase the CVD risk. ARO: Misreports of product use history is possible. |
ARO: The authors’ |
L: Small group sizes; chronic EC use only 1.7 y (on average). G: No N-free EC group. |
? | ||||||
B |
Cross-sectional |
97,586 Male construction workers: • 23,885 NU • 5,014 SLT users • 8,823 Smokers (CC), ≥15 cig/d Duration of SLT use: 10–30 y (estimate) |
Sign. OR ( • • SBP > 160 mm Hg: SLT: OR=1.8/1.3 (in age groups: 46–55/56–65); CC: OR=0.8/0.7 |
AO: Also SLT use is associated with elevated risk for CVD. ARO: No verification of SLT only use. |
The authors cite evidence and conclude from their results that ARO: |
L: Only males included; healthy-worker-effect? No objective verification of SLT group. G: No other NGPs, no N-free group. |
1 / ? | ||||||
H |
Prospective | 120,930 healthy, never-smoking men (construction workers), enrolled 1971–1978 (BL), follow-up (health-checks) 1978–1993; follow-up cohort: 42,005 (normotensive at BL) |
• BL: 1.23 (1.15–1.33) • Follow-up: 1.39 (1.07–1.72) No clear dose-response |
AO: Snuff use increases the risk of hypertension. |
The authors cite evidence that |
L: No clear dose-response; tobacco habits rely on self-reports only; changes in habits are not assessed. |
0.5 / ? | ||||||
M |
Cross-sectional |
PATH study 2015–2016, 19,147 participants: • 8,783 NS (never CC or EC) • 183 CEV-NS (current EC, never CC) • 334 CEV-FS (current EC, former CC) • 3,938 FS (former CC) • 5,056 CES (current CC only) • 581 CDU (current dual) Duration of EC use: ~ 5 y (estimate) |
Prevalence of self-reported |
AO: Current EC use is similar to CC in terms of hypertension. ARO: Misclassification in product use possible (not verified) |
The authors cite evidence that use of N-free ECs were associated with higher BP reduction. ARO: |
L: Authors consider a number of limitations including dietary factors (not assessed) and (unreliable) self-reports. |
0.5 / 1 | ||||||
K |
Cross-sectional |
Community Health Survey, 2019, groups: • Dual users (EC and CC) • EC only users • CC only users Duration of EC use: 5–10 y (estimate) |
OR for Males: • Dual: 1.24* • EC only: 1.22* • CC only: 1.16* Females: • Dual: 1.44 • EC only: 1.41 • CC only: 1.35* *: p < 0.05 |
AO: Also EC and dual user have an increased risk for hypertension. ARO: Bias for misreport (particularly in female) is possible. No verification of product use. |
The authors cite evidence that ARO: Involvement of |
L: Small group sizes for EC users (particularly female); misreport of product use cannot be excluded. G: No N-free EC group. |
0.5–1.0 | ||||||
B |
Cross-over |
10 Healthy volunteers (smokers, 24–61y): • Smoking CC, 12 puffs, intervals of 45 s (1–1.3 cig), 9 min • Oral snuff, 2.5 g, 30 min • Chewing tobacco, avg 7.9 g, 30 min • Nicotine gum (NG), 2 pieces, 30 min Random order, 24 h between conditions |
Comparable increases in |
AO: N-related adverse effects also to be expected with the other N-products. |
(See left cell) ARO: All effects caused by |
L: Low number of subjects. G: No ‘sham’ experiments. |
1 | ||||||
V |
Cross-over |
15 SLT users, 18–33 y performed exercises under 2 conditions: • SLT, 2.5 g SLT: rest, 60%, 85% VO2max • Placebo: same exercises |
Cardio-respiratory responses: (SLT |
AO: SLT compared to placebo under workload increases HR and anaerobic energy production. |
The authors ascribe the observed (acute) effects to |
L: Only few and young males were investigated; only acute effects were studied. P: A study with long-term, older users including other NGPs would be of interest. |
1 | ||||||
B |
Cross-sectional |
135 Healthy men, 35–60 y : • 59 NU, 45.1 y • 47 SLT users, 44.3 y • 29 Smokers (CC); 47.2 y |
24 h- • Daytime Sign. positive correlation between CotP and BP in SLT, negative (not sign.) in CC. |
AO: Increases in HR and BP in CC and SLT were most likely due to the effects of Nicotine, in CC additional influences play a role. ARO: A few dual users were in the CC group. No verification of SLT only use. |
The author cite evidence that |
L: Small group sizes; only men. G: No other NGPs; no N-free EC. P: Studies avoiding these weaknesses would be of interest. |
0.5 / 1.0 | ||||||
M |
Cross-over |
33 Users of CC or EC were assigned to 3 conditions with > 4 weeks separation: • C1: EC with 1.2% • C2: EC without • C3: Sham (vaping without e-liquid) |
Fibrinogen? |
AO: Habitual EC use was associated with a shift in cardiac autonomic balance toward sympathetic predominance and increased oxidative stress, both associated with increased cardiovascular risk. |
Sympathomimetic effect after acute EC use is causally related to |
L: Small subject numbers; low |
1 | ||||||
B |
Cross-sectional |
Selected from 31 healthy subjects: • 9 NU (29 y) • 9 EC users (28 y, 2.1 y EC use) • 9 CC users (27.1 y, 7.3 pack x years) |
• • FDG uptake in spleen and aorta sign. trend of increase NU < EC < CC (indicator for spleenocardiac axis) |
ARO: Compliance status of EC users is unclear (although authors exclude dual use). |
ARO: Sympathomimetic effect of |
L: Very small group sizes; compliance unclear. |
0.5 / 1 | ||||||
R |
Cross-over |
• 9 Vapers (EC for > 3 months, no CC in last months), 28.5 y ; 4 conditions (separated by 1 week)
– 3 Types of CL (ciglike EC), 18 mg N/mL, 10 3-s-puffs at 26 s intervals – TEC (tank EC), 18 mg N/mL, same puffing pattern • 11 Smokers (CC for > 3 years), 26.2 y:
– 1 CC, 10 2-s-puffs at 28 s intervals (0.8 mg N/cig) |
• Nicotine in plasma: CC >> TEC > CL • |
AO: TEC are potential cessation products but also have an addiction potential (like CC and unlike CL). |
ARO: The results suggest that |
L: Small group sizes, only short-term EC users. G: No N-free condition, only HR no other physiological changes. |
1 | ||||||
S |
Cross-over |
30 Dual users (< 5 cig/d, > 1 mL e-liquid/d), performed 4 conditions (EC with 18 mg N/mL, 2 sessions, each 10 puffs every 30 s, PG/VG varied: • 1. 100% PG • 2. 55% PG • 3. 20% PG • 4. 2% PG |
• Nicotine in plasma: Higher in condition 1 and 2 • 100% PG less pleasant and satisfying |
AO: The PG/VG ratio must be also considered when evaluating the |
ARO: |
L: Small group sizes, only short-term EC users. G: No N-free condition, only HR no other physiological changes. |
0.5 / 1 | ||||||
H |
Longitudinal (6 weeks) | 50 Smokers (with schizophrenia and other mental disoders), 30 y, were provided with free ECs (4.5% |
Changes to BL at week 6: • −37% reduced CPD • 7% stopped • • |
AO: The provision of ECs is a potentially useful harm reduction intervention in smokers with a psychotic disorder. |
ARO: |
L: Small group size, only short-term effects were assessed. G: No N-free group. P: Patients with mental disorders might be a suitable group to investigate the long-term effects of EC (relatively high smoking rate). |
? | ||||||
S |
Cross-sectional | Meta-analysis of 14 studies, in total 441 participants: Healthy smokers and switchers to ECs |
Acute changes after EC use (* = sign.): • • • Changes after switching to EC: • HR: −0.03 bpm (3 studies) • SBP: −7.00 mm (3 studies) • DBP: −3.65 mm* (3 studies) |
AO: EC should not be labelled as CV safe. |
ARO: Effects could be caused partly of completely by |
L: Low number of studies and subjects. G: No separate evaluation for N-effects possible. |
0.5–1 | ||||||
P |
RCT |
186 Smokers (CC), African Americans/Latinx: 92/94, 43.3 y, 12.1 cig/d; randomized to • 125 EC use, 5% • 61 Controls (CC use as usual) |
Sign. changes EC • NNAL • COex No sign. changes EC • Cotinine in urine • Respiratory symptoms (weeks 2 and 6) • • • Significances similar in EC only users |
AO: ECs may be an inclusive harm reduction strategy for this population. ARO: 58–68% in EC group were dual users, 4% were CC only users in EC group. Compliance was not enforced. |
ARO: All EC contained 5% |
L: Only short- to medium-term study (6 weeks). G: No N-free EC group. P: Long-term study (> 1 year) including an N-free EC group would be of interest. |
? | ||||||
B |
Cross-over | 20 Smokers (CC) were assigned to CC, EC and HTP, with 1 week wash-out periods. One unit of each product was used (1 CC, 9 puffs of EC, 1 stick of HTP). |
Biomarkers in blood were measured before and after product use: • • • • • • • • • • All changes were sign., except NO and Vitamin E after HTP; CC use showed the largest changes |
AO: Acute effects of HTPs, ECs, and CCs are different on several oxidative stress, antioxidant reserve, platelet function, cardiovascular, and satisfaction dimensions, with CCs showing the most detrimental changes in clinically relevant features. |
ARO: Involvement of |
L: Too short study duration. G: Condition EC without nicotine is missing. P: Long-term study (> 12 months) with larger group sizes (> 100/group) and an additional condition (EC without nicotine). |
? | ||||||
M |
Cross-over |
24 Smokers (CC for > 1 y), 30.9 y, were allocated to 4 conditions: • 1. EC (36 mg N/mL), 2 sessions with 10 puff, separated by 20 min • 2. EC (0 • 3. CC (10 puffs, own brand) • 4. Nicotine inhaler (10 mg |
• • |
ARO: Incomplete reporting, abstinence (prior to experimental sessions) doubtful (according to the authors). |
ARO: It can be deduced that |
L: Only smokers were investigated, small group, incomplete reporting (only HR, no results on BP). P: A larger study with (long-term) EC users and more physiological measurements would be of interest. |
1 | ||||||
B |
Cross-over |
36 Dual users of CC and EC were investigated in the clinic under three conditions: • C1: • C2: • C3: abstinence from nicotine |
• • • Urinary biomarkers: • Blood biomarkers: • |
AO: CC and EC had similar patterns of hemodynamic effects compared with NU, with a higher average HR with CC |
ARO: Involvement of nicotine in observed effects is possible but cannot be evaluated (EC without nicotine is lacking). |
L: Too short study duration. G: Condition EC without nicotine is missing. P: Long-term study (> 12 months) with larger group sizes (> 100/group) and an additional condition (EC without nicotine). |
? | ||||||
G |
Various (systematic review) |
19 Studies evaluated,: • Smokers (CC) • Vapers (1. generation ECs, with • Vapers (1. generation EC−, without |
Acute CV effects (sign. diff.) CC • • • EC+ • ΔHR (4 studies): +6.44 bpm • ΔSBP (5 stud.): +3.73 mm Hg • ΔDBP (5 stud.): +3.25 mm Hg HRV for CC Sign. increased |
AO: EC are sympatho-excitatory, the effect is lower for the 1. generation ECs compared to CCs. |
ARO: The effects are caused (completely?) by |
L: Studies were done with 1. generation of ECs only. P: Similar studies with newer generations of ECs and also other NGPs. |
1 | ||||||
H |
Cross-over |
32 Vapers (EC use since > 3 months, partly CC), 25.6 y, were allocated to 4 EC conditions, separated by 48 h: • 1: 0.5 Ω/3 mg N/mL • 2: 0.5 Ω/8 mg N/mL • 3: 1.5 Ω/3 mg N/mL • 4: 1.5 Ω/8 mg N/mL 10 puffs at 30 s intervals, from min. 70 to 130: |
Changes by condition: • Plasma • • Puff number ( |
ARO: Changes in topography and physiology (HR) follow the nicotine delivery. |
ARO: Increase in HR directly dependent on |
L: Only acute effects were studied; relatively young subjects; 14 vapers were naive to sub-ohm ECs. P: Study with older, long-term users, extension to other CV paramters: BP, FMD, PWV, AI. |
1 | ||||||
I |
Cross-over and cross-sectional |
• 37 CC users, 26.7 y • 43 EC users (self-reported), 28.0 y • 65 NU, 21–45 y Groups allocated to • CC (1 CC in 7 min)/straw (CC group only) • ECN (with 1.2% • Nicotine inhaler (NI)/straw (EC and NU) |
• • |
AO: If one does not currently smoke, one should not use ECs due to adverse CV effects. NI only slightly increase plasma ARO: Unclear how long EC was used in EC group. |
ARO: Use of EC with |
L: Small groups, only young subjects, EC use duration not provided. P: Larger study with long-term EC users would be of interest. |
1 | ||||||
ECG-indices: only partial influence of |
||||||
0.5 | ||||||
G |
Cross-over |
15 NU, healthy, 21 y, were assigned to 2 conditions: • EC(+) with • EC(−) without, same puffing profile, 0 mg N/mL Conditions were separated by ~1 month; measurements were done before (BL), during and after vaping (recovery), each for ~10 min |
Sign. changes occurred only in EC(+) condition: • • • All changes lasted into the recovery phase |
AO: Suggest that the decrease in MSNA is mediated by an intact baroreflex (resulting from the increase in MAP) in the healthy young subjects. In older population |
ARO: The results suggest the CV effects were caused by |
L: Very small number of subjects; changes after only one use of product was investigated; very young population. G: Data allow no deduction of a dose-response relationship for P: A study with long-term EC users avoiding the weaknesses would be of interest. |
1 | ||||||
C |
Longitudinal (12 weeks) | 40 Smokers (schizophrenics), 48.3 y, 28 cig/d, were provided with ECs for free for 12 weeks |
37 vapers decreased CPD from 28 (BL) to 6.4 cig/d (12 weeks and 6 months); |
ARO: EC group was actually a dual user group. |
ARO: Role of |
L: Small group size, only medium term effects can be observed. G: No N-free group. P: Schizophrenics might be suitable group to investigate the long-term effects of EC (very high smoking rate). |
? | ||||||
E |
Cross-sectional |
• 18 NU, male, 24.4 y • 21 Snuff users, male, 24.1 y, duration of snuff use: 7.0 y • 19 Smokers (CC), male, 25.3 y, duration of CC: 9.1 y |
Sign. diff. in CVD-related BOBEs (≈ : not sign.): • • • • • • Not sign. diff. between groups: |
AO: Snuff use has similar but lower effects on CVD-related BOBEs, except for lipids. ARO: Use of snuff only not verified. |
The authors cite evidence that NG use does not affect lipids and that CC-related hyperlipidemia is not due to ARO: |
L: Small group sizes; only very young men included. G: Other NGPs (EC, HTP), N-free EC. P: Larger study with older subjects, including additional NGPs would be of interest. |
? | ||||||
S |
Cross-sectional |
1,061 Baseball players (mostly 20–29 y): • 477 SLT users • 584 NU CC excluded |
No sign. difference SLT • • • • • |
AO: SLT use has at most a modest effect on CVD risk factors. ARO: No verification of SLT use. |
The authors cite evidence that ARO: Results suggest that |
L: Only young and fit subjects included. G: No other NGPs. |
0 / ? | ||||||
E |
Cross-sectional |
Swedish men, 25–64 y : • 124 Smokers (CC) • 130 Ex-CC • 92 Snuff dippers • 38 Snuff+CC • 220 NU |
BMs for fibrinolysis (t-PA, PAI-1, • CC: Fibrinogen sign. increased No sign. diff. for other groups and BMs |
AO: Snuff use does not appear to affect potential CVD risk factors. ARO: Possibility of mis-report and -classification of product use. |
The authors cite evidence that ARO: |
L: Relatively small group sizes; only male snuff users. |
0 / ? | ||||||
M |
Cross-over (longitudinal) | Smokers (CC, 10 m/17 f, 35 y/38 y), 29 cig/d, stopped CC at day 0, NRT (N-patch) until day 35, no CC and NRT until day 77 Non-smokers (NU, 7 m/9 f, 42 y/40 y) |
• Day 0: NU > CC • Day 35: no change in HDL • Day 77: CC: increase in HDL to NU levels Weight gain: • Day 35: no changes • Day 77: increase in CC (f) |
AO: |
AO: see left column. Evidence is cited that weight gain occurs in long-term NRT users. ARO: HDL increase: 1 ARO: Weight gain: 1/0 |
L: Small sample sizes; only short-term NRT use. G: No other NGPs tested, in particular EC with/without P: Long-term study including NGPs would be of interest. |
M |
Cross-sectional |
• 16 Habitual EC users, 28.6 y, EC use: 241 min/d, EC use duration: 1.6 y • 18 NU, 26.6 y |
• • |
AO: EC use increases the risk for CVD. ARO: Some CC use cannot be excluded (also conceded by the authors). |
The authors cite evidence that ARO: An effect of |
L: Small sample sizes; only young subjects; short period of EC use. G: no other NGPs studied; no group with N-free ECs. P: A study avoiding these weaknesses would be of interest. |
0.5 / ? | ||||||
L |
Cross-over (longitudinal, 90 d) |
160 Smokers (CC menthol), randomized to: • 78 HTP (menthol, 1.21 mg N/stick), 39.2 y • 42 CC (menthol), 33.7 y • 40 Smoking abstinent (SA), 38.8 y 5 d confined, 85 d ambulatory conditions |
Sign. improvement after 90 d • No sign. diff. HTP • All BOBEs were not sign. diff. between HTP |
Compliance (checked with COex < 10 ppm for HTP and SA) was high: 89.7% (HTP), 97.6% (CC), 92.5% (SA). Dual use (HTP + CC): 2.6% AO: The reductions in HTP users were promising and reached almost the levels in the SA group. |
ARO: |
L: Low actual compliance in HTP and SA group after 90 d (could have spoiled the results); 3 months might be too short for biological effects. P: Larger and longer study with better compliance would be of interest. |
? | ||||||
W |
Cross-over (longitudinal, up to 24 months) |
206 Users of CCs and ECs were switched to vaping (EC, 1.6 % Follow-ups (FUs) at 1, 3, 6, 12, 18 and 24 months; 102 subjects completed the study. |
No clinically relevant adverse effects (AE) were observed during the 24 months study. No consistent changes over time were observed for EC-compliant subjects: |
Authors’ definition: “EVP-compliant subjects” were defined as subjects who were abstinent from CCs for “at least 80% of the completed study days.” |
ARO: |
L: Compliance criteria not sufficient to see effects. G: Control groups are missing: CC, NU. |
? | ||||||
H |
Cross-over (longitudinal, 90 d) |
160 Smokers (CC), randomized to: • 80 HTP (menthol, 1.21 mg N/stick), 39.2 y • 41 CC (menthol), 33.7 y • 39 Smoking abstinent (SA), 38.8 y 5 d confined, 86 d ambulatory conditions |
Sign. improvement after 90 d compared to CC: • No sign. diff. HTP • All BOBEs were not sign. diff. between HTP |
Compliance (checked with COex < 10 ppm): 51% in HTP group, 18% in SA group. AO: The reductions were promising with respect to health risk reduction. |
ARO: |
L: Low actual compliance in HTP and SA group after 90 d (could have spoiled the results); 3 months might be too short for biological effects. P: Larger and longer study with better compliance would be of interest. |
? | ||||||
F |
Cross-sectional |
• 94 NS, 29 y • 285 CC, 32 y • 36 EC, 29 y • 52 Dual, 33 y |
Vascular measures sign. diff. between groups: • Carotid-femoral • Carotid-radial • • • No sign. diff.: • • |
AO: EC use is not associated with a more favorable vascular profile. ARO: No information on EC use duration. |
ARO: |
L: Most groups too small. G: No information on EC use duration; EC without |
0.5 / ? | ||||||
K |
Cross-sectional |
All men: • 337 Dual users (CC + EC), 36.7 y, CotU: 1,303 ng/mL, 15.1 cig/d • 4079 CC only, 46.3 y, CotU: 1,236 ng/mL, 14.8 cig/d • 3,027 Never smokers (NS), 39.8 y, CotU: 0.7 ng/mL |
Sign. diff. of dual users to other groups: • • • • • • |
AO: Given that most EC users are dual users and dual users are more vulnerable to CV risk factors than CC-only smokers and NU, more active treatment for smoking cessation should be considered with priority. ARO: Proportion of EC use in dual users appears low. |
ARO: Role of |
L: EC only group is missing. |
? | ||||||
M |
Cross-sectional |
• 104 Never users, 29 y, CotU: 3 ng/dL • 290 CC users, 33 y, CotU: 927 ng/dL • 42 Sole EC users, 28 y, CotU: 686 ng/dL • 47 Dual (EC+CC) users, 33 y, CotU: 851 ng/dL • 23 Sole pod users, 26 y, CotU: 970 ng/dL (pods are new generations of ECs) • 19 Dual pod users, 24 y, CotU: 508 ng/dL |
Sign. diff.: • NU • NU • NU • CC • NS • NS |
AO: Overall, users of early generation electronic cigarettes display adverse metabolic profiles. In contrast, pod-based electronic cigarette users have similar lipid profiles to never users. ARO: Duration of use of ECs and pods not provided (probably shortest in pod users). |
ARO: Relative high cotinine levels in pod users and lack of sign. diff. to NS suggest only a minor (if any) role of |
L: Duration of EC/pod use was least 3 months, but might be too short. G: Role of |
0–0.5 | ||||||
G |
Cross-over (longitudinal, 180 d) |
Healthy current smokers (CC) were allocated to 3 groups: • 59 CC (continue smoking), 17.9 cig/d (at 180 d) • 127 HTP use, 21.9 sticks/d (at 180 d) • 109 Cessation (NU) 40 Never-smokers also included |
Sign. diff. HTP • No sign. diff. HTP • |
AO: Larger studies are needed for evaluating the risk reduction. ARO: Compliance was approved by CEVal: 76% of HTP and 73 % of NU group (180 d). |
ARO: |
L: Too short durations o HTP use. G: No comparisons of NU P: A larger and longer study would be of interest. |
? | ||||||
A |
Cross-sectional |
324 Healthy participants, 21–45 y • 65 NU, CotU: 3 mg/dL • 19 EC users, CotU: 826 mg/dL • 212 Smokers (CC), CotU: 854 mg/dL • 28 Dual users, CotU: 910 mg/dL |
Number of sign. changes in • EC: 2 • CC: 4 • Dual: 6 No sign. diff. when EC and Dual groups were compared to CC |
AO: EC use is associated with higher endothelial inflammation. ARO: Product habits rely on self-reports (no verification). |
ARO: |
L: Small group sizes; self-reports only for product habits; temporal issues (cross-sectional study). G: No N-free EC group. |
? |
Cancer and cancer-related BOPH/BOBEs.
Author, year, country (Ref) | Study type | User groups / duration of product use | Endpoints and findings | Comments (bias, compliance, etc.) | Conclusions regarding nicotine's ( |
Limitations (L) / Gaps (G) / Proposals (P) |
---|---|---|---|---|---|---|
B |
Prospective |
Male construction workers, up to 65 y (1970/71), follow-up after 12 y for mortalities: • 32,546 NU • 6,297 SLT users • 14,983 Smokers (CC1), < 15 cig/d • 13,518 Smokers (CC2), ≥ 15 cig/d Duration of SLT use: 10–30 y (estimate) |
RR (CI) compared to NU: • – SLT: 1.4 (1.2–1.6) – CC1: 1.8 (1.6–2.0) – CC2: 1.9 (1.7–2.2) • – – CC1: 1.5 (1.3–1.8) – CC2: 2.5 (2.2–2.0) • – SLT: 1.4 (1.3–1.8) – CC1: 1.7 (1.6–1.9) – CC2: 2.2 (2.0–2.4) |
AO: Both CC and SLT users have an increased risk for CVD, risk for SLT is lower. ARO: SLT (only) use was not verified, dual use is not unlikely. |
The authors cite evidence that ARO: |
L: Only male workers (healthy-worker effect?); dual use (SLT + CC) is possible. G: Other NGPs; ECs without |
0 / ? | ||||||
A |
Prospective |
NHANES I (BL), 20 y-follow-up: • 5,192 NU (no tobacco), 47.8 y • 505 SLT (exclusive), 54.0 y • 5,523 CC (exclusive), 44.9 y |
Hazard ratio for SLT • • • Dual use did not increase all cause mortality beyond the sum of CC and SLT risks. • Borderline increase in SLT (f) for all cancers (not sign.) |
AO: See a limitation that only ever use of SLT could be included in the study. ARO: Use pattern could have changed during the 20 y of follow-up. |
ARO: Overall results suggest that |
L: SLT use not completely assessed. G: No other NGPs included. P: Future evaluations of NHANES data could include NGPs. |
0 / ? | ||||||
A |
Case-control |
• 123 Pancreatic cancer cases • 682 Matched controls All non-CC users (life-long) Duration of SLT use: 10–30 y (estimate) |
OR for • Cigar (ever/only): 1.7/1.9 • Pipe (ever/only): 0.6/0.3 • SLT (ever/only): 1.4/1.1 All ORs not sign. SLT: sign. (p = 0.04) trend with amount/d |
AO: Suggest that heavy use of SLT may increase risk for pancreas cancer. ARO: Compliance with product use was not checked. |
ARO: Most probably, TSNAs play a role. Involvement of |
L: Product use relies on self-reports, past tobacco history may be questionable |
0–0.5 | ||||||
M |
Prospective |
Lung Health Study (substudy), 3,320 subjects (smoking intervention with NRT, • 1,986 NRT users, mean age 48 y • 1,329 no NRT users, mean age 48 y • Unclear what the CC group during 5-year surveillance is |
Cancer risks: • CC: sign. increase • NRT: not sign. • • |
AO: Despite short FU time period, smoking predicted cancer in this analysis and nicotine replacement therapy did not. ARO: Danger of misreports of product use (CC, NRT) and abstinence. |
The authors cite genetic evidence that |
L: Small number of cancer cases; short FU period; unclear CC group; low G: Nicotine inhaler not studied (of interest for lung cancer). |
0 / ? | ||||||
C |
Cross-sectional |
• 9 Smokers (CC), 42.2 y, CotU: 5.87 ng/mL • 15 Vapers (EC, all containing • 21 Ex-smokers, 43.0 y, CotU: 1.23 ng/mL, quit CC since 67.0 months |
468 (of 3,165) genes varied between EC and Ex-CC, 79 of these were in accordance with CC; downregulated genes in EC were mostly also downregulated in cells exposed to EC aerosol. |
AO: Pattern of EC is closer to former CC than to current CC users. ARO: No check of dual use (CC and EC) was performed. ARO: CotU in CC and EC appears much too low (μg/mL?). |
ARO: Role of |
L: Small group sizes. G: No N-free EC group; also no initial EC user group (only former CC users who switched to EC). |
? | ||||||
F |
Observational study (longitudinal) |
At BL: • 469 CC users, ≥1 cig/d, ~50 y • 228 EC users, ≥50 puffs/week, ~50 y • 215 Dual users, ~50 y FU after 6 y |
Incidence of Not sign. diff. between 3 groups |
AO: That there was no evidence for harm reduction in EC only or dual users after 6 y. ARO: Possibility of mis-reports of product use (COex in only 50% of subjects). |
ARO: |
L: Small group sizes; misclassification not excluded. G: No N-free EC group. |
? | ||||||
C |
Cross-sectional |
• 15 Vapers (EC), 29.3 y, EC but no CC use for at least 6 months • 15 Smokers (CC), 29.5 y, CC use for at least 1 year • 15 Controls (NU), 28.9 y |
• 5-mC in LINE-1: NU* > EC ≈ CC • 5-hmC (global): NU* > EC ≈ CC *: sign. diff. from other 2 groups Expression levels of various DNA methyl transferases: not sign. diff. between groups. |
AO: In conclusion, we have demonstrated, for the first time, key epigenetic modifications, including hypomethylation of LINE-1 repeat elements and global loss of DNA hydroxymethylation, in a well-defined population of exclusive vapers (EC) and smokers (CC) relative to controls. ARO: Dual users excluded (but only COex and COHb applied for approval). |
ARO: |
L: Small group sizes; no objective check of dual use; changes in peripheral leukocytes may differ from those in target cells. G: No inclusion of N-free EC group. P: Larger study with similar endpoints but inclusion of an N-free EC group. |
? | ||||||
R |
Cross-sectional |
• 116 EC users, 20.9 y, e-liquid consumption: 7.8 mg/d, 5.6 mg N/mL • 117 CC users, 22.8 y • 117 NU, 20.6 y |
• EC were distinct from CC • Biological aging profile: EC more similar to NU than CC • EC profile did not discriminate between lung cancer from normal tissue (CC profile did) • EC profiles did not replicate in independent samples |
AO: DNA methylation profiles are clearly distinct from CC. ARO: Relationship to chronic effects are not yet clear. |
ARO: Role of |
L: Very young population; only short durations of products use possible. G: No N-free EC group. P: Endpoints may be of interest when more data are collected. |
? | ||||||
H |
Longitudinal (3 visits over 3 weeks) | 3 Vapers (EC, 6 mg N/mL), had not smoked for 2 months: 20 EC puffs/visit, 3 visits; blood and buccal cell samples taken before and after EC use |
|
AO: A single EC use can modify gene expressions (towards a cancer risk). |
ARO: Role of |
L: Extremely small group. G: No N-free EC group. P: Perform larger study including CC group, N-free EC group; investigate effects after long-term (chronic) use. |
? | ||||||
A |
Cross-sectional |
• 269 Controls, NU, 30.4 y • 22 Control subgroup, NU, 33.5 y (= controls who had BOEs measured in urine) • 112 Smokers (CC), 41.2 y • 35 Vapers (EC), 23.5 y • 19 SLT users, 36.6 y |
CC had sign. lower |
AO: Methylation extent of cg05575921 together with CEMA is suitable to distinguish CC from other NGP users. ARO: The same can be achieved by CEMA alone! |
ARO: |
L: Small group sizes; short product use durations. |
0 |
Respiratory/Lung diseases (RLD) and RLD-related biomarkers of potential harm (BOPH).
Author, year, country (Ref) | Study type | User groups / duration of product use | Endpoints and findings | Comments (bias, compliance, etc.) | Conclusions regarding nicotine's ( |
Limitations (L) / Gaps (G) / Proposals (P) | |
---|---|---|---|---|---|---|---|
M |
Cross-sectional |
Healthy adults, 18–50 y • 13 NU, 30.4 y, CotS: 0.08 ng/mL • 12 EC users, 28.7y, CotS: 200.7 ng/mL, predominantly used EC in last 6 months • 14 Smokers (CC), 30.7 y, CotS: 159.0 ng/mL |
• 53 genes common in CC and EC • 305 additional genes in EC |
AO: EC use leads to immune suppression in the nasal mucosa. ARO: Dual users were excluded, but not verified. |
ARO: |
L: Small group sizes; probably only short use duration of EC; relatively young subjects. G: No N-free EC group. |
|
? | |||||||
C |
Cross-over (longitudinal, up to 1 y) |
134 Smokers (CC) were assigned to ECs with: • A: 49 subjects, 2.4% • B: 45 subjects, 2.4% • C: 40 subjects 0% For final evaluation, subjects were classified into: • Failures (F): continued CC, not meeting criteria for reducers (R) or quitters (Q) • R: reduced CC by ≥50% • Q: no CC, COex<7ppm |
• FeNO: stayed at BL level for F and R groups, sign. increased for Q • COex after 52 weeks: F > R > Q |
AO: Switching from CC to EC can revert harm in the lung. |
ARO: Unfortunately, data were not evaluated to EC N-content. |
L: Small group sizes; no evaluation by N-content. P: A larger study avoiding the weaknesses would be of interest. |
|
? | |||||||
M |
Cohort study (FU after 12 months) |
2,086 Adolescents (16–18 y) • 502 Ever EC users (past users) • 201 Current EC users (EC use in last 30d) |
OR (CI) for • Past EC: 1.85 (1.37–2.49) • Current EC: 2.02 (1.42–2.88), become insign. after adjustment for life-time CC use OR not increased for wheeze after adjustment for CC. |
AO: EC use increases risk for bronchitis in adolescents. ARO: EC only use not verified (authors also concede confounding by CC). |
ARO: |
L: Possibly insufficient assessment of CC use in EC groups. |
|
? | |||||||
P |
Longitudinal (42 months) |
• 9 Vapers (EC), 26.6 y, 0.0–1.8% • 12 NU, 27.8 y |
No sign. changes between BL, 12, 24 and 42 months for: • • • • • • • • • |
AO: EC long-term use is not associated with health concern in young users. ARO: Non-compliant subjects were excluded (but no objective prove for compliance). |
ARO: |
L: Very small groups; use of only 1. generation of EC with probably low G: No N-free EC group. P: A larger study including N-free EC group would be of high interest. |
|
? | |||||||
P |
Longitudinal (36 months) |
• 22 Smokers with COPD, switched to EC, 65.2 y • 22 Smokers with COPD, continued CC use, 66.5 y |
BL, and follow-up (FU) at 12, 24 and 36 months • CC group: CPD almost unchanged at 20 cig/d; no sign. change in • EC group: decrease in CPD (20 to 1.5 cig/d); sign. improvements in lung function and walk distance Also improvements in dual users |
AO: EC use ameliorates COPD outcomes and might also reverse the harm of some smoking effects. ARO: Although dual use was evaluated separately, compliance is an open question. |
The authors speculate that |
L: Small group sizes. See also Polosa |
|
?/0 | |||||||
ARO: From the study data, the role of |
|||||||
? | |||||||
L |
Cross-over (acute) |
• 27 healthy smokers (H-CC), 23.0 y • 27 smokers with mild asthma (MA-CC), 23.0 y Both groups performed a control (EC without liquid) and vaping session (e-liquid with 12 mg/mL |
• Control session: no changes • EC session: acute increase in |
AO: One EC session has acute mechanical and inflammation effect on the respiratory tract (larger in smokers with MA). |
ARO: |
L: Only acute effects of EC smokers were investigated. G: No N-free group included. |
|
? | |||||||
S |
Cross-over |
10 NS were assigned to one of 2 conditions: • C1 (N=7): • C2 (N=3): BM measurements pre and 30 min after vaping |
Observed changes (post • C1: EMPs elevated, • C2: No changes found |
AO: This study provides |
ARO: Effects were found only after exposure to EC with |
L: Very low subject numbers, only acute effects were investigated, which were completely reversible. G: No information available whether chronic use of N-products can lead to persistent changes. |
|
1 | |||||||
M |
Cross-sectional |
• 30 Vapers (EC), males, 27.1 y, former and current CC or tobacco users were excluded; self-reported EC use for > 6 months • 30 NU, males, 25.9 y, former CC and tobacco users were excluded; self-reported |
Sign. lower in EC • • • Not sign. diff.: • • • |
AO: EC use impairs lung function. ARO: Product use status replies on self-reports, not objectively approved. |
ARO: |
L: Small groups, only short- to medium term use. G: No N-free EC group; no CC group (as a positive control). |
|
? | |||||||
C |
Cross-over |
30 NS performed one • 5 min EC session (1.8% • 5 min CC session (0.6 mg N/cig) |
• • • |
AO: EC use may be dangerous for CC smokers. ARO: AO appears at least questionable. ARO: Only short term use and effects were observed. |
ARO: |
L: Only short-term use was investigated. G: No N-free EC condition included. P: A study with long-term EC users (included N-free) would be warranted. |
|
? | |||||||
R |
Cross-sectional |
• 16 NU, 29.6 y, CotP: 0.06 ng/mL • 17 CC, 31.8 y, 10.5 cig/d, CotP: 184 ng/mL • 16 EC, 28.3 y, 218 puffs/d, CotP: 218 ng/mL |
• • • • • • • |
AO: EC use alters the profile of innate defense proteins in airway secretions. ARO: Only self-reports for product use, not objectively verified. |
ARO: |
L: Small group sizes, no verification of product use, short EC use? G: No other NGPs, no N-free ECs. P: Improved study with these endpoints would be of interest. |
|
? | |||||||
G |
Cross-sectional |
• 18 NU, 27.3 y • 13 CC, 34.0 y: 9.5 pack-years, 10.1 cig/d (last 2 weeks) • 10 EC, 26.8 y: last 2 weeks: 44.1 puffs/d, 11.4 mL e-liquid/d |
|
AO: EC use has long-term effects on the lung, possibly mediated by PG/VG. ARO: Unclear for how long ECs were used. |
ARO: Effect of N cannot be excluded. Effects of PG/VG alone also possible. |
L: Small group sizes, long-term use (in EC users) is not well defined. P: Proteome study with long-term users would be of interest. |
|
0.5 / ? | |||||||
W |
Cross-over |
206 Users of CCs and ECs were switched to vaping (EC, 1.6% Follow-ups (FUs) at 1, 3, 6, 12, 18 and 24 months; 102 subjects completed the study |
No clinically relevant adverse effects (AE) were observed during the 24 months study No consistent changes over time were observed for EC-compliant subjects: |
Authors’ definition: “EVP-compliant subjects” were defined as subjects who were abstinent from CCs for “at least 80% of the completed study days.” |
ARO: |
L: Compliance not sufficient to see effects. G: Control groups are missing: CC, NU. |
|
? | |||||||
G |
Cross-sectional |
• 14 NU, 25.8 y • 14 CC, 29.5 y: 9.5 pack-years, 10.1 cig/d (last 2 weeks) • 14 EC, 26.1 y: last 2 weeks: 44.1 puffs/d, 11.4 mL e-liquid/d |
|
AO: EC users are at increased risk for chronic lung disease. ARO: Unclear for how long ECs were used. |
ARO: |
L: Small group sizes, long-term use (in EC users) is not well defined. P: Study of anti-protease/protease balance in NGP long-term users (EC, HTP) would be of interest. |
|
0.5 / ? | |||||||
K |
Cross-over |
20 Smokers (CC), assigned to two conditions, separated by 24 h: • C1: Vaping, 15 puff, EC with • C2: Smoking 1 CC ad lib |
Acute biomarker changes pre/post, sign. for C1 and C2: • • • Sign. change only in C2: • Sign. change only in C1: • No sign. change (C1 or C2): • |
AO: These findings suggest that both electronic cigarettes and tobacco smoking negatively impact vascular function. |
ARO: Involvement of |
L: Small group sizes, only acute changes. G: No condition EC without |
|
0.5 | |||||||
Sign. role of |
|||||||
0 | |||||||
Role of |
|||||||
? | |||||||
A |
Cross-over |
15 Occasional smokers (< 10 CC/month): Cross over of two conditions separated by 1 week: • • |
Vascular measurements over 4 h: • Respir. measurements over 6 h: • No sign. diff. + • FeNO sign. increased in EC (+/−N) • VC sign. decreased in EC (+/−N) |
AO: ECs with |
ARO: |
L: Small group sizes; only acute effects investigated. P: Investigate long-term effects in users of EC with and without |
|
0.5 – 1 | |||||||
C |
Cross-over |
25 Occasional smokers (CC) were assigned to 3 conditions (random order): • Sham vaping (EC switched off) • EC with • EC without 20 Heavy smokers (CC): • 10 assigned to sham EC • 10 assigned to EC without Vaping: 25 puffs at 30 s intervals, 4 s inhalation |
• • • • |
AO: Effect on PO2 is caused by PG/VG in ECs rather than |
ARO: |
L: Results are valid for intense vaping under acute conditions only with a low number of subjects. P: A larger study under long-term, realistic use conditions would be of interest. |
|
0 | |||||||
T |
Cross-sectional |
• 12 Never-smokers (NS), 26 y • 15 Vapers (EC), 27 y: 80% were former smokers, duration of EC use (average, range): 3 (0.5–4) y, 127 puff/d, 7 mL e-liquid/d, N-content: 12 (1.5–36) mg/mL • 16 Smokers (CC), 26 y |
Sign. diff.: a: NS Total cells: b |
AO: Suggest to also investigate NS who started EC use (in order to avoid the influence of former smoking) and to study the role of ARO: EC were relatively well characterized. EC use was relatively short. |
ARO: The observation that EC users were close to never-smokers suggests that |
L: Small group sizes; relatively short duration of EC use. G: No cessation group, no group using N-free ECs. |
|
0 / ? | |||||||
V |
RCT |
263 Smokers (CC) at baseline assigned to replace CC progressively by • EC (N = 191, 3 groups: 0, 6, 36 mg/mL • EC-dummy (fresh air) (N = 72), 18.1 cig/d at BL: after 1 month: −5 cig/d, after 3 months: −6 cig/d |
Lung function parameters • • • • • • and • • • were not sign. diff. between EC and fresh air at BL, 1 and 3 months |
AO: EC use sign. contributes to health outcome. ARO: Amount of CC used by the two groups might be too high to see an effect. |
ARO: No effects were observed, therefore, role of |
L: Sensitivity of the measured study parameters might be too low; study duration might be too short. |
|
? | |||||||
O |
Cross-sectional (BRFSS) |
402,822 Never CC users: • 399,719 NU (no CCs or ECs), median age group: 45–49 y • 3,103 EC only users, median age group: 18–25 y (!) Duration of EC use: ~ 5 y (estimate) |
OR for self-reported • Occasional EC: 1.31 (1.05–1.62) • Daily EC: 1.73 (1.21–2.48) |
AO: EC use is a risk factor for asthma (to be approved in future longitudinal studies). ARO: Dual use cannot be excluded. |
ARO: |
L: EC use not further characterized; EC users much younger than NU; self-selection (to use ECs because of asthma) possible. |
|
? | |||||||
P |
Cross-sectional (PATH) |
32,320 Adults: Propensity matching: • 2,727 EC users • 2,727 NU Duration of EC use: < 10 y (estimate) |
OR (CI) for self-reported |
AO: EC use is associated with COPD in adults, long-term studies are required. ARO: Confounding is possible. |
Possible ARO: |
L: Data rely on self-reports; confounding possible (EC used started after diagnosis?); duration and dose of EC not considered. G: No long-term use of ECs. |
|
? | |||||||
B |
Cross-sectional (chronic (BL) and acute) |
• 30 Smokers (CC), 23.2 y, CC since 50 months, 0.6 mg/cig, 6.2 cig/d • 30 Vapers (EC), 22.2 y, EC since 29 months, 12 mg N/mL, 15.6 sessions/d • 30 Dual (CC/EC), 22.3 y, since 67.3/27.7 months, 0.6/12 mg • 30 NU, 22.9 y |
• – BL: NU > CC ≈ Dual ≈ EC – 1 m: NU > CC ≈ Dual ≈ EC – 30 m: CC ≈ Dual < EC • – BL: no clear diff. between groups(same after acute exposure 1 and 30 min) |
AO: EC use is similar in terms of reduced airflow (PEF) and FeNO as smoking. ARO: Long-term use was not well assessed. Changes in terms of lung function are variable. |
ARO: |
L: Long-term use of EC (> 2 y), but compliance not well assessed. G: No long-term, N-free EC group. P: Long-term study with these groups (+ N-free EC) would be of interest. |
|
? | |||||||
L |
Cross-sectional |
58,336 Adolescents, 12–18 y Self-reported tobacco/N use: • 49,542 NU • 4,496 CC only users • 540 EC only users • 51 HTP only users • 2,344 Dual users (CC + EC) |
Sign. increased OR (NU = 1): • • Allergic rhinitis: none • Atopic dermatitis: CC, (EC), dual |
AO: Any product use might be risk for the indicated allergic diseases, however, longitudinal studies are required. ARO: No verification of product (only) use. |
ARO: |
L: Some groups are very small (EC, HTP); high probability of dual/multi use in the “only” groups; very young subjects and short product uses. G: No N-free EC group. |
|
? | |||||||
G |
Cross-sectional (5 studies), prospective (1 study) |
Review of 6 epidemiological studies with former CC users who switched to ECs Duration of EC use: < 10 y (estimate) |
EC • 3 Studies on RD ( • 3 Studies on |
AO: Switching to ECs reduces risk for RD but does not change risk for CVD. ARO: General issue with misclassification in epidemiological studies. |
ARO: |
L: Low number of studies, problem of misclassification. G: No N-free EC group. P: Authors emphasize need for prospective studies and RCTs. |
|
? | |||||||
S |
RCT |
• G1: 15 NU (< 100 CC in lifetime, no EC in past year) • G2: 15 NU switched to EC without |
Biomarkers in • Biomarkers in bronchial brush: • |
AO: Although limited by study size and duration, this is the first experimental demonstration of an impact of e-cig use on inflammation in the human lung among never-smokers. ARO: G2 had sign. elevated PG levels in urine after EC use. |
ARO: Role of |
L: Too short use of ECs; low numbers of subjects in both groups. P: Long-term study (> 12 months) with larger group sizes (> 100/group). |
|
? | |||||||
S |
Cross-sectional |
• 42 Never-smokers, 25 y • 15 EC users, 27 y: 80% were former smokers, duration of EC use (average, range): 2.6 (0.5–4) y, 163 puff/d, 8.3 mL e-liquid/d, N-content: 10.7 (1.5–36) mg/mL • 16 Smokers (CC), 26 y |
Level in EC group mostly between NS and CC (closer to NS): Cells in Sign. diff: a: NS • • • • • • Differential |
AO: Suggest to also investigate former smokers without switching to ECs. ARO: EC were relatively well characterized. EC use relatively short. |
ARO: The observation that EC users were close to never-smokers suggests that |
L: Small group sizes; relatively short duration of EC use. G: No cessation group, no group using N-free ECs. |
|
0 / ? | |||||||
A |
Cross-sectional |
61 College students: • 32 self-reported EC use in the last 30 d, 34.4% reported CC use in last month • 29 NU in the last 30 d, 10.3% reported CC use in last month |
EC Recent Not sign. diff.: |
AO: Findings reveal dysregulation of salivary immune profiles toward a TH1 phenotype in emerging adult EC users and short-term immune function may be dysregulated in young adult EC users. ARO: No pure EC users of NU (almost multi-product users). |
ARO: |
L: Small groups, no ‘pure’ product use; probably very short time of product use (< 30 d). G: No data to evaluate role of |
|
? | |||||||
K |
Cross-sectional |
• 6 Vapers (EC), EC use since ≥ 6 months • 6 Smokers (CC), CC since ≥ 6 months • 6 WP smokers, WP since ≥ 6 months • 6 Dual CC/WP smokers • 6 NU Age range (all groups) 18–65 y |
|
AO: lncRNAs allow risk estimates for COPD, asthma, IPF. ARO: No verification of EC only use. |
ARO: |
L: Small group sizes; no verification of product compliance (especially EC). G: No N-free EC group. |
|
? | |||||||
S |
Cross-sectional |
• 22 Vapers (EC), 35.5 y • 26 Smokers (CC), 32.8 y • 12 WP smokers, 32.8 y • 10 Dual CC/WP smokers, 35.5 y • 26 NU, 33.9 y |
The 4 user groups show common differential expression of micro-RNAs which are different from NU. |
AO: The exosomes/microRNAs are BMs to understand the lung injury caused by smoking and vaping. |
AO: Suggest that the differences between the user groups and NU demonstrate “nicotine-specific” effects. ARO: Given the study design, the role of |
L: Small group sizes; no verification of product compliance. G: No N-free EC group. |
|
? | |||||||
C |
Cross-over |
30 EC users (former CC, EC since 38 months), 38 y, randomly allocated to 3 conditions, separated by 7 d): • (1) EC with • (2) EC without • (3) Cessation (EC stop), 5 d |
Sign. diff. between conditions: • PG in serum: 1 ≈ 2 > 3 • PG in urine: 1 ≈ 2 > 3 • • • • • • Serum • |
AO: Short-term EC cessation can lead to decrease in lung inflammation (indicated by change in CC16). Effects appear to be related to a disturbance of the lung gas exchange. |
ARO: |
L: Only acute effects in a limited population were investigated. P: Investigations of long-term EC use (with and without |
|
0 | |||||||
|
|||||||
1 | |||||||
P |
Longitudinal (60 months) |
• 19 Smokers with COPD, switched to EC, 65 y, 22.1 cig/d at BL • 20 Smokers with COPD (control), continued CC use, 65.9 y, 20.2 cig/d at BL |
BL, and follow-up (FU) at 12, 24, 48 and 60 months • CC group: CPD almost unchanged at 20 cig/d; no sign. change or slight improvement in • EC group: decrease in CPD (20 to 1.5 cig/d); sign. improvements in lung function and walk distance, COPD exacerbations, CAT score Also improvements in dual users (about 3 cig/d) |
AO: EC use ameliorates COPD outcomes and might also reverse the harm of some smoking effects. ARO: Although dual use was evaluated separately, compliance is an open question. |
The authors speculate that ARO: From the study data, the role of |
L: Small group sizes. P: A larger study over longer time periods including a N-free EC group would be of value. |
|
0/? | |||||||
Of note: |
|||||||
J |
Cross-sectional |
• Cohort 1: 26 NU, 22 vapers (EC) • Cohort 2: 25 NU, 26 CC, 12 Waterpipe (WP), 10 Dual (CC/WP) Grouping according to self-reports |
Self-reported • EC and CC reported the most symptoms |
AO: Our pilot study showed that users have a preference toward fruit and more sweet flavors and that EC and dual use resulted in an augmented systemic immune response. ARO: Only self-reported data (except IgE and IgG). No verification of product use (particularly EC only). |
ARO: Role of |
L: Small group sizes; probably too short product use durations. G: No N-free EC group. |
|
? | |||||||
K |
Cross-over |
25 healthy and 25 asthmatic smokers (aged 40 y) vaped 1 EC (with nicotine) |
Acute changes (after Healthy subjects: • • • All BM sign changed in asthmatics after 1 EC |
AO: EC vaping resulted in acute alteration of both pulmonary function and airway inflammation in stable moderate asthmatic patients. |
The authors cite evidence that EC use without ARO: |
L: Small group sizes; only acute effects. G: No N-free EC group; no long-term observations. P: A study without these weaknesses would be of interest. |
|
0.5 / ? | |||||||
L |
Cross-over |
Evaluation of RNA expression data sets from: • Smokers (CC) • Vapers (EC with • Vapers (EC without |
• ACE2: upreg. in CC • • |
AO: CC and EC (with ARO: Product use not well characterized |
Authors do not clearly separate effects of ARO: |
L: Product use not well characterized, misclassification possible |
|
0.5 / ? | |||||||
S |
Cross-sectional |
64 Healthy, young adults, mean age: 26 y • 28 NU, PG in urine: 2.1 mg/L • 13 Vapers (EC for > 1 y, no CCs for > 5 month), PG in urine: 25.5 mg/L • 27 Smokers (CC), PG in urine: 6.6 mg/L |
• NU: 18% • EC: 54% • CC: 96% |
AO: LLM are related to EVALI, relation to inflammation is open. ARO: Dual use cannot be excluded |
ARO: |
L: Small group sizes; dual use in EC group is possible; not clear what LLM indicates. G: No N-free EC group. |
|
? | |||||||
P |
RCT |
186 Smokers (CC), African Americans/Latinx: 92/94, 43.3 y, 12.1 cig/d; randomized to • 125 EC use, 5% • 61 Controls (CC use as usual) |
Sign. changes EC • NNAL • COex No sign. changes EC • Cotinine in urine • • • • • Significances similar in EC only users |
AO: ECs may be an inclusive (suitable) harm reduction strategy for this population. ARO: 58–68% in EC group were dual users, 4% were CC only users in EC group. Compliance was not enforced. |
ARO: All EC contained 5% |
L: Only short- to medium-term study (6 weeks). G: No N-free EC group. P: Long-term study (> 1 year) including an N-free EC group would be of interest. |
|
? | |||||||
K |
Cross-sectional (acute and chronic (BL)) |
• 9 Vapers (EC since > 1 y), 23 y, range EC use: 1.5–4 y, 3.3 pack-year equivalents • 7 NU, 21 y |
Sign. diff. at BL: • • • VA/Q mismatch: EC > NU BL • No sign. diff. at BL: • SPO2 (oxygen saturation) • HR (but sign. increase after acute vaping) |
AO: EC use leads to early lung changes. Authors could not exclude some dual use. The authors suppose that nicotine is involved in the VA/Q changes. |
ARO: No direct involvement of |
L: Very small groups, dual use cannot be excluded. G: No N-free EC group. P: Larger, long-term study with N-free EC group would be of interest. |
|
?/1 | |||||||
M |
Cross-sectional (acute resp. changes) |
• 76 Vapers (EC), 20 min EC use with 5% • 73 NU, passively exposed to EC for 20 min |
Sign. changes after 20 min (active) vaping: • • • • Passive exposure: • oral temp, ↑ |
AO: Vaping with mint-flavored ECs with 5% |
ARO: |
L: Only short-term effects. |
|
? | |||||||
R |
Cross-over study (BL and 3 months investigations) |
• 60 Smokers (CC), 39.1 y, reduced CC and increased EC use (still 25% CC use after 3 months) • 20 Smokers (CC), 44.2 y; stopped CC use |
Changes after 3 months: • • • No sign. diff. in the changes between both groups |
AO: Whether the decrease in BHR observed after 3 months is maintained when using ECs over longer time periods or has an individual prognostic value, must be clarified in long-term studies. ARO: No clear improvements by EC use or stopping smoking were observed. Both groups contain CC users after 3 months. |
ARO: Role of |
L: Use of CCs in both groups. G: No N-free EC group. |
|
? | |||||||
C |
13 Cross-sectional studies (meta-analysis) |
1,039,203 Subjects • Current EC users • Ever EC users • NU Duration of EC use: < 10 y (estimate) |
Pooled OR (CI) for • Current EC: 1.36 (1.21–1.52) • Ever EC: 1.24 (1.13–1.36) |
AO: EC use is correlated with asthma (however, limitations are considered). |
ARO: |
L: All weaknesses of cross-sectional studies: temporality, misclassifications by self-reports. |
|
? | |||||||
X |
11 Cross-sectional studies (meta-analysis) |
Groups: • EC ever • EC current • EC former • Dual • CC • NU Duration of EC use: < 10 y (estimate) |
OR (CI) for • EC ever: 1.27 (1.17–1.37) • EC current: 1.30 (1.17–1.45) • EC former: 1.22 (1.08–1.39) • Dual: 1.47 (1.13–1.91) • CC current: 1.33 (1.19–1.49) |
AO: Current and former EC use is associated with asthma. ARO: Usual weaknesses of cross-sectional studies. |
ARO: Cannot be deduced from this study. |
L: Cross-sectional study: no causality, temporality open; mis-report of product use possible. G: No N-free EC group. |
|
? |
Oral mucosa/cell changes and related biomarkers of potential harm (BOPH).
Author, year, country (Ref) | Study type | User groups / duration of product use | Endpoints and findings | Comments (bias, compliance, etc.) | Conclusions regarding nicotine's ( |
Limitations (L) / Gaps (G) / Proposals (P) |
---|---|---|---|---|---|---|
J |
Cross-sectional |
94 Males: • 33 Smokers (CC), 41.3 y, CC use since 5.4 y, 13.3 cig/d • 31 Vapers (EC), 37.6 y, EC use since 2.2 y, 6.8 sessions/d • 30 NU, 40.7 y |
Perceived oral symptoms (OS): • • • |
AO: periodontal inflammation and self-perceived OS were poorer among CC than among EC. ARO: Dual users were excluded, but no verification of EC only users. |
The authors cite evidence that ARO: Study data do not allow to deduce |
L: Small groups. G: No verification of EC only use; no N-free EC group. |
? / 0.5 | ||||||
B |
Cross-sectional |
• 45 Former smokers (FCC), mean 47 y • 45 EC users (EC), mean age 47 y, ECs for at least 6 months, |
• • • Not sign. diff.: • • • • • • • Total |
AO: EC use is linked to three types of inflammatory lesions, but not in precancerous lesions. ARO: Only self-reports, no objective check for dual use. |
ARO: |
L: Small group sizes, only medium- to short-term use of EC. G: No check for dual use; no N-free EC group. P: Larger long-term study with EC only use verification and an N-free EC group would be of interest. |
? | ||||||
M |
Cross-sectional |
154 Males: • 39 Smokers (CC), 42.4 y, duration of habit: 17.2 y, 16.2 cig/d, 4.8 min/cig • 40 Waterpipe (WP), 44.7 y, duration of habit: 14.6 y, 4.3 WP/d, 17.1 min/WP • 37 Vapers (EC), 28.3 y, duration of habit: 3.1 y, 9.2 cig/d, 8.1 min/cig • 38 NU, 40.6 y |
Oral health parameters, > / <: sign. diff.: • PI: CC ≈ WP > EC* ≈ NU * not sign. diff. from all other groups • BoP: CC ≈ WP > EC ≈ NU • PD: CC ≈ WP > EC ≈ NU • CAL: CC ≈ WP > EC ≈ NU • MBL: CC ≈ WP > EC ≈ NU BMs in saliva: • Cot: CC ≈ WP ≈ EC > NU • IL-1ß: CC ≈ WP > EC ≈ NU • IL-6: CC ≈ WP > EC ≈ NU |
AO: Parameters of oral health were poorer in CC and WP than EC and NU. ARO: Dual users were excluded, but no verification of EC only use. EC group is significantly (?) younger! |
Authors cite constricting effect of ARO: |
L: Small group sizes; EC only use not objectively verified. G: No inclusion of an N-free EC group. |
? | ||||||
A |
Cross-sectional |
Male subjects with teeth implant : • 40 Smokers (CC), 45.8 y, CC since 21.3 y • 40 Water pipe users (WP), 43.5 y, WP use for 19.5 y • 40 Vapers (EC), 35.6 y, EC use for 8.7 y, 6.5 sessions/d, 37.7 min/session • 40 Non-smokers (NS), 42.6 y |
• PI: Sign. higher in CC, WP, EC • • • Sign, higher in CC, WP, EC • Sign. higher in CC, WP, EC than in NS |
ARO: The authors do not interpret their results with EC users. No information on possible dual use of EC and other products. |
The authors state that ARO: A role of |
G: No N-free EC group; no information on possible dual use EC/other products (CC, WP). P: A study with these gaps filled would be of interest. |
0.5 / ? | ||||||
A |
Cross-sectional |
Subjects with teeth implants: • 47 Male vapers (EC), 35.8 y, mean EC use: 4.4 y, 6.5 sessions/d, 37.7 min/session • 45 Male never smokers (NS), 42.6 y |
Peri-implant parameters: • • • PD: sign. higher in EC than NS • TNF-α and IL-1ß in PISF: sign. higher in EC than NS |
ARO: No information on possible additional CC use. |
The authors state that ARO: A role of |
G: No N-free EC group; no CC group (positive control); no information on possible dual use EC/CC. P: A study with these gaps filled would be of interest. |
0.5 / ? | ||||||
A |
Longitudinal |
• 9,632 Never EC users (nEC) • 329 Longitudinal EC users (LEC) for at least 1 year • 8,298 Occasional EC users (OEC) PATH study, waves 1, 2, 3 |
LEC sign. increased compared to nEC at wave 3 for: • • • any nEC and OEC were not sign. different |
AO: EC use may be harmful to oral health. ARO: All data on behavior and endpoints were self-reports. |
ARO: |
L: Only self-reports; EC use might be too short. G: No objective verification of EC only use; no N-free EC group. |
? | ||||||
B |
Cross-sectional |
• 46 CC users (14.2 pack × years) • 44 EC users (duration of use: 9.4 y) • 45 NU (never used CC or EC) |
Periodontal health status: CC < EC < NU Indicators: PI, BOP, |
AO: Periodontal status is poorer and GCF levels of proinflam. cytokines are higher in CC compared with EC and NU. There is evidence for increased periodontal inflammation in EC users. ARO: Compliance of EC use not approved (could be questionable). |
ARO: |
L: Small group sizes; EC compliance questionable (given the long duration of use). |
? | ||||||
A |
Cross-sectional |
102 Males with tooth implants: • 35 Smokers, 36.3 y, daily CC use for > 12 months • 33 Waterpipe (WP) users, 34.1 y, daily WP use for > 12 months • 34 Vapers, 33.5 y, daily EC use for > 12 months, 8.4 mg N/mL • 35 NU, 32.2 y |
• |
AO: Cotinine peri-implant in fluid was increased in users of ARO: Dual users were excluded, but not verification. |
Authors suggest that ARO: |
L: Small group sizes, unclear compliance (particularly of EC group). G: No N-free EC group, no objective verification of compliance. |
? / 1.0 | ||||||
A |
Cross-sectional |
95 Males with tooth implants: • 32 Smokers (CC), 40.4 y, CC since 13.7 y, 11.3 cig/d • 41 Vapers (EC), 35.8 y, EC since 4.4 y, 6.5 sessions/d, 37.7 min/session |
Peri-implant sign diff: • • • • • • |
AO: Peri-implant is compromised by CC and (to smaller degree) also by EC. ARO: Dual users were excluded, but not verification of status. |
The authors point out that ARO: |
L: Small group sizes; unclear compliance. G: No N-free EC group; no objective verification of EC only use. |
0.5 / ? | ||||||
A |
Longitudinal |
89 Males, at least 30% BOP: • 28 Vapers (EC use daily since at least 12 months, no history of tobacco use), 32.5 y • 30 Smokers (CC, > 5 cig/d on the previous 12 months), 36.4 y • 31 NU, 32.6 y Investigations at BL, 3 and 6 months; FMUS after BL |
|
AO: State to be cautious with the interpretation of the results due to weaknesses in the study design. ARO: Dual users excluded, but no verification of EC only use. |
ARO: |
L: Low number of subjects, short duration of product use. G: No N-free EC group, no verification of EC only use. |
0.5 / ? | ||||||
T |
Cross-sectional |
• 42 EC users, 28 y, CotP: 115 ng/mL • 24 CC users, 42 y, CotP: 122 ng/mL • 27 NU, 24 y, CotP: 2.5 ng/mL |
|
AO: The findings have significant impact on public health. ARO: Possible dual use not considered. |
ARO: cannot be deduced from the study results. |
L: Small group sizes; dual use is possible. G: No N-free group. P: Study with the weaknesses eliminated would be of interest. |
? | ||||||
A |
Cross-sectional |
71 Subjects with chronic periodontitis: • 36 Vapers (EC), 47.7 y, mean duration of EC: 3.3 y, 17.6 sessions/d, 8.4 puffs/session, all were former smokers • 35 NU, 46.5 y Investigations at BL and 3 months, in between: SRP |
BL: no sign. diff. between EC and NU in |
AO: The anti-inflammatory effect of SRP was higher in NU than in EC. ARO: No verification of EC only use. |
ARO: |
L: Small group sizes. G: No verification of EC only use; no N-free EC group. |
? | ||||||
K |
Cross-sectional |
Periodontitis patients: • 19 Smokers (CC), 35.3 y, smoking for 14.0 y • 19 Vapers (EC), 34.7 y, CC use for 12.1 y than switched to EC since at least 12 months • 19 Former smokers (FS), 35.6 y, CC use for 12.1 y then stopped since at least 12 months |
• • • BMs in GCF: • • • • |
AO: CCs and ECs had the same unfavourable effects on the markers of oxidative stress and inflammatory cytokines. ARO: Dual smokers (CC and EC) were excluded. No information on compliance. |
ARO: Role of nicotine cannot be deduced from the study. |
L: Small group sizes, no long-term use of ECs, no information on unique EC use in vapers. G: No N-free EC group. |
? | ||||||
Y |
Cross-sectional |
• 12 NU, 35.7 y, CotS: 0.56 ng/mL • 12 CC, 40.3 y, CotS: 142.5 ng/mL • 12 EC, 34.9 y, CotS: 180.2 ng/mL, • 12 Dual (EC, CC) users (DU), 39.4 y, CotS: 299.0 ng/mL |
Sign. diff. between groups: CotS: DU > NU • • GCF • • • Various growth factors: none |
AO: EC/CC induced differential changes on oral health. ARO: Strange sign. diff. for CotS and some other BMs. No detailed assessment of product use. |
ARO: |
L: Small group sizes; EC compliance questionable. G: No N-free EC group. |
? | ||||||
V |
Cross-sectional |
105 Males: • 28 Smokers (CC), 33.3 y, 6.1 pack-years • 26 EC users, 31.6 y, 0.9 y EC use, 30.2 sessions/d • 25 JUUL (JU) users, 32.1 y, 0.8 y JU use, 25.3 sessions/d • NU, 33.5 y |
Self-rated • • • • Periodontal parameters, sign. diff.: • • • • |
AO: Pain in teeth and gums are more often perceived by CC than EC and JUUL users and NU. ARO: Dual users were excluded, but no verification of EC or JUUL only use. |
Authors cite evidence that ARO: Study results do not provide evidence for N's role in oral health. |
L: Small group sizes; only short use of EC and JU. G: No N-free EC group. |
? | ||||||
I |
Cross-sectional |
Male subject • 30 Smokers (CC), CC habit: 18.3 y, 12.6 cig/d, 8.3 min/cig • 30 WP users, WP habit: 15.6 y, 5.5 WP/d, 22.6 min/WP • 30 EC users, EC habit: 6.4 y, 15.4 sessions/d, 20.5 min/session • 30 NU |
Oral health, sign. diff. (</>): • • Markers in GCF: • • |
AO: All product users (including EC) show impairment of oral health. ARO: Dual users were excluded. No verification of possible dual use in subgroups. |
The authors cite some evidence that ARO: From this study, no involvement of |
L: Small group sizes; unclear, whether only EC were used (no objective verification). G: No N-free EC group. P: A larger study without these weaknesses would be worthwhile. |
? / 0.5 | ||||||
P |
Cross-sectional |
• 39 NU, (m/f): 29/38 y, COex: 1.8 ppm, CotS: 11.9 ng/mL • 40 EC users, (m/f): 36/36 y, COex: 5.1 ppm, CotS: 104 ng/mL • 40 CC users, (m/f): 46/45 y, COex: 18.8 ppm, CotS: 536 ng/mL |
Sign. diff. in EC from NU and also from CC |
AO: EC users are more prone to infections. ARO: Dual use not unlikely (see COex in EC). |
The authors mention evidence that ARO: |
L: Small group sizes; long-term product use not well characterized, misclassification possible. G: No N-free EC group. |
? | ||||||
F |
Cross-sectional |
64 Subjects, 28–83 y: • 15 Controls (NU) • 18 CC users • 16 Mixed (CC, EC) • 15 EC users |
• • *: sign. diff. in ANOVA EC closer to CC and mixed than to NU. |
AO: The combined findings of this study and previous studies put into question the safety of ECs as a smoking cessation mechanism. ARO: No statement on duration of EC use, no check of self-reported product use. |
ARO: |
L: Small group sizes. G: No information on duration of use of products. |
? | ||||||
A |
Longitudinal |
• 30 Male vapers (EC), ≥ 2 y EC use • 30 Male smokers (CC), ≥ 2 y CC use • Investigations at BL, 3 and 6 months |
Sign. differences • • Sign. dose-response in CC group (pack-years) for: • PD, Sign. dose-response in EC group (session-years) for: • PD (all time points), MMP-8 (3 and 6 months) Effects higher in CC than EC. |
AO: CC showed higher periodontal worsening than EC. MMP-8, CTX are prognostic factors for clinical attachment loss in CC and EC users. ARO: No verification of pure EC or CC status. |
ARO: |
L: Small groups, 6 months might be too short. G: No N-free group. P: Larger study with verified long-term users would be of interest. |
? / 0.5 | ||||||
T |
Longitudinal |
• 27 CC users, (m/f): 48/51 y • 28 EC users, (m/f): 36/40 y • 29 NU, (m/f): 29/39 y Investigations at BL and 6 months later |
• consistent for 3 groups over time • Unique in EC group, higher agreement with CC • No clear group diff. for • |
AO: Suggest that there is a unique periodontal risk associated with e-cig use (similar to CC). ARO: EC only use not verified. |
The authors assume that ARO: |
L: Small group sizes; duration of EC use too short? G: No N-free EC group. |
? | ||||||
C |
Longitudinal (6 months) |
• 20 NU • 20 EC users • 8 CC users |
CC / EC / NU: 446 /179 / 21.0 |
AO: This is the first identification of a carcinogen-DNA adduct in any tissue of EC users. |
ARO: No involvement of |
L: Small group sizes; dual use cannot be completely excluded. P: Larger study with a long-term verification marker would be of interest. |
0 | ||||||
M |
Cross-sectional |
76 Subjects, ~25 y : • 12 Snus (including • 19 Smokers (CC) • 8 Vapers (EC) • 37 NU |
• Only seen in snus group • • • • |
AO: Saliva is a suitable matrix for detecting oral mucosa changes. Product use relies on self-reports. |
ARO: |
L: Small groups; not well characterized product use history; snus and G: No N-free EC group. |
? | ||||||
T |
Cross-sectional |
72 Healthy, young subjects: • 24 EC only users, 24.3 y, CotP: 84.9 ng/mL • 24 CC only users, 26.0 y, CotP: 76.7 ng/mL • 24 NU (no CC, no EC), 25.3 y, CotP: 2.6 ng/mL |
• • EC: dose-dependent and device-dependent |
AO: DNA damage was shown for the first time. ARO: EC/CC use only short-term verified. |
The authors state that N-content in e-liquid was not a predictor for DNA damage. ARO: No role of |
L: Product use not verified (long-term); small group sizes; DNA lesions are unspecific (strand breaks, bulky adducts, oxidation, etc.). P: A larger study, avoiding the weaknesses with a specific DNA analysis would be of interest. |
0 / ? |
Inflammation and oxidative stress.
Author, year, country (Ref) | Study type | User groups / duration of product use | Endpoints and findings | Comments (bias, compliance, etc.) | Conclusions regarding nicotine's ( |
Limitations (L) / Gaps (G) / Proposals (P) |
---|---|---|---|---|---|---|
C |
Cross-over |
10 NU (CC and EC naive), 28.7 y: Vaped an EC (without Blood samples at −30 (BL), 30 min, 1, 2, 4, 6 h |
Sign. changes of ox. stress and inflammation BMs ( • • • • BMs returned to BL after 6 h |
AO: EC use (also without N) increases ox stress and inflammation and thus vascular pathologies. |
The authors cite evidence that EC could adverse impacts also without ARO: |
L: Small sample size; only young and EC/CC-naive subjects; only acute effects. G: No group with N-containing ECs. P: A study with chronic EC users would be of interest. |
? | ||||||
S |
Cross-sectional |
• 26 NU, 33.9 y • 22 EC users (mean duration of use 2.00 ± 1.64 y), 35.5 y |
|
AO: EC use is risk factor for various systemic diseases and lung injuries. |
ARO: |
L: Small group sizes; short use of ECs. G: No positive control (CC); no N-free EC group. |
M |
Cross-sectional |
• 430 Non-smokers (NS), 38.4 y • 715 CC users, 42.3 y • 63 EC users, 37.1 y |
Sign. diff. in baseline biomarker levels between groups: • • • • Not sign. diff. between groups: • |
AO: EC use may be associated with systemic inflammation as in CC users. ARO: only deducible from model calc. |
ARO: No conclusions on |
L: Small group size for EC users; EC use possibly only in last month. |
? | ||||||
O |
Cross-sectional |
• 62 Smokers (CC), 47.1 y • 132 Vapers (EC, 70 tank, 62 cartridge), 44.4 y Subjects used own brands Minimum use of EC: 6 months |
Nequ (mg/g crea): • CC: 10.1; EC: 6.3 • CC: 7.3; EC: 6.6 • CC: 56.0; EC: 55.4 • CC: 952.6; EC: 844.2 • CC: 480.9; EC: 342.7 • CC: 266.9; EC: 217.9 Model calc.: all diff. CC |
AO: EC users may have lower health risks than CC users. ARO: 6 months EC use approaches long-term use. Compliance is somewhat uncertain. |
ARO: Since Nequ are sign. lower in vapers, an influence of |
L: Larger group sizes and longer EC use would be better. G: No inclusion of N-free ECs. |
? | ||||||
S |
Cross-sectional |
• 19 NS, 23–66 y • 21 Vapers (EC only in the past 6 months, confirmed by NNAL in urine), 19–66 y • 13 Smokers (CC), 24–75 y |
BMs in urine for ox stress: • • • Sign. corr. between total metals and metallothioneine and 8-OHdG in EC users. |
AO: The biomarker levels in EC users were similar to (and not lower than) CC. In EC users, there was a link to elevated total metal exposure and oxidative DNA damage. ARO: At least mid-term use of ECs only (6 months). EC compliance not sufficiently approved. |
ARO: Role of |
L: Small groups. G: No N-free EC group. |
? | ||||||
P |
Cross-sectional |
Women in reproductive age (WRA) (18–49 y): • 74 EC users (all former smokers), CotU: 91.9 ng/mL • 536 Smokers (CC), CotU: 1,508 ng/mL • 448 NU (controls), CotU: 0.4 ng/mL |
• • |
AO: WRA who use ECs had lower levels of some of the evaluated urinary BMs of toxicant exposure and serum BMs of inflammation and oxidative stress than those who use CCs. ARO: |
ARO: A role of |
L: Small EC group size; EC use appears to be low (or only occasional); duration of EC use not provided. |
? | ||||||
S |
Cross-sectional |
PATH Wave 1 (2013–2014): • 2,191 NU • 261 EC only • 3,261 CC only • 1,417 Dual |
Ratios of BMs for ox. stress and inflamm. • • • • • Ratios • EC: < 1* (all BMs) • Dual: ~1 (not sign., all BMs) *: sign. |
AO: We observed no difference in inflammatory and oxidative stress biomarkers between exclusive EC users and NU, and levels were lower in exclusive EC users relative to exclusive CC. ARO: Results were surprisingly consistent. Same weaknesses: Danger of product misclassification. |
Authors do not discuss the role of ARO: |
L: Only short period of EC use possible; mis-report of product use possible. G: No N-free EC group. P: Study with other NGPs and N-free group would be of interest. |
? | ||||||
T |
Cross-sectional |
Study with: • 23 NU, 24.0 y, CotP: 2.5 ng/mL • 37 EC only users, 28.0 y, CotP: 115 ng/mL, 8.0 y CC, 3.0 y EC • 22 CC only users, 36.5 y, CotP: 121 ng/mL, 21.9 y CC |
|
AO: Important genes for disease development are dysregulated, with high impact on public health. ARO: Dual use possible chronic or acute effects? |
ARO: |
L: Small samples sizes; misclassification of product use not excluded. G: No N-free EC group. |
? | ||||||
K |
Cross-over |
Smokers (CC) allocated to switch to: • 8 NRT/Varenicline, no CCs, 55 y • 7 EC, no CC, 57 y • 7 continued CC, 55 y After 12 weeks inflammation BMs were analyzed in ELF (NEC) |
• NRT/Var: • EC and CC: all three BMs unchanged |
AO: Inflammation in the upper airways persisted after switching to EC. ARO: Compliance only checked by COex. |
ARO: Findings with NRT suggest that systemic |
L: Very small group sizes; compliance over 12 weeks not verified. G: No N-free EC group P: A study avoiding these weaknesses would be of interest. |
0 / ? | ||||||
L |
Cross-sectional |
PATH study Wave 1: • 2,442 Smokers (CC only) • 169 Vapers (EC only) • 970 Dual users: with increasing frequency of EC use • 1,700 NU |
BOBEs: • • • • BOBEs levels decrease with increasing EC use. |
AO: Dual users must be differentiated according to frequency of use. ARO: Same weaknesses as other PATH studies. |
ARO: Role of |
L: Certainty of self-reports for product use not reliable. G: No N-free EC group. |
? | ||||||
A |
Cross-sectional |
195 Subjects • 97 Nicotine pouch users (NP), 25.6 y, mean NP duration: 2.8 y • 30 Smokers (CC), 29.7 y, CC use for 11.4 y • 29 Former smokers (fCC), 32.5 y • 39 NU, 29.6 y, no CCs since 3.5 y |
BOBEs diff. between groups (≈ not sign.): • • • • • • |
AO: NP users have more favorable BOPH than smokers. ARO: Sampling during clinic stay, CEVal for long-term compliance. |
ARO: No effect of NP on BOBEs for ox. stress and inflammation, therefore |
L: Partly small groups; relatively short NP use. G: no other NGPs, no N-free EC group. P: A study avoiding these weaknesses would be of interest. |
0 / ? |
Metabolic syndrome.
Author, year, country (Ref) | Study type | User groups / duration of product use | Endpoints and findings | Comments (bias, compliance, etc.) | Conclusions regarding nicotine's ( |
Limitations (L) / Gaps (G) / Proposals (P) |
---|---|---|---|---|---|---|
E |
Cross-sectional |
• 18 NU, male, 24.4 y • 21 Snuff users, male, 24.1 y, duration of snuff use: 7.0 y • 19 Smokers (CC), male, 25.3 y, duration of CC: 9.1 y |
Sign. diff. in CVD-related BOBEs (≈ : not sign): • • • • • • Not sign. diff. between groups: |
AO: Snuff use has similar but lower effects on CVD-related BOBEs, except for lipids. ARO: Use of snuff only not verified. |
The authors cite evidence that NG use does not affect lipids and that CC-related hyperlipidemia is not due to ARO: |
L: Small group sizes; only very young men included. G: Other NGPs (EC, HTP), N-free EC. P: Larger study with older subjects, including additional NGPs would be of interest. |
? | ||||||
E |
Cross-sectional |
• 20 Males, nicotine gum (NG) users (> 11 months, mean: 50 months), 48.8 y • 20 NU, 51.0 y |
Sign. diff. NG • • • • |
AO: |
ARO: |
L: Small group sizes. P: Other NGPs should be used in long-term studies (> 1 year) with these endpoints. |
0.5–1 | ||||||
O |
Cross-sectional (NHANES: 2013–2016) |
3,415 Subjects: • 2,636 NU • 30 Vapers (EC) • 711 Smokers (CC) • 38 Dual users Similar age and sex distributions Duration of EC use: < 10 y (estimate) |
No sign. diff. between groups: • • CC and dual group tend to have higher insulin resistance. Also no sign. diff. in a 12-week mice study exposed to air, CC, EC (with and without |
AO: EC use is not linked to insulin resistance. ARO: The authors concede that the EC use was not well characterized (confounding possible). |
Authors cite evidence that ARO: Data suggest that EC and |
L: Small EC and dual group sizes; no verification of EC only status; too short EC use? G: No N-free EC group. |
0 / ? | ||||||
K |
Cross-sectional |
All men: • 337 Dual users (CC+EC), 36.7 y, CotU: 1,303 ng/ml, 15.1 cig/d • 4,079 CC only, 46.3 y, CotU: 1,236 ng/ml, 14.8 cig/d • 3,027 Never smokers (NS), 39.8 y, CotU: 0.7 ng/ml |
Sign. diff. of dual users to other groups: • • • • • • |
ARO: Proportion of EC use in dual users appears low. |
ARO: Role of |
L: EC only group is missing. |
? | ||||||
A |
Cross-over |
11 Smokers (CC), healthy, middle-aged were investigated at 3 timepoints: • 1. Prior to CC cessation with NRT • 2. After 6 weeks with NRT (N patch) • 3. After further 2 weeks with no CC and no NRT |
• • |
AO: |
ARO: |
L: Very small group sizes; short phases with G: No NGPs studied (including EC with/without P: Larger long-term study with the mentioned groups would be of interest. |
0 / ? | ||||||
|
||||||
1 | ||||||
C |
Prospective (5 pooled cohort studies) |
54,531 Never-smoking men, mean age 49 y, among them never and current snus users mean FU: 10.3 y Duration of snus use: 10–30 y (estimate) |
Harm ratio (CI) for • • (boxes/week) • use (<30 |
AO: High consumption. of snus is a risk factor for DT2, as is use of CC. ARO: Use of snus only not verified. |
The authors state that the results support the notion that ARO: |
L: Only self-reports on product use, no verification. P: Study including NGPs (with/without |
0.5–1.0 | ||||||
A |
Cross-sectional |
• 143,952 Never EC users • 1,339 Current EC users (EC) • 7,625 Former EC users (FEC) Duration of EC use: < 10 y (estimate) |
Self-reported • EC: 1.97 (1.25–3.10) • FEC: 1.07 (0.84–1.37) Risk was higher in males History in never EC users sign. higher than in the other 2 groups (Table 1)? |
AO: EC use may be associated with prediabetes. ARO: No verification of reported EC use was performed. |
ARO: |
G: No verifications of self-reports on prediabetes and EC use. P: A long-term study with objective verifications (dual use, HbA1c, blood glucose) would be of interest. |
? |
Reproduction.
Author, year, country (Ref) | Study type | User groups / duration of product use | Endpoints and findings | Comments (bias, compliance, etc.) | Conclusions regarding nicotine's (N) role | Limitations (L) / Gaps (G) / Proposals (P) |
---|---|---|---|---|---|---|
C |
Cross-sectional |
248 Pregnant women, 232 with singleton life-birth: • 17 Dual EC/CC users • 6 Current EC only users • 23 Any current EC users • 56 Current CC users • 97 NU |
• Dual EC: 2.5 (0.7–8.8) • Current EC only: 5.1 (1.2–22.2) • Any current EC: 3.8 (1.3–11.2) • Current CC: 2.6 (0.9–7.2) |
AO: Suggest that EC use is associated with an increased risk of SGA. ARO: Strange results! Misclassification is likely. |
The authors cite (weak) evidence that ARO: |
L: Very small groups; misclassification is likely. |
? | ||||||
H |
Cross-sectional |
2,008 Men, median age: 19 y, were asked for their smoking habits (multiple use possible): • 52% CC users • 13% EC users (mostly with N) • 25% snuff users • 33% marijuana users |
Sign. diff. • Total • • Higher in daily CC |
AO: Stated that ‘confounding by behavioral factors cannot be excluded’. ARO: There is probable significant dual use in EC group. |
The authors cited evidence that EC effects were dependent and independent of ARO: |
L: Dual use (CC/EC) highly likely. G: No N-free EC group. |
? | ||||||
M |
Cross-sectional |
Pregnancy outcome in a clinic: • 218 EC users, 31 y • 195 Dual users, 29 y • 99 Smokers (CC), 29 y • 108 NU, 33 y |
Mean • EC: 3,470 • Dual: 3,140* • CC: 3,166* • NU: 3,471 * sign. lower than NU and EC |
AO: Birthweight of EC users is similar to NU. ARO: Product use relies on self-reports at 2nd trimester. |
The authors cite evidence that ARO: No effect of EC and, therefore, also of |
L: Product use at delivery not assessed; socioeconomic status higher in NU and EC. |
0 | ||||||
H |
Cross-sectional |
4,586 Women, 21–45 y, web-based study, question on current, former, never use of ECs and CCs |
|
AO: Stated that FR estimates were inconsistent and imprecise because lack of independence of CC use. |
ARO: N-free EC users were excluded. N's role cannot be deduced. |
L: No clear user groups defined. G: No N-free EC group included. |
? | ||||||
R |
Cross-sectional |
Pregnancy monitoring study (PRAMS), 79,176 women, 72,256 using no CC during pregnancy: • 241 EC before preg. (EC1) • 73 EC during preg. (EC2) • 9,795 NU (no EC, no CC) |
• EC1: no adv. effects • EC2: sign. increased prevalence in |
AO: Daily use of EC during pregnancy leads to adverse outcome. ARO: Product use relies on self-report. |
The authors cite evidence that ARO: |
L: Small EC groups; dual use in EC groups possible; heterogeneity in ECs; recall bias; false report of product use. G: No N-free EC group. P: A study including an N-free EC would be of interest (also other weaknesses avoided). |
? |
Other disorders and diseases (eyes, bones, physical performance, brain/mood).
Author, year, country (Ref) | Study type | User groups / duration of product use | Endpoints and findings | Comments (bias, compliance, etc.) | Conclusions regarding nicotine's ( |
Limitations (L) / Gaps (G) / Proposals (P) |
---|---|---|---|---|---|---|
M |
Single (acute) vaping | 64 Subjects, 21 y (CC/EC history not reported, EC-naive); measurements pre and post vaping: 0.05 mL e-liquid (10 puffs), 8 mg N/mL |
AO: More frequent and higher EC use is required, experienced EC users should be used. |
The authors speculate that little or no ARO: |
L: Small sample size, EC-naive subjects, only young people, only acute effects. G: N-uptake completely unknown. |
|
? | ||||||
M |
Cross-sectional |
• 21 Male vapers (~23 y), EC use: ≥1 y, 3 mL/d, quit of occasional CC use • 21 Male NU (~23 y) |
Effects increase with EC voltage (3.0–5.9 V). |
AO: Vaping leads to moderate to severe impairment of OSH. ARO: No verification of EC only use (probably dual users included). |
Authors suggest that irritating compounds may be responsible for the observed effects. ARO: |
L: Small group sizes, only young subjects, only short duration of EC use, probably dual users included. |
? | ||||||
K |
Cross-sectional |
• 21 Male vapers (EC), 28.8 y, ECs (3 mg N/mL) since > 3 y • 21 Male NU, 28.8 y |
|
AO: EC use enlarges FAZ and decreases vascular density in retina micro-circulation. ARO: Possible dual use not mentioned. |
The authors cite evidence that ARO: The study data cannot provide involvement of |
L: Small group sizes, only young males; EC use relatively short. G: No check of dual use; no N-free EC group. |
0.5 / ? | ||||||
M |
Cross-over |
47 Dual users (daily CC (duration: 6 y), at least once per week EC use, 25 y, EC mean duration: 2.4 y, allocated to 4 conditions: • 1. CC: 1 cig, 10 puffs in 5 min • 2. EC, 10 puffs in 5 min, 18 mg N/mL • 3. EC, 10 puffs in 5 min + 25 min • 4. Sham, 60 min |
No sign. changes in |
AO: CC and EC use does not result in acute changes in central foveal (CFT) and choroid thickness (CT) in young subjects. |
ARO: No effects observed, therefore |
L: Low number of subjects, only young subjects, only short- no long-term effects were studied. G: No N-free EC group. P: A larger study, including an N-free group looking for long-term effects would be of interest. |
0 (acute effects) / ? | ||||||
A |
Cross-sectional |
NHANES 2017–2018, 5,569 subjects: • 4,519 NU, 54.3 y • 1,050 Ever EC users (EEC), 56.1 y • 463 CC (no EC) users • 143 Dual users Duration of EC use: < 10 y (estimate) |
Adjusted prevalence ratio, PR (CI) • EEC: 1.46 (1.12–1.89) • CC: 1.63 (1.18–2.25) • Dual: 2.41 (1.28–4.55) |
AO: EC use can be detrimental to bone health. ARO: Data rely on self-reports. |
The authors discuss a possible involvement of ARO: |
L: All data rely on self-reports; EC use not well characterized; subjects may have started EC use after the bone fracture. G: No N-free EC group. |
? | ||||||
T |
Cross-sectional |
Behavior and Risk Factor Surveillance System (BRFSS), 924,882 participants • 30,569 Current EC users (cEC) • 119,309 Former EC users (fEC) • 775,004 Never EC users (nEC) • 486,015 Never EC, never CC (NU)+ +: contain 29.7% former CC and 7.6% current CC (!?) Duration of EC use: < 10 y (estim.) |
Adjusted OR (*=sign) for • fEC • cEC • fEC • cEC |
AO: EC use is an important risk factor for arthritis. ARO: Usual issues with cross-sectional studies: causality/temporality, recall bias, misreports. Unclear NU group! |
The authors cite evidence that ARO: A role of |
L: Weaknesses of a cross-sectional study; no classification of the arthritis type. G: No N-free EC group. |
0.5 / ? | ||||||
B |
Cross-sectional |
151 Healthy males: • 68 NU, 44 y • 50 SLT, 45 y, 25 y SLT use (median) • 48 CC, 48 y, 28 y CC use (median) |
Sign. diff. of CC • • • • No sign. diff. between SLT and NU |
AO: Long-term use of SLT does not sign. influence exercise capacity in healthy, young subjects. |
The authors cite some evidence for negative effects of ARO: The study suggest that |
L: Small group sizes; only rel. young and well trained subjects included. P: Long-term study including more NGPs and older subjects would be of interest. |
0 | ||||||
L |
Cross-sectional |
Web-based survey with 62,276 students: • 53,466 NU • 4,508 Smokers (CC only) • 660 Vapers (EC only) • 3,642 Dual users Duration of EC use: < 10 y (estimate) |
Prevalence of • Sign. increased |
AO: Claim an urgent need for cessation programs. ARO: Misclassification of product use cannot be excluded. |
The authors cite evidence that |
L: Data rely on self-reports; misclassification possible. G: No N-free EC group. P: A study including a N-free EC group would be of interest. |
0.5–1 | ||||||
P |
Cross-sectional |
Self-reports in a Community Health Survey with 53,050 subjects from 2015/2016, mean age 45 y: • Smokers (CC, no EC) • Dual (CC and EC) • EC users • NU Duration of EC use: < 10 y (estimate) |
• • • • EC use is associated with adverse MHS, particularly in women (but no sign. diff.). |
AO: EC use is associated with adverse MHS, particularly in non-smokers and women. ARO: General problem of self-reports and bi-directionality in cross-sectional studies. |
The authors cite evidence that ARO: Study data do not allow to identify a role of |
L: Misclassification of product use and symptoms; bi-directionality in cross-sectional studies. G: No N-free EC group. |
0.5 / ? | ||||||
M |
Clinical trial |
Meta-analysis of 31 studies with 978 subjects (non-smokers) allocated to: • Nicotine patch • Placebo patch |
• • Attention* • *statistically sign. |
AO: |
ARO: Observed effects are causally related to |
L: Only acute effects; only non-smokers investigated; authors list 8 additional shortcomings. P: Study with long-term NGP users would be of interest. |
1 |
Probability for an involvement of nicotine in various diseases, disorders, detrimental changes in NGP users (evaluations extracted from Tables 1–8).
Diseases / disorder / detrimental changes | Number of evaluations | Class I (%) | Class II (%) | Class III (%) |
---|---|---|---|---|
Myocardial infarction (MI) | 7 | 28.5 | 28.5 | 43 |
Stroke | 5 | 20 | 40 | 40 |
Atherosclerosis (related diseases) | 8 | 25 | 50 | 25 |
Arterial stiffness | 19 | 21 | 32 | 47 |
Hypertension (HT) | 4 | 0 | 0 | 100 |
Heart rate (HR) / blood pressure (BP) | 18 | 0 | 28 | 72 |
CVD related BOBEs | 14 | 21 | 50 | 29 |
Sum of CVD | 75 | 16 | 35 | 49 |
Cancer (various organs or all) | 10 | 40 | 50 | 10 |
Respiratory disorders (RD) | 43 | 16 | 65 | 19 |
Oral health disorders | 23 | 9 | 57 | 35 |
Inflammation / oxidative stress | 11 | 18 | 82 | 0 |
Metabolic syndrome | 7 | 14 | 43 | 43 |
Reproduction | 5 | 20 | 80 | 0 |
Eye disorders | 4 | 20 | 50 | 20 |
Bone disorders | 2 | 0 | 50 | 50 |
Physical performance | 1 | 100 | 0 | 0 |
Mental disorders | 2 | 0 | 0 | 100 |
Frequent limitations, weaknesses and gaps in human studies investigating the association between NGP use and detrimental health effects as well as suggestions for avoidance and improvements.
Limitations / weaknesses / gaps | Avoidance / improvements |
---|---|
1. Duration of NGP use in most studies was too short for the development of diseases or disorders | Inherent weakness, due to the relative short market availability of modern NPGs (ECs, HTPs, NPs). Improvement can only come with time |
2. Group sizes in most studies was too small | Larger studies have to be performed in the future |
3. Many studies included only one sex (mostly males) | Males and females should be included |
4. In many studies, the NGP users were relatively young (hence also the controls) | Inherent weakness (see 1.) |
5. The majority of studies investigated ECs (HTPs and NPs are clearly under-represented) | All NGPs should be evaluated for the health risks. With respect to NPs (and partly also to HPTs), presently this is an inherent weakness (see 1.) |
6. Concealed dual use (mostly CC + NGP) was a general problem in epidemiological and field studies. Erroneously increased risks for NGP could be the consequence | Exclusive NGP use (‘NGP only’) is preferable for a reliable product risk evaluation. To achieve this goal will be quite difficult for the years to come. The application of suitable (ideally product-specific) biomarkers which indicate concurrent CC use over weeks to months could help to circumvent this problem |
7. The long-term use history of tobacco/nicotine products in study subjects was usually not adequately assessed | More efficient questionnaires have to be developed for this purpose. Where applicable, interviewers have to be well-trained. Combining questionnaires/interviews with suitable biomarkers would be also of advantage |
8. The majority of studies did not include dose-response relationships (DRR) | An existing DRR is very strong evidence for a (causal) effect. Therefore, future NGP study designs should allow to investigate DRRs |
9. In most studies, only one control group was included | Ordinarily, NGP studies can (and should) have a positive and a negative control group: positive controls are usually smokers (or in longitudinal studies: smokers who continue to smoke); negative controls are usually (‘life-time’) non-users (NU) (or in longitudinal studies: smokers who quit smoking) |
10. Almost all (long-term) human studies do not include a nicotine-free product group (only a few short-term experimental studies do) | For elucidating the role of nicotine in disease/disorder development upon NGP use, comparison to a nicotine-free NGP would be ideal. However, it appears rather unlikely that this goal can be achieved in field studies |
11. In many studies NGP users are former smokers, there was rarely a group of initial NGP users | For a proper evaluation of the health risk of NGP use, initial NGP user would be most suitable. However, this again is an inherent weakness. Improvement (i.e. inclusion of groups of initial NGP users) would be possible in some years from now. On the other hand, the main focus of NGP evaluation is presently to approve their suitability for tobacco harm reduction. For this purpose, no initial NGP users are required. |
12. Cross-sectional and case-control studies (most frequently used in epidemiology) have immanent limitation: in principle no causality can be deduced, temporality (what is first, product use or disorder?) | In principle, prospective studies can avoid these weaknesses. However, cross sectional studies are faster and much cheaper and will, therefore, always take up an important role. More important is the careful interpretation of results from cross-sectional studies, clearly pointing to weaknesses and limitations |