Abstract
Since 2007, the electronic cigarette (EC), with its increasingly diverse array of
device options, has gained popularity both among long-term tobacco cigarette (TC)
smokers and among never-smoking youth. The absence of a number of known toxic by-products
of TC smoking has helped cultivate the perception that ECs are healthy. However, an
expanding literature has provided concerning evidence that a number of EC constituents,
including nicotine, and their thermal degradation by-products may have adverse effects,
including cardiovascular effects. In this review, we discuss the cardiovascular risks
associated with EC vaping and compare this risk profile with TC smoking. Acknowledging
the dynamic nature of EC vaping, we will focus on the latest developments, including
the introduction of the pod-like device, which is the most popular EC device used
today. We discuss the implications of a new, unique, nicotine chemistry that mimics
the efficient and addictive nicotine delivery of TCs. Furthermore, we touch on the
outbreak of the lethal lung disease associated with ECs, which exposed the lack of
quality control in the EC industry. Along the way, we will identify the limitations
of current knowledge and provide suggestions for future research. Overall, we conclude
that although ECs may once have held promise as part of a harm-reduction strategy
in people who smoke lethal TCs, this role has been largely offset by the unconscionable
marketing to our youth, in addition to a failure of regulation and enforcement, leading
to significant harm, especially in never-smokers who use them.
Résumé
Depuis 2007, la cigarette électronique (CE), qui s’accompagne de plus en plus d’options,
a gagné en popularité tant chez les fumeurs de cigarettes au tabac (CT) de longue
date que chez les jeunes qui n’ont jamais fumé. L’absence de certains sous-produits
toxiques liés à la consommation de CT a contribué à alimenter la perception que la
CE est sans danger. Cependant, de plus en plus de publications font état de données
préoccupantes quant au fait que certains constituants des CE, y compris la nicotine,
et leurs sous-produits de dégradation thermique pourraient avoir des effets indésirables,
notamment des effets cardiovasculaires. Nous présentons ici les risques cardiovasculaires
associés au vapotage et comparons les profils de risque de la CE et de la CT. Compte
tenu de l’évolution dynamique de la CE, nous nous concentrons sur les nouveautés les
plus récentes, notamment les dispositifs à capsule, l’un des types de CE les plus
populaires de l’heure. Nous discutons des répercussions d’une nouvelle chimie de la
nicotine unique qui reproduit l’inhalation efficace de la nicotine créant la dépendance
à la CT. Nous traitons également de la flambée de troubles pulmonaires mortels associés
à la CE, qui a révélé l’absence du contrôle de la qualité dans l’industrie du vapotage.
En cours de route, nous cernons les lacunes des connaissances actuelles et formulons
des suggestions pour de futures études. Dans l’ensemble, nous arrivons à la conclusion
que même si on a autrefois cru que la CE pourrait jouer un rôle dans le cadre d’une
stratégie de réduction des méfaits mortels de la CT, ce rôle est considérablement
amoindri par les torts importants, en particulier chez les personnes n’ayant jamais
fumé qui utilisent la CE, découlant de la publicité sans scrupules faite auprès des
jeunes ainsi que de l’inefficacité de la réglementation et de l’application des lois.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Canadian Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- WHO report on the global tobacco epidemic 2011: warning about the dangers of tobacco. Geneva: World Health Organisation.(Available at:) (Accessed October 10, 2020)
- Current cigarette smoking among adults—United States 2016.MMWR Morb Mortal Wkly Rep. 2018; 67: 53
- Current cigarette smoking among adults in the United States.(Available at:) (Accessed October 10, 2020)
- Office on Smoking and Health. The health consequences of smoking—50 years of progress: a report of the Surgeon General.Centers for Disease Control and Prevention, Atlanta2014
- The costs of substance abuse in Canada 2002. Highlights. Canadian Centre on Substance Use and Addiction, March 2006.(Available at:) (Accessed October 10, 2020)
- Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit.Addiction. 2014; 109: 1801-1810
- Electronic cigarettes: a policy statement from the American Heart Association.Circulation. 2014; 130: 1418-1436
- Electronic cigarettes—a narrative review for clinicians.Am J Med. 2015; 128: 674-681
- Prevalence and distribution of e-cigarette use among U.S. adults: behavioral risk factor surveillance system 2016.Ann Intern Med. 2018; 169: 429-438
- Vital signs: tobacco product use among middle and high school students—United States 2011-2018.MMWR Morb Mortal Wkly Rep. 2019; 68: 157-164
- Changes in prevalence of vaping among youths in the United States, Canada, and England from 2017 to 2019.JAMA Pediatr. 2020; 174: 797-800
- Electronic cigarettes and cardiovascular health: what do we know so far?.Vasc Health Risk Manag. 2019; 15: 159-174
- Update: product, substance-use, and demographic characteristics of hospitalized patients in a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury—United States, August 2019–January 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 44-49
- Prevention and treatment of tobacco use: JACC health promotion series.J Am Coll Cardiol. 2018; 72: 1030-1045
- Low-tar medium-nicotine cigarettes: a new approach to safer smoking.Br Med J. 1976; 1: 1430-1433
- Activation of the “splenocardiac axis” by electronic and tobacco cigarettes in otherwise healthy young adults.Physiol Rep. 2017; 5e13393
- Adverse effects of cigarette and noncigarette smoke exposure on the autonomic nervous system: mechanisms and implications for cardiovascular risk.J Am Coll Cardiol. 2014; 64: 1740-1750
- The pathophysiology of cigarette smoking and cardiovascular disease: an update.J Am Coll Cardiol. 2004; 43: 1731-1737
- Design features in multiple generations of electronic cigarette atomizers.Int J Environ Res Public Health. 2019; 16: 2904
- Nicotine arms race: Juul and the high-nicotine product market.Tob Control. 2019; 28: 623-628
- Free radical, carbonyl, and nicotine levels produced by Juul electronic cigarettes.Nicotine Tob Res. 2019; 21: 1274-1278
- Cardiovascular events associated with smoking cessation pharmacotherapies: a network meta-analysis.Circulation. 2014; 129: 28-41
- Impact of smokeless tobacco products on cardiovascular disease: implications for policy, prevention, and treatment: a policy statement from the American Heart Association.Circulation. 2010; 122: 1520-1544
- Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis.BMJ. 2009; 339: b3060
- Levels of selected carcinogens and toxicants in vapour from electronic cigarettes.Tob Control. 2014; 23: 133-139
- Nicotine, carcinogen, and toxin exposure in long-term e-cigarette and nicotine replacement therapy users: a cross-sectional study.Ann Intern Med. 2017; 166: 390-400
- Exposure to nicotine and selected toxicants in cigarette smokers who switched to electronic cigarettes: a longitudinal within-subjects observational study.Nicotine Tob Res. 2017; 19: 160-167
- Lung cancer and cardiovascular disease mortality associated with ambient air pollution and cigarette smoke: shape of the exposure-response relationships.Environ Health Perspect. 2011; 119: 1616-1621
- Association between electronic cigarette use and myocardial infarction.Am J Prev Med. 2018; 55: 455-461
- Electronic cigarette use and myocardial infarction among adults in the US population assessment of tobacco and health.J Am Heart Assoc. 2019; 8e012317
- Association of electronic cigarette use with myocardial infarction: persistent uncertainty.Am J Prev Med. 2019; 56: 159-160
- Cardiovascular autonomic effects of electronic cigarette use: a systematic review.Clin Auton Res. 2020; 30: 507-519
- Alterations in vascular function associated with the use of combustible and electronic cigarettes.J Am Heart Assoc. 2020; 9e014570
- Sympathomimetic effects of acute e-cigarette use: role of nicotine and non-nicotine constituents.J Am Heart Assoc. 2017; 6e006579
- Increased cardiac sympathetic activity and oxidative stress in habitual electronic cigarette users: implications for cardiovascular risk.JAMA Cardiol. 2017; 2: 278-284
- Prolonged Tpeak-to-Tend interval on the resting ECG is associated with increased risk of sudden cardiac death.Circ Arrhythm Electrophysiol. 2011; 4: 441-447
- Tobacco and electronic cigarettes adversely impact ECG indexes of ventricular repolarization: implication for sudden death risk.Am J Physiol Heart Circ Physiol. 2020; 318: H1176-H1184
- Acute impact of tobacco vs electronic cigarette smoking on oxidative stress and vascular function.Chest. 2016; 150: 606-612
- Acute effects of heat-not-burn, electronic vaping, and traditional tobacco combustion cigarettes: the Sapienza University of Rome—Vascular Assessment of Proatherosclerotic Effects of Smoking (SUR-VAPES ) 2 randomized trial.J Am Heart Assoc. 2019; 8e010455
- Elevated cellular oxidative stress in circulating immune cells in otherwise healthy young people who use electronic cigarettes in a cross-sectional single-center study: implications for future cardiovascular risk.J Am Heart Assoc. 2020; 9e016983
- Impact of Tobacco Versus Electronic Cigarette Smoking on Platelet Function.Am J Cardiol. 2018; 122: 1477-1481
- Differential effects of tobacco cigarettes and electronic cigarettes on endothelial function in healthy young people.A J Physiol Heart Circ Physiol. 2020; 319: H547-H556
- Cardiovascular effects of switching from tobacco cigarettes to electronic cigarettes.J Am Coll Cardiol. 2019; 74: 3112-3120
- Nicotine replacement therapy versus control for smoking cessation.Cochrane Database Syst Rev. 2018; 5: CD000146
- A randomized trial of e-cigarettes versus nicotine-replacement therapy.N Engl J Med. 2019; 380: 629-637
- Socioeconomic Disparities in Electronic Cigarette Use and Transitions from Smoking.Nicotine Tob Res. 2019; 21: 1363-1370
National Institute on Drug Abuse. Monitoring the Future survey. Available at: www.drugabuse.gov/drug-topics/trends-statistics/infographics/monitoring-future-2019-survey-results-overall-findings. Accessed October 10, 2020.
- Youth tobacco use: results from the National Youth Tobacco Survey.(Available at:) (Accessed October 10, 2020)
- Noncigarette tobacco products—gateway or diversion?.JAMA Pediatr. 2018; 172: 784
- Analysis of cannabinoid-containing fluids in illicit vaping cartridges recovered from pulmonary injury patients: identification of vitamin E acetate as a major diluent.Toxics. 2020; 8: 8
- Potential deaths averted in USA by replacing cigarettes with e-cigarettes.Tob Control. 2018; 27: 18-25
Article info
Publication history
Published online: December 15, 2020
Accepted:
December 8,
2020
Received:
October 13,
2020
Footnotes
See editorial by Pipe, pages 683–685 of this issue.
See page 697 for disclosure information.
Identification
Copyright
© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Vaping, Smoking Cessation, and Harm Reduction? Look Before You LeapCanadian Journal of CardiologyVol. 37Issue 5
- PreviewTobacco addiction, arguably the most significant and deadly of the modifiable cardiovascular risk factors—and the most neglected—has long been a challenge for the cardiovascular specialist.1 Notwithstanding the significant reduction in smoking that has occurred in Canada over the past 50 years—only 14%-16% of Canadians are now smokers—it remains a persistent pathologic feature of the lives of many of our patients. Cardiovascular clinicians have been enjoined to address the challenge of smoking cessation by supporting a systematic approach to the management of their smoking patients with the use of cessation aids and supportive counselling.
- Full-Text
- Preview
