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Early Cardiovascular Risk in E-cigarette Users: the Potential Role of Metals

A Correction to this article was published on 16 December 2020

This article has been updated

Abstract

Purpose of Review

Electronic cigarettes (e-cigs) are a source of metals. Epidemiologic and experimental evidence support that metals are toxic to the cardiovascular system. Little is known, however, about the role that e-cig metals may play as toxicants for the possible cardiovascular effects of e-cig use. The goal of this narrative review is to summarize the evidence on e-cig use and metal exposure and on e-cig use and cardiovascular toxicity and discuss the research needs.

Recent Findings

In vitro studies show cytotoxicity and increased oxidative stress in myocardial cells and vascular endothelial cells exposed to e-liquids and e-cig aerosols, with effects partially reversed with antioxidant treatment. There is some evidence that the heating coil plays a role in cell toxicity. Mice exposed to e-cigs for several weeks showed higher levels of oxidative stress, inflammation, platelet activation, and thrombogenesis. Cross-over clinical experiments show e-cig use alters nitric oxide–mediated flow-mediated dilation, endothelial progenitor cells, and arterial stiffness. Cross-sectional evidence from large nationally representative samples in the USA support that e-cig use is associated with self-reported myocardial infarction. Smaller studies found associations of e-cig use with higher oxidized low-density protein and heart variability compared to healthy controls. Numerous studies have measured elevated levels of toxic metals in e-cig aerosols including lead, nickel, chromium, and manganese. Arsenic has been measured in some e-liquids. Several of these metals are well known to be cardiotoxic.

Summary

Numerous studies show that e-cigs are a source of cardiotoxic metals. Experimental studies (in vitro, in vivo, and clinical studies) show acute toxicity of e-cigs to the vascular system. Studies of long-term toxicity in animals and humans are missing. Longitudinal studies with repeated measures of metal exposure and subclinical cardiovascular outcomes (e.g., coronary artery calcification) could contribute to determine the long-term cardiovascular effects of e-cigs and the potential role of metals in those effects.

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Change history

  • 16 December 2020

    A Correction to this paper has been published: <ExternalRef><RefSource>https://doi.org/10.1007/s40572-020-00302-4</RefSource><RefTarget Address="10.1007/s40572-020-00302-4" TargetType="DOI"/></ExternalRef>

References

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Funding

National Institute of Environmental Health Sciences (NIEHS) - R01ES029967, R01ES030025, R21ES029777, P30ES009089, P42ES010349.

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Correspondence to Nancy J. LoIacono.

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The original online version of this article was revised: The description of reference 55 should be changed to: This population-based study from the Population Assessment of Tobacco and Health Wave 1 survey found that e-cigarette use is associated with a higher risk of myocardial infarction. A limitation of the study is that there are few participants who solely used e-cigarettes in the absence of past or current traditional smoking. This manuscript has been retracted but understanding the limitations of the study remains relevant.

This article is part of the Topical Collection on Metals and Health

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Navas-Acien, A., Martinez-Morata, I., Hilpert, M. et al. Early Cardiovascular Risk in E-cigarette Users: the Potential Role of Metals. Curr Envir Health Rpt 7, 353–361 (2020). https://doi.org/10.1007/s40572-020-00297-y

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  • DOI: https://doi.org/10.1007/s40572-020-00297-y

Keywords

  • Cardiovascular disease
  • Coronary artery calcification
  • E-cigarettes
  • Endothelial cell health
  • Metals
  • Vaping