While smoking is a known cause of cardiovascular diseases such as coronary heart disease and strokes, 1 there is currently insufficient evidence to draw conclusions on the long-term effects of vaping. Investigating the long-term cardiovascular risks of e-cigarette use has been challenging due to 1) the short time period in which e-cigarettes have been popular, 2) the inclusion in many studies of younger people who are unlikely to experience cardiovascular problems until much later in life, and 3) the failure of many studies to account for the effects of smoking in the past.
Many researchers and medical organisations are concerned that vaping will lead to cardiovascular disease. 2 There are also concerns that the risk of cardiovascular disease may be increased for dual users and people who use e-cigarettes after successfully quitting smoking (see Sections 18.6.3.5 and 18.6.3.6). These concerns are informed by the known health effects of the chemicals in e-cigarettes (see Section 18.5.5 and Table 18.5.1), the demonstrated short-term effects of e-cigarettes on cardiovascular health (Section 18.6.3.4) and information from animal exposure experiments (Section 18.6.3.7).
E-cigarette emissions contain some of the same chemicals that cause damage to the cardiovascular system as tobacco smoke, such as nicotine and toxic aldehydes. However, aside from nicotine, most of these chemicals are present at considerably lower concentrations in e-cigarette aerosols compared to conventional cigarette smoke. Furthermore, e-cigarettes do not produce cardon monoxide, one of the mechanisms by which tobacco smoke causes cardiovascular damage. See Section 18.5 for more information on the chemicals in e-cigarettes.
Appropriate epidemiological studies on the cardiovascular effects of e-cigarette use
Longitudinal studies are the most appropriate for investigating the long-term cardiovascular effects of e-cigarette use. Some of these studies have used data from the US-based Population Assessment of Tobacco and Health (PATH study), 3 a nationally representative, population-based, longitudinal study involving approximately 49,000 people aged 12 years and above. Data have been collected in various waves since 2013.
Many cross-sectional studies have shown relationships between e-cigarette use and cardiovascular diseases using data from surveys. However these do not include sufficient information about when participants first started smoking or vaping, nor when diseases were diagnosed. 4 It is therefore not possible to use such studies to draw conclusions regarding cause and effect. For the most part, cross-sectional studies on the health effects of e-cigarettes are not presented in this section.
18.6.3.1 Heart attack and coronary heart disease
Coronary heart disease is the most common type of cardiovascular disease and includes two main clinical forms: heart attacks (when the heart is damaged by a blocked blood vessel) and angina (pain due to reduced blood flow to the heart). 5 While smoking tobacco is known to be an important cause of coronary heart disease and heart attacks, 1 , 6 the evidence for an association with e-cigarette use is less clear.
A number of cross-sectional studies have found no significant associations between e-cigarette use and coronary heart disease or heart attacks for people who exclusively use e-cigarettes compared to those who do not use e-cigarettes or smoke. 7 , 8
PATH studies examining the relationship between vaping and new cases of cardiovascular diseases (heart attack, bypass surgery, heart failure, other heart condition or stroke) 9 and new cases of heart attack 10 did not find evidence of increased risk among e-cigarette users. Both studies adjusted for previous tobacco use, though many participants in these and the cross-sectional studies above were young or middle-aged adults, who are generally at low risk for heart disease.
Another study using PATH data examined rates of cardiovascular diseases (congestive heart failure, stroke, heart attack, bypass surgery or other heart condition) for people who smoke aged 40+ who switched to e-cigarettes compared to those who quit completely. 11 People who became dual users of e-cigarettes and cigarettes had a comparable risk of cardiovascular diseases to those who continued smoking. Unfortunately, there were insufficient numbers of people who switched from smoking to vaping to examine health outcomes. 11
A longitudinal study of heart attacks using a different source of data (the Kaiser Permanente Research Bank) also failed to find a significant association with e-cigarette use. 12 However the follow-up time was relatively short (median 504 days) and some e-cigarette users reported a history of smoking.
One longitudinal study has found a difference in cardiovascular diseases among people who have quit smoking who vape. This Korean study used data for over 5 million male participants from 2014-2015 to 2018. Women were not included due to the very low proportion of women who smoke in Korea. Cardiovascular disease (defined as having been hospitalised for 2 or more days because of coronary heart disease or stroke) was higher in former smokers who used e-cigarettes than former smokers who quit completely. 13
Overall, studies have generally not found an increased risk of coronary heart disease among people who vape after taking into account history of tobacco use; however, the limited time period of these studies (maximum 4-year intervals) mean that long-term effects cannot be ruled out. 10 There is some evidence for increased risk of cardiovascular disease (as a composite outcome) in former smokers who used e-cigarettes compared to those who quit all nicotine/tobacco products completely.
18.6.3.2 Stroke
Smoking is a known cause of strokes, 1 in which the brain is damaged by a lack of blood flow. Strokes are a common form of cardiovascular disease and a major cause of morbidity and mortality in Australia. 14
Results from cross-sectional studies on the risk of stroke among people who vape have been mixed, with some finding an increased risk 15 and others finding no association. 7 , 16 However as described above cross-sectional studies cannot establish causation.
Several longitudinal studies in the US have found no found no association between vaping and stroke. 10 , 12 However similar to the research on coronary heart disease and heart attacks, the relatively short-term follow-up, lower risk of heart disease prior to older age, and smoking history among some participants in these studies means that there is insufficient evidence to date to establish whether vaping increases the risk of strokes in non-smokers.
18.6.3.3 Other cardiovascular conditions
Chest pain
Chest pain is an important cardiovascular symptom but is not the same as cardiovascular disease and may be a symptom of a non-cardiovascular condition. A PATH study did not find evidence of an increase in chest pain for people who use e-cigarettes for up to two years of follow-up. 17
Hypertension
Hypertension is a long-term condition of high blood pressure. It is a risk factor for many types of cardiovascular disease as well as kidney disease. 18 Blood pressure is measured using two parameters: highest reading (systolic) over lowest reading (diastolic). 19 Hypertension is defined as having a persistent systolic blood pressure of ≥ 140 mmHg or diastolic blood pressure of ≥ 90 mmHg, or receiving medication for high blood pressure. 20 This differs from a transient increase in blood pressure, as discussed below in Section 18.6.3.4.
Two longitudinal studies using data from the PATH study have not found significant increases in the risk of hypertension for e-cigarette users. 21 , 22 One of these studies found a possible trend for women but not men for increased risk, but the results were not statistically significant. 21 However, the short time period of these studies means that an increased risk of hypertension with long-term vaping cannot be ruled out.
18.6.3.4 Short-term effects of e-cigarettes on the cardiovascular system
Heart rate and blood pressure will vary with differing daily activities such as exercise, which requires greater blood flow. These attributes of the cardiovascular system are tightly regulated for quick responses to a variety of changes required during normal daily activities.
The use of conventional cigarettes also increases the heart rate and blood pressure and changes other measures of cardiovascular health in the short term. 23 Nicotine is considered one of the causes of these effects. 23
Many studies have shown that the use of e-cigarettes containing nicotine leads to similar effects, described below. These studies typically take measurements of markers of cardiovascular health in the immediate 5 mins to one hour after use of an e-cigarette, but some studies use longer periods of time.
Heart rate
In short term trials, vaping leads to a transient increase in heart rate within approximately one to 15 minutes after use. 24 , 25 This has been demonstrated to occur in exclusive e-cigarette users, 26 people with no history of e-cigarette use or tobacco use, 27 people who smoke but had never vaped, 26 , 28 and dual users of conventional and e-cigarettes. 29 However, some experimental studies did not find evidence of this effect. 30 A meta-analysis concluded that the increase in heart rate occurred after using nicotine e-cigarettes but not nicotine-free products, and that the effects of e-cigarette use on heart rate were less than that for conventional cigarettes. 31 Over 24 hours of e-cigarette use, heart rates were elevated during the daytime but not overnight. 29
It is not known whether the transient increases in heart rate for e-cigarette users will lead to an increased risk of cardiovascular disease.
Blood pressure
Like the heart rate, a person’s blood pressure needs to change rapidly to accommodate a variety of daily activities. But the use of drugs such as nicotine can also lead to transient increases in blood pressure.
Vaping has been shown to temporarily increase both systolic and diastolic blood pressure soon after use. This occurs in people that only use e-cigarettes, 26 people with no history of e-cigarette use of tobacco use, 27 people who smoke but had never used e-cigarettes, 26 and dual users of conventional and e-cigarettes. 29 Most of the people with elevated blood pressure did not meet the 140 mmHg criteria used for diagnosis of hypertension. 29
A temporarily elevated blood pressure is not the same as hypertension, which involves permanent high blood pressure, as described above in Section 18.6.3.3. In the absence of evidence for increased risk of hypertension, the long-term health consequences of temporary increases in blood pressure are unknown.
Vascular function
One mechanism by which smoking is thought to increase the risk of cardiovascular disease is by damaging the functioning of blood vessels (vascular function). Some markers of vascular function have been shown to temporarily change soon after use of an e-cigarette in short-term studies. A study of e-cigarette users showed that one minute after use there was an increase in vasoconstriction (narrowing of blood vessels due to contraction of the muscles in the vessel walls). 26 Vasoconstriction is a normal physiological process that can slow blood flow, but improper vasoconstriction may be associated with hypertension. Signs of vasoconstriction have also been detected in people who smoke after e-cigarette use. 28 In non-smokers who did not use e-cigarettes, acute increases in arterial pressure were detected as well as decreases in muscle sympathetic nerve activity (a likely mechanism behind the increased arterial pressure). 27 These effects were seen after nicotine-containing but not nicotine-free e-cigarette exposure. The long-term consequences of these changes in people who vape are not yet known.
Arterial stiffness is a hardening of the arteries that is associated with high blood pressure and ageing, as opposed to atherosclerosis, which is associated with risk factors for metabolic diseases. A short-term increase in arterial stiffness has been reported immediately after e-cigarette use in people who smoke tobacco, 32 people who occasionally smoke, 25 , 33 and never-smokers. 34 One study of increased arterial stiffness found that nicotine was required for this effect. 32
A trial of non-smokers showed that blood markers of inflammation and vascular changes increased after one session of e-cigarette use. 35
Other markers of vascular health appear to be worse in people who regular use e-cigarettes. 36-38 These effects often appear in young, seemingly healthy people, without symptoms. But the cross-sectional nature of these studies mean that it is not known whether e-cigarette use has caused this effect.
18.6.3.5 Cardiovascular effects of e-cigarette use compared to smoking
Substituting e-cigarette use for cigarette smoking
Some people who smoke have been able to completely replace smoking with vaping in the hope that this will reduce their risk of disease. Initial studies have examined markers of cardiovascular health in the short and medium term after switching, but the long-term effects of this substitution on cardiovascular risk are not yet known.
One longitudinal study of cardiovascular diseases in people who replaced conventional cigarettes with e-cigarettes used data from over 5 million male participants who underwent health screening during the first (2014–2015) and second (2018) periods of the Korean National Health Insurance Service database. 13 Women were not included due to the very low proportion of women who smoke in Korea. People who smoked were found to have a lower risk of heart disease if they switched to vaping rather than continued smoking. However, those who switched to vaping had a higher risk of cardiovascular disease compared to those who quit both products. 13 These results indicated that switching to e-cigarettes may be better for cardiovascular health than continued smoking, but still has a higher risk than quitting completely. Longer term studies are needed to confirm these results.
A trial that examined markers of cardiovascular health, such as arterial stiffness, three days after quitting smoking found that many of these markers improved after switching to e-cigarettes. There was no difference in these markers for people who quit using nicotine e-cigarettes, non-nicotine e-cigarettes or nicotine replacement therapy up to six months after cessation. 39 A similar trial also showed improvements in some markers of vascular health but not others, one month after switching by long-term cigarette smokers, and particularly for females more than for males. 40 Inconsistencies between the results of such trials have been noted. 41 Furthermore, these studies did not find consistent differences between people who continued with nicotine exposure compared to those who used non-nicotine e-cigarettes, despite evidence that nicotine is at least partially responsible for some of the markers of worsening cardiovascular health. 41 These inconsistencies make the interpretation of these studies challenging.
E-cigarette use compared to conventional cigarettes
Longitudinal data from the PATH study (described above) was used to compare cardiovascular disease in people who solely used e-cigarettes compared to those who solely smoked cigarettes, adjusting for past use of cigarettes. 9 People who vaped had a 30% to 40% lower risk of cardiovascular disease than people who smoked, but the analysis was unable to determine if there was a difference for heart attacks or stroke as individual outcomes. 9 In this study, no difference was detected between non-users and exclusive e-cigarette users, but the short time period of this longitudinal study means that it is difficult to rule out the existence of such a difference. 9
Sole users of e-cigarettes had a lower risk of chest pain than people who used conventional cigarettes. 17 Chest pain can be a symptom of cardiovascular as well as non-cardiovascular conditions.
18.6.3.6 Dual use of e-cigarettes and conventional cigarettes
Some people both smoke and vape. This may occur when people have been unsuccessful in attempts to quit smoking using e-cigarettes, or for other reasons. Most of the studies examining the risk of cardiovascular disease in dual users have been cross-sectional, which cannot establish whether dual use causes differences in risk.
Cross-sectional studies have shown that dual users have higher nicotine dependency and nicotine intake than people who only smoke cigarettes. 42 Dual users also had a higher daily intake of energy, higher rates of obesity and metabolic syndrome (a cluster of ≥ 3 out of 5 medical conditions that increases the risk of cardiovascular disease), compared to people who smoke and never smokers. 42 A cross-sectional study has also found a higher chance of having had a stroke for young adult dual users compared to sole users of conventional or e-cigarettes. 16
A longitudinal study using PATH data found that dual users had a similar risk of chest pain compared to people who smoke cigarettes, but a lower risk for those who used e-cigarettes. 17
18.6.3.7 Animal studies
Experimental studies have used rats or mice exposed to e-cigarette aerosols for varying periods of time to examine the effects on indicators of cardiovascular health. These experiments have found a number of effects that are consistent with an increased risk of cardiovascular diseases caused by e-cigarette use and may help determine the mechanisms by which e-cigarette use affect the cardiovascular system. Limitations of animal studies can include poor extrapolation of animal findings to humans and a number of ethical concerns—see Section 10.14.5.
Compared to exposure to clean air, e-cigarette aerosol exposure for two weeks in mice increased the risk of thrombotic (blood-clot formation) events. 43 Exposure to a single e-cigarette session in rats lead to similar impairments in the function of blood vessels that restrict blood flow 44 , 45 as seen after single exposures in humans, described above in Section 18.6.3.4 (vascular function). Single exposures in rats also impaired the function of arteries in the brain, consistent with a potential risk for stroke. 46 This effects was not dependent on nicotine. 46 An elevated heart rate is seen in mice exposed to e-cigarette aerosols. 47
One study involved exposing mice to e-cigarette aerosols for up to 60 weeks. 48 Long-term exposure led to significant increases in blood pressure, vasoconstriction (see 18.6.3.4 vascular function) and increased heart weight and aorta wall thickness, consistent with the type of damage that occurs when the heart needs to work harder. 48
Relevant news and research
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References
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