18.6.3 E-cigarette use and possible cardiovascular disease risk

Last updated:  November 2018  

Suggested citation: Greenhalgh, EM & Scollo, MM. 18.6.3 E-cigarette use and possible cardiovascular risk. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023.  Available from:  https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/18-6-the-health-effects-of-e-cigarette-use/18-6-3-e-cigarette-use-and-possible-cardiovascular-disease-risk 


Conflicting findings have been reported about the potential health effects of e-cigarette use on the cardiovascular system.1-5 The current body of research is limited and short-term, with a lack of high-quality studies and adequate follow-up. Some evidence suggests that e-cigarettes have sympathomimetic effects (i.e., mimicking the action of the sympathetic system) related to nicotine exposure. Limited data suggests that vascular injury may be another concern.6 The user’s heart rate and diastolic blood pressure increase after nicotine intake from e-cigarettes, and e-cigarette use may also be associated with a short-term increase in systolic blood pressure, changes in biomarkers of oxidative stress, increased endothelial dysfunction and arterial stiffness, and autonomic control.7 However, short-term changes are not necessarily associated with long-term outcomes, and there are no long-term studies to establish whether or not e-cigarette use is associated with cardiovascular disease.7, 8 Given the non-linear relationship between smoking and cardiovascular mortality—i.e., even light smoking can cause significant cardiovascular health effects—reductions in exposure to certain constituents (such as carbonyls and nicotine) through switching from tobacco to e-cigarettes may not result in proportional harm reduction.9 One study reported that compared to non-users, e-cigarette use was associated with a higher likelihood of chest pain, palpitations, coronary artery disease, and arrhythmia, though it should be noted that this study did not fully control for extent of prior use of cigarettes.10 A cross-sectional study found an association between daily e-cigarette use and increased risk of heart attacks, with a greater risk for those who also smoke, although the authors note that this type of study precludes establishing causal relationships.11

Given the lack of epidemiological data, the probability of cardiovascular disease risk needs to be assessed from data on toxicity of constituents, levels of exposure, mechanisms, and studies using experimental models. Although the cardiovascular risk is likely much less than that from smoking, e-cigarette emissions of concern for cardiovascular health may include nicotine, oxidizing chemicals, aldehydes (especially acrolein), and particulates.12 Overall, existing evidence is limited and further research is needed to establish the cardiovascular risks of using e-cigarettes long-term. 

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1. Lippi G, Favaloro EJ, Meschi T, Mattiuzzi C, Borghi L, et al. E-cigarettes and cardiovascular risk: beyond science and mysticism. Seminars of Thrombosis and Hemostasis, 2014; 40(1):60–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24343348

2. Farsalinos KE, Romagna G, and Le Houezec J. Comment on "E-cigarettes and cardiovascular risk: beyond science and mysticism". Seminars of Thrombosis and Hemostasis, 2014; 40(4):517–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24802086

3. Callahan-Lyon P. Electronic cigarettes: human health effects. Tobacco Control, 2014; 23 Suppl 2:ii36–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24732161

4. Vlachopoulos C, Ioakeimidis N, Abdelrasoul M, Terentes-Printzios D, Georgakopoulos C, et al. Electronic cigarette smoking increases aortic stiffness and blood pressure in young smokers. Journal of the American College of Cardiology, 2016; 67(23):2802–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27282901

5. Hua M and Talbot P. Potential health effects of electronic cigarettes: A systematic review of case reports. Preventive Medicine Reports, 2016; 4:169–78. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27413679

6. Nelluri B, Murphy K, Mookadam F, and Mookadam M. A review of the current literature regarding the cardiovascular effects of electronic cigarettes. Future Cardiology, 2016; 12(2):167–79. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26916427

7. National Academies of Sciences Engineering and Medicine. Public health consequences of e-cigarettes. The National Academies Press, Washington, DC 2018. Available from: http://nationalacademies.org/hmd/Reports/2018/public-health-consequences-of-e-cigarettes.aspx.

8. Byrne S, Brindal E, Williams G, Anastasiou K, Tonkin A, et al. E-cigarettes, smoking and health. A Literature Review Update. CSIRO, Australia,  2018. Available from: https://researchnow.flinders.edu.au/en/publications/e-cigarettes-smoking-and-health-a-literature-review-update.

9. Bhatnagar A. E-cigarettes and cardiovascular disease risk: evaluation of evidence, policy implications, and recommendations. Current Cardiovascular Risk Reports, 2016; 10(7):1–10. Available from: http://dx.doi.org/10.1007/s12170-016-0505-6

10. Wang JB, Olgin JE, Nah G, Vittinghoff E, Cataldo JK, et al. Cigarette and e-cigarette dual use and risk of cardiopulmonary symptoms in the Health eHeart Study. PLoS One, 2018; 13(7):e0198681. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30044773

11. Alzahrani T, Pena I, Temesgen N, and Glantz SA. Association Between Electronic Cigarette Use and Myocardial Infarction. American Journal of Preventive Medicine, 2018; 55(4):455–61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30166079

12. Benowitz NL and Fraiman JB. Cardiovascular effects of electronic cigarettes. Nature Reviews Cardiology, 2017; 14(8):447–56. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28332500