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Profiling the Acute Effects of Modified Risk Products: Evidence from the SUR-VAPES (Sapienza University of Rome-Vascular Assessment of Proatherosclerotic Effects of Smoking) Cluster Study


Purpose of Review

Modified risk products (MRP) are promoted as a safer alternative to traditional combustion cigarettes (TCC) in chronic smokers. Evidence for their lower hazardous profile is building, despite several controversies. Yet, it is unclear whether individual responses to MRP differ among consumers. We hypothesized that different clusters of subjects exist in terms of acute effects of MRP.

Recent Findings

Pooling data from a total of 60 individuals, cluster analysis identified at least three clusters (labelled 1 to 3) of subjects with different electronic vaping cigarettes (EVC) effects and at least two clusters (labelled 4 to 5) of subjects with different heat-not-burn cigarettes (HNBC) effects. Specifically, oxidative stress, platelet aggregation, and endothelial dysfunction after EVC were significantly different cluster-wise (all p < 0.05), and oxidative stress and platelet aggregation after HNBC were significantly different (all p < 0.05). In particular, subjects belonging to Cluster 1 appeared to have less detrimental responses to EVC usage than subjects in Cluster 2 and 3, as shown by non-significant changes in flow-mediated dilation (FMD) and less marked increase in Nox2-derived peptide (NOX). Conversely, those assigned to Cluster 3 had the worst reaction in terms of changes in FMD, NOX, and P-selectin. Furthermore, individuals belonging to Cluster 4 responded unfavorably to both HNBC and EVC, whereas those in Cluster 5 interestingly showed less adverse results after using HNBC than EVC. Results for main analyses were consistent employing different clusters, tests, and bootstrap.


Individual responses to MRP differ and smokers aiming at using EVC or HNBC as a risk reduction strategy should consider trying different MRP aiming at finding the one which is less detrimental, with subjects resembling those in Cluster 1 preferably using EVC and those resembling Cluster 5 preferably using HNBC.

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This work was supported in part by grant RM11715C7852D47E from Sapienza University of Rome to Prof. Frati, without any direct or indirect funding from tobacco companies. Data related to this work can be requested from the corresponding author.

Author information

GF, RC, SS, and GBZ conceived and designed the study; CN, MP, AGM, EDF, IC, VC, VV, EC, and AC participated in experimental activities; FV, MV, and AG participated in data interpretation and manuscript drafting; GBZ performed statistical analysis; GF, RC, SS, and GBZ drafted the manuscript; all authors critically revised and approved the manuscript; GBZ acts as guarantor of the paper, taking responsibility for the integrity of the work as a whole, from inception to published article.

Correspondence to Giacomo Frati or Giuseppe Biondi-Zoccai.

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Conflict of Interest

Giacomo Frati, Roberto Carnevale, Cristina Nocella, Mariangela Peruzzi, Antonino G. M. Marullo, Elena De Falco, Isotta Chimenti, Vittoria Cammisotto, Valentina Valenti, Elena Cavarretta, Albino Carrizzo, Francesco Versaci, Matteo Vitali, Carmela Protano, Leonardo Roever, Arturo Giordano, and Sebastiano Sciarretta each declare that they have no conflict of interest. Giuseppe Biondi-Zoccai has consulted for InnovHeart and reports personal fees from Abbott Vascular and personal fees from Bayer outside the submitted work.

Human and Animal Rights and Informed Consent

All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).

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Frati, G., Carnevale, R., Nocella, C. et al. Profiling the Acute Effects of Modified Risk Products: Evidence from the SUR-VAPES (Sapienza University of Rome-Vascular Assessment of Proatherosclerotic Effects of Smoking) Cluster Study. Curr Atheroscler Rep 22, 8 (2020).

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  • Cluster analysis
  • Electronic cigarette
  • Electronic vaping cigarette
  • Heat-not-burn cigarette
  • Modified risk product
  • Smoking
  • Tobacco