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.
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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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
• GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet 2017;389:1885–906. This report highlights the persisting ominous health impact of tobacco-related disease with a global perspective.
• Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2019 Update: a report from the American Heart Association. Circulation. 2019;139:e56–528 This additional report highlights the persisting ominous health impact of tobacco-related disease in the USA.
Czoli CD, White CM, Reid JL, OConnor RJ, Hammond D. Awareness and interest in IQOS heated tobacco products among youth in Canada, England and the USA. Tob Control. 2019 Jan 29. pii: tobaccocontrol-2018-054654. doi: https://doi.org/10.1136/tobaccocontrol-2018-054654. [Epub ahead of print].
Huang J, Feng B, Weaver SR, Pechacek TF, Slovic P, Eriksen MP. Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 US National Surveys from 2012 to 2017. JAMA Netw Open. 2019;2:e191047.
• Carnevale R, Sciarretta S, Violi F, Nocella C, Loffredo L, Perri L, et al. Acute Impact of Tobacco vs Electronic Cigarette Smoking on Oxidative Stress and Vascular Function. Chest. 2016;150:606–12 This report highlights the comparative cardiovascular safety of tobacco combustion cigarettes and electronic vaping cigarettes.
Górski P. E-cigarettes or heat-not-burn tobacco products - advantages or disadvantages for the lungs of smokers. Adv Respir Med. 2019;87:123–34.
Conklin DJ, Schick S, Blaha MJ, Carll A, DeFilippis A, Ganz P, et al. Cardiovascular injury induced by tobacco products: assessment of risk factors and biomarkers of harm. A Tobacco Centers of Regulatory Science compilation. Am J Physiol Heart Circ Physiol. 2019;316:H801–27.
•• Darville A, Hahn EJ. E-cigarettes and atherosclerotic cardiovascular disease: what clinicians and researchers need to know. Curr Atheroscler Rep. 2019;21:15 This report emphasizes the potential detrimental health impact of modified risk products of tobacco.
Li D, Sundar IK, McIntosh S, Ossip DJ, Goniewicz ML, O’Connor RJ, Rahman I. Association of smoking and electronic cigarette use with wheezing and related respiratory symptoms in adults: cross-sectional results from the Population Assessment of Tobacco and Health (PATH) study, wave 2. Tob Control. 2019 Feb 13. pii: tobaccocontrol-2018-054694. doi: https://doi.org/10.1136/tobaccocontrol-2018-054694. [Epub ahead of print].
Lee WH, Ong SG, Zhou Y, Tian L, Bae HR, Baker N, et al. Modeling cardiovascular risks of E-cigarettes with human-induced pluripotent stem cell-derived endothelial cells. J Am Coll Cardiol. 2019;73:2722–37.
Glantz SA, Bareham DW. E-cigarettes: use, effects on smoking, risks, and policy implications. Annu Rev Public Health. 2018;39:215–35.
• Bullen C. Rise in e-cigarette use linked to increase in smoking cessation rates. BMJ. 2017;358:j3506 This report highlights the potential role of modified risk products to improve cessation rates from tobacco combustion cigarettes.
Madias JE. Applying cluster analysis to data of previously published chronic heart failure trials. J Am Coll Cardiol. 2015;65:1268–9.
Babbin SF, Velicer WF, Paiva AL, Brick LA, Redding CA. Replicating cluster subtypes for the prevention of adolescent smoking and alcohol use. Addict Behav. 2015;40:57–65.
Diller GP, Kempny A, Babu-Narayan SV, Henrichs M, Brida M, Uebing A, et al. Machine learning algorithms estimating prognosis and guiding therapy in adult congenital heart disease: data from a single tertiary centre including 10 019 patients. Eur Heart J. 2019;40:1069–77.
• Horiuchi Y, Tanimoto S, Latif AHMM, Urayama KY, Aoki J, Yahagi K, et al. Identifying novel phenotypes of acute heart failure using cluster analysis of clinical variables. Int J Cardiol. 2018;262:57–63 This report highlights the usefulness of unsupervised machine learning approaches in cardiovascular medicine.
Ahmad T, Desai N, Wilson F, Schulte P, Dunning A, Jacoby D, et al. Clinical implications of cluster analysis-based classification of acute decompensated heart failure and correlation with bedside hemodynamic profiles. PLoS One. 2016;11:e0145881.
Ahmad T, Pencina MJ, Schulte PJ, O’Brien E, Whellan DJ, Piña IL, et al. Clinical implications of chronic heart failure phenotypes defined by cluster analysis. J Am Coll Cardiol. 2014;64:1765–74.
Guo Q, Lu X, Gao Y, Zhang J, Yan B, Su D, et al. Cluster analysis: a new approach for identification of underlying risk factors for coronary artery disease in essential hypertensive patients. Sci Rep. 2017;7:43965.
Nocella C, Biondi-Zoccai G, Sciarretta S, Peruzzi M, Pagano F, Loffredo L, et al. Impact of tobacco versus electronic cigarette smoking on platelet function. Am J Cardiol. 2018;122:1477–81.
Mastrangeli S, Carnevale R, Cavarretta E, Sciarretta S, Peruzzi M, Marullo AGM, et al. Predictors of oxidative stress and vascular function in an experimental study of tobacco versus electronic cigarettes: a post-hoc analysis of the SUR-VAPES 1 (Sapienza University of Rome-Vascular Assessment of Proatherosclerotic Effects of Smoking) Study. Tob Induc Dis. 2018;16:11.
• Biondi-Zoccai G, Sciarretta S, Bullen C, Nocella C, Violi F, Loffredo L, et al. 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;8:e010455 This report highlights the comparative cardiovascular safety of tobacco combustion cigarettes and electronic vaping cigarettes vs heat-not-smoke cigarettes.
Haig C, Carrick D, Carberry J, Mangion K, Maznyczka A, Wetherall K, McEntegart M, Petrie MC, Eteiba H, Lindsay M, Hood S, Watkins S, Davie A, Mahrous A, Mordi I, Ahmed N, Teng Yue May V, Ford I, Radjenovic A, Welsh P, Sattar N, Oldroyd KG, Berry C. Current smoking and prognosis after acute ST-segment elevation myocardial infarction: new pathophysiological insights. JACC Cardiovasc Imaging. 2018. pii: S1936-878X(18)30512–30516. doi: https://doi.org/10.1016/j.jcmg.2018.05.022. [Epub ahead of print].
•• Fairchild AL, Lee JS, Bayer R, Curran J. E-Cigarettes and the Harm-Reduction Continuum. N Engl J Med. 2018;378:216–9 This report highlights the potential role of electronic vaping cigarettes and heat-not-smoke cigarettes as a strategy to improve cessation rates from tobacco combustion cigarettes.
Biondi-Zoccai G, Peruzzi M, Frati G. E-cigarettes, incentives, and drugs for smoking cessation. N Engl J Med. 2018;379:991–2.
Avdalovic MV, Murin S. POINT: does the risk of electronic cigarettes exceed potential benefits? Yes. Chest. 2015;148:580–2.
Middlekauff HR. COUNTERPOINT: does the risk of electronic cigarettes exceed potential benefits? No. Chest. 2015;148:582–4.
Mejía-Rentería H, Matias-Guiu JA, Lauri F, Yus M, Escaned J. Microcirculatory dysfunction in the heart and the brain. Minerva Cardioangiol. 2019;67:318–29.
Nicol P, Xhepa E, Bozhko D, Joner M. Neoatherosclerosis: from basic principles to intravascular imaging. Minerva Cardioangiol. 2018;66:292–300.
Suissa K, Larivière J, Eisenberg MJ, Eberg M, Gore GC, Grad R, et al. Efficacy and safety of smoking cessation interventions in patients with cardiovascular disease: a network meta-analysis of randomized controlled trials. Circ Cardiovasc Qual Outcomes. 2017;10:e002458.
Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, Williman J, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013;382:1629–37.
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.
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.
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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). https://doi.org/10.1007/s11883-020-0824-4
- Cluster analysis
- Electronic cigarette
- Electronic vaping cigarette
- Heat-not-burn cigarette
- Modified risk product