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4088122 
Journal Article 
Nicotine, carcinogen, and toxin exposure in long-term e-cigarette and nicotine replacement therapy users: A cross-sectional study 
Shahab, L; Goniewicz, ML; Blount, BC; Brown, J; Mcneill, A; Alwis, KU; Feng, J; Wang, L; West, R 
2017 
Yes 
Annals of Internal Medicine
ISSN: 0003-4819
EISSN: 1539-3704 
166 
6 
390-400 
English 
28166548 
WOS:000397025800014 
Background: Given the rapid increase in the popularity of e-cigarettes and the paucity of associated longitudinal health-related data, the need to assess the potential risks of long-term use is essential.

Objective: To compare exposure to nicotine, tobacco-related carcinogens, and toxins among smokers of combustible cigarettes only, former smokers with long-term e-cigarette use only, former smokers with long-term nicotine replacement therapy (NRT) use only, long-term dual users of both combustible cigarettes and e-cigarettes, and long-term users of both combustible cigarettes and NRT.

Design: Cross-sectional study.

Setting: United Kingdom.

Participants: The following 5 groups were purposively recruited: combustible cigarette-only users, former smokers with long-term (≥6 months) e-cigarette-only or NRT-only use, and long-term dual combustible cigarette-e-cigarette or combustible cigarette-NRT users (n = 36 to 37 per group; total n = 181).

Measurements: Sociodemographic and smoking characteristics were assessed. Participants provided urine and saliva samples and were analyzed for biomarkers of nicotine, tobacco-specific N-nitrosamines (TSNAs), and volatile organic compounds (VOCs).

Results: After confounders were controlled for, no clear between-group differences in salivary or urinary biomarkers of nicotine intake were found. The e-cigarette-only and NRT-only users had significantly lower metabolite levels for TSNAs (including the carcinogenic metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]) and VOCs (including metabolites of the toxins acrolein; acrylamide; acrylonitrile; 1,3-butadiene; and ethylene oxide) than combustible cigarette-only, dual combustible cigarette-e-cigarette, or dual combustible cigarette-NRT users. The e-cigarette-only users had significantly lower NNAL levels than all other groups. Combustible cigarette-only, dual combustible cigarette-NRT, and dual combustible cigarette-e-cigarette users had largely similar levels of TSNA and VOC metabolites.

Limitation: Cross-sectional design with self-selected sample.

Conclusion: Former smokers with long-term e-cigarette-only or NRT-only use may obtain roughly similar levels of nicotine compared with smokers of combustible cigarettes only, but results varied. Long-term NRT-only and e-cigarette-only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.

Primary Funding Source: Cancer Research UK. 
Adult; Biomarkers/analysis/urine; Carcinogens/analysis; Cross-Sectional Studies; Electronic Nicotine Delivery Systems/adverse effects; Nicotine/analysis/urine; Nitrosamines/analysis/urine; Salvia/chemistry; Smoking Cessation/methods; Time Factors; Tobacco Use Cessation Devices/adverse effects; Volatile Organic Compounds/analysis/urine; 6M3C89ZY6R