Introduction
The archetypal physics cigaret (e-cigarette) was patented and marketed successful 20041. Since then, e-cigarette usage (or “vaping”) has grown exponentially crossed the globe2. As the usage of vaping devices evolves with policy, the consequences of vaping connected wellness are becoming an progressively important nationalist wellness issue. E-cigarettes are being studied for harm simplification successful individuals who usage cigarettes and arsenic a smoking cessation aid, arsenic they are believed to beryllium little harmful to wellness than smoking3. However, determination is expanding grounds demonstrating adverse respiratory effects of vaping compared to vaping abstinence. In particular, an outbreak of E-Cigarette and Vaping-Associated Lung Illness (EVALI) brought the short-term respiratory consequences of vaping into question, particularly if cannabis oregon THC-containing products are used4. Other short-term respiratory changes that person been linked to vaping see accrued airway resistance5, breathing difficulty6, and transient lung inflammation7. Vaping has besides been associated with chronic respiratory conditions specified arsenic asthma8 and chronic bronchitis9. Despite these reports, the short- and semipermanent respiratory information of vaping is inactive mostly unknown. Several tiny studies person examined the effects of e-cigarettes connected lung function, including measures specified arsenic forced expiratory measurement successful 1 2nd (FEV1), forced captious capableness (FVC), and airway resistance. However, nary grounds syntheses person been completed connected this topic. Therefore, we conducted a systematic reappraisal to find the effects of vaping connected measures of lung function.
Methods
Our systematic reappraisal was conducted pursuing a protocol developed anterior to initiating the review, which was registered connected the PROSPERO registry of systematic reviews (CRD42021227121)10. This systematic reappraisal is reported pursuing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines11.
Search strategy and survey selection
Using a hunt strategy (Supplementary Tables 1–5) developed by an experienced wellness sciences librarian (G.G.), we systematically searched EMBASE, MEDLINE, and PsycINFO databases via Ovid, the Cochrane CENTRAL database, and the Web of Science Core from 2004 (the twelvemonth of the archetypal e-cigarette patent) until July 12, 2021. We additionally conducted a grey lit hunt by searching the websites of cardinal governmental and nationalist wellness organizations (the World Health Organization, Health Canada, the US Centers for Disease Control and Prevention, the US Food and Drug Administration, the Canadian Center connected Substance Use and Addiction, the European Centre for Disease Prevention and Control, and the European Public Health Association). Additional articles were identified by manually searching the notation lists of included publications arsenic good arsenic SCOPUS and Google Scholar (first 10 pages). Articles were included if they reported quantitative superior information connected changes successful lung relation associated with vaping, defined arsenic the usage of immoderate instrumentality that functions by transforming an e-liquid to an aerosol utilizing metallic coils, among quality participants of immoderate age. Studies of cells and those conducted successful animals were excluded. Studies utilizing heat-not-burn devices were besides excluded, arsenic these bash not conscionable the supra explanation of vaping. Eligible studies included randomized controlled trials (RCTs), non-randomized studies of interventions (NRSIs), and cohort studies; cross-sectional studies and lawsuit reports were excluded. We included studies that utilized non-users of some vaping devices and accepted cigarettes arsenic a examination radical and those that utilized a pre- and post-design successful which individuals acted arsenic their ain controls. Inclusion was not restricted by connection oregon state of publication. Abstracts and league proceedings were included if capable information could beryllium extracted from these publications.
Search results were downloaded from databases into notation absorption bundle (EndNote X9) oregon manually added (e.g., for grey lit results). Duplicates were removed successful EndNote and entries were uploaded to Covidence (Veritas Health Innovation, Melbourne, Australia), a systematic reappraisal software. Two reviewers (L.H. and K.H.) independently screened the titles and abstracts of each identified publications for eligibility. Citations considered perchance eligible by either reviewer, based connected the pre-specified reappraisal inclusion/exclusion criteria (Supplementary Table 6), were retrieved for full-text screening and assessed for inclusion. The reasons for exclusion aft full-text reappraisal were annotated successful Covidence and immoderate disagreements were resolved by statement oregon a 3rd reviewer (A.H-L.).
Data extraction
Two autarkic reviewers (L.H and K.H.) extracted methodological, demographic, and result information from included studies successful duplicate; disagreements were detected successful Covidence and were resolved by statement or, if necessary, by a 3rd reviewer (A.H-L.). Extracted information included survey characteristics (first author, journal, twelvemonth of publication, years(s) of information collection, funding, information source, survey design, recruitment strategy, duration of follow-up, state of origin, illustration size); colonisation characteristics (sex, gender, age, race, ethnicity, socioeconomic status, dose/frequency of e-cigarette use, accepted cigaret smoking status, smoked cannabis use); and vaping behavior, including the benignant of vaping instrumentality utilized (e.g., disposable e-cigarette vs. pod instrumentality specified arsenic JUUL), vaping products utilized (e.g., nicotine cartridges exclusively vs. THC cartridges exclusively vs. dual usage of nicotine and THC products), and root of the vaping merchandise (informal [i.e., friends, household members, oregon dealers] vs. commercialized [i.e., vape shops, stores, dispensaries]).
Initially, extracted outcomes of superior involvement were respiratory signs and symptoms, arsenic these are important to patients and are the aboriginal signs of respiratory disease. Secondary outcomes included: findings connected lung function; Computed tomography (CT) findings of emphysema, airway remodeling, and tiny airway loss; respiratory-related prime of beingness and workout limitations; incidence and/or prevalence of respiratory illness arsenic good arsenic exacerbations of erstwhile respiratory disease; and wellness attraction assets usage including respiratory disease-related ambulatory care, exigency section visits, and hospitalization. Given the constricted fig of studies disposable and the heterogeneity of the information extracted from these studies, nary meta-analysis was conducted.
Risk of bias
The hazard of bias successful included publications was assessed independently by 2 reviewers (L.H. and K.H.), and discrepancies were resolved by statement or, if necessary, by a 3rd reviewer (A.H-L.). The hazard of bias of included non-randomized studies (pre-post studies, NRSI with non-vaping notation group, cohort study) was assessed utilizing the Risk of Bias successful Non-randomized Studies—of Interventions (ROBINS-I) tool12. The ROBINS-I instrumentality evaluates intervention-specific outcomes for a survey done 7 domains which measure the hazard of bias pre-intervention, at-intervention, and post-intervention. For each result of involvement extracted from an included study, the hazard of bias wrong each domain was reported arsenic “low”, “moderate”, “serious”, oregon “critical”. Included RCTs were assessed utilizing the Cochrane Collaboration’s Tool for Assessing Risk of Bias (ROB V1)13. Similar to ROBINS-I, this instrumentality evaluates the hazard of bias done the appraisal of 5 domains; for each result of involvement extracted from an included study, the hazard of bias for each domain was reported arsenic “low hazard of bias”, “high hazard of bias”, oregon “unclear hazard of bias.” All eligible publications were included successful the qualitative synthesis careless of their assessed hazard of bias.
Reporting summary
Further accusation connected probe plan is disposable successful the Nature Research Reporting Summary linked to this article.
Results
As our hunt did not place studies which focused connected the wide outcomes elaborate above, we chose to bounds our absorption to studies connected lung function. Our database searches identified 14,307 perchance eligible studies (Fig. 1). After duplicates were removed, 8856 titles and abstracts were assessed. After this archetypal screening, 44 afloat texts were retrieved and reviewed successful further detail, yielding 8 studies eligible for inclusion.
PRISMA travel diagram of included studies assessing the effect of e-cigarettes connected lung function.
Study and subordinate characteristics
Of the 8 included studies (273 full participants), seven14,15,16,17,18,19,20 progressive short-term vulnerability to e-cigarettes with contiguous result assessment, and the remaining survey followed vapers and non-vapers implicit 3.5 years21 (Table 1). This prospective cohort survey examined 21 participants (12 nonsmokers and 9 vapers) astatine means of 12 (standard deviation: 1), 24 (2), and 42 (2) months aft baseline21. Of the 7 short-term studies, 4 were NRSIs (three pre-post studies14,15,16 and 1 NRSI with a non-vaping notation group20) and 3 were RCTs17,18,19. Among these 7 studies, 2 included 70–80 participants14,15 and 5 included 10–30 participants16,17,18,19,20. Exposures varied successful presumption of e-cigarettes, e-liquids, and vaping league timings. Most studies did not grow connected their explanation of “non-smoker/non-vaper”15,16,18,19,20,21, but 2 studies clarified that these participants were never-smokers14,17. One of these 2 studies further elaborated that participants had nary vulnerability to baccy products oregon e-cigarettes17. Few studies gave elaborate accusation connected the benignant of e-cigarette used. Three studies reported a circumstantial marque oregon merchandise (Blu17, eGo16, Joytech elips-C series18, Puff bar20). Polosa et al. listed immoderate of the assorted e-cigarettes utilized by participants passim the longitudinal study, including modular refillable (eGo benignant products) and much precocious refillable (Provari, Innokin, Joytech, eVIC, Avatar Puff)21. The remaining studies did not study a circumstantial brand, though 1 survey described the e-cigarette utilized arsenic a “1st procreation e-cigarette fashionable successful Greece”15. All studies clarified whether the e-cigarettes utilized during the survey contained nicotine.
Risk of bias
The included RCTs (n = 3)17,18,19 had an unclear hazard of bias, with each survey demonstrating an unclear hazard of bias successful 3+ domains (Table 2). This was chiefly owed to missing accusation successful the manuscripts required to marque an capable judgment, specified arsenic a deficiency of item surrounding randomization. The hazard associated with the blinding of participants and unit was judged to beryllium debased for each 3 included RCTs. These studies were not blinded, and 1 was placebo-controlled. However, it was judged that this deficiency of blinding would not power measures of lung function. Of the included non-randomized studies (n = 5)14,15,16,20,21, four14,15,16,20 were judged to beryllium astatine mean hazard of bias and one21 was recovered to person a superior hazard of bias (Table 3). The astir accordant root of bias successful these studies was bias owed to confounding, with lone one16 survey judged to person a debased hazard of bias owed to confounding. Of the remaining 4 studies, three14,15,20 were recovered to person a mean hazard of bias owed to confounding and one21 was recovered to beryllium astatine superior hazard of bias owed to confounding, with important confounding variables not accounted for successful the plan oregon analysis.
Effects of E-cigarette usage connected lung function
Seven studies14,15,16,17,18,19,20 reported contiguous measures of lung relation aft short-term vulnerability to e-cigarettes (Table 4), including FEV1, FVC, and FEV1/FVC. Two studies, Boulay et al. and Staudt. et al. suggested nary changes successful FEV1 oregon FEV1/FVC aft vaping among nonsmokers17,19. Kizhakke Puliyakote et al. observed little baseline FEV1 and FEV1/FVC values among nonsmokers compared to vapers20. Coppeta et al. recovered a alteration successful FEV1 and FEV1/FVC among nonsmokers aft 1 min of vaping; however, these values returned to baseline aft 15 min16.
Airway absorption and circumstantial airway conductance aft 10 min of vaping were measured successful two14,15 of the 7 short-term studies (Table 4). Both Palamidas et al. 2013 and 2017 suggested that vaping accrued airway absorption and decreased circumstantial airway conductance among nonsmokers and smokers with and without respiratory disease. Oxygen saturation was assessed successful 4 studies15,17,19,20. Three studies suggested nary changes aft vaping, with lone Palamidas et. al. 2017 suggesting decreased oxygen saturation pursuing vaping among smokers with and without asthma15.
Long-term changes (3.5 years) successful lung relation measurements were assessed successful lone 1 tiny (n = 21) survey (Polosa 2017)21. This survey suggested that FEV1, FVC, FEV1/FVC, and forced mid-expiratory travel (FEF25-75) did not alteration implicit clip among vapers and non-vapers (Table 5).
Discussion
This systematic reappraisal was designed to find the effect of vaping connected measures of lung function. We recovered that determination were lone 8 studies successful the lit assessing this issue, each of which were small, and lone 1 examined longer-term outcomes (3.5 years follow-up). In general, these studies suggest that determination are nary acute changes associated with vaping. However, airway absorption and conductance whitethorn beryllium influenced by e-cigarettes, with 2 studies reporting changes successful these values successful aggregate colonisation subgroups. It is important to enactment that determination were fewer studies disposable for this systematic reappraisal and that astir of these studies focused connected the acute effects of vaping; therefore, these results are suggestive but not definitive, and aboriginal probe indispensable beryllium conducted successful this area. Furthermore, 3 of the included studies had an unclear hazard of bias, 4 had a mean hazard of bias, and 1 had a superior hazard of bias, which further limits the mentation of this review’s findings.
In summation to the limitations above, this reappraisal lacks subgroup analyses oregon a meta-analysis. This is owed to the heterogeneity of the included studies, some successful presumption of survey plan and outcomes. Few studies were eligible for this reappraisal owed to the saltation successful survey designs and definitions of e-cigarettes and smoking status. For example, immoderate studies included some accepted cigaret smokers and nonsmokers successful their explanation of “non-vapers” and did not analyse information separately based connected accepted smoking status. Other studies utilized a “sham” vaping league for controls wherever either an e-cigarette with an bare cartridge (i.e., without e-liquid) oregon second-hand fume were used. More commonly, studies were conducted connected smokers only, without nonsmokers arsenic a examination group. Future studies could analyse subgroups based connected some smoking and vaping presumption to let for a much elaborate quantitative analysis.
E-cigarettes are becoming much fashionable for recreational usage and are being studied for harm simplification among smokers arsenic a smoking cessation aid, arsenic they are believed to beryllium little harmful to wellness than smoking. However, determination are constricted information disposable and virtually nary semipermanent studies assessing however prolonged e-cigarette usage could interaction lung function. As the usage of vaping devices evolves and becomes much widespread, the wellness consequences of vaping are becoming an progressively important nationalist wellness issue. This is simply a cognition spread that indispensable beryllium addressed. Knowledge of the information of e-cigarettes, peculiarly their semipermanent safety, volition pass nationalist wellness argumentation and e-cigarette regulations, arsenic good arsenic the guidance clinicians, connection to their patients connected smoking harm reduction. For these policies, regulations, and guidelines to beryllium developed, we indispensable recognize however e-cigarettes tin power one’s health. This includes establishing the effects of e-cigarettes connected objective outcomes specified arsenic respiratory symptoms (cough, dyspnea), measures of lung function, and hazard of processing respiratory disease. Further probe is required to elucidate the short- and semipermanent consequences of vaping to find whether e-cigarettes are genuinely a “safer” alternate to accepted cigarettes for smoking cessation oregon for recreational use. Future studies should beryllium long-term, person ample illustration sizes, and whitethorn see antithetic types of e-cigarettes arsenic good arsenic accepted cigarettes for comparison. In addition, it is important for aboriginal probe to see objective outcomes arsenic described above. This volition let for amended translation of the probe findings to assistance pass objective decision-making.
Data availability
No further information were available, arsenic this survey is simply a cognition synthesis that relied connected aggregate, published results disposable successful the nationalist domain. Any inquiries should beryllium directed to the corresponding author.
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Acknowledgements
The authors would similar to convey Jenna Glidden and Andrea Hebert-Losier for their assistance with survey screening, information abstraction, and hazard of bias assessment. The authors would besides similar to convey Francesca Frati, who peer-reviewed the hunt strategy. This enactment was funded by the Canadian Institutes for Health Research (#HEV-172891). The funder of the survey had nary relation successful survey design, information collection, information analysis, information interpretation, penning of the report, oregon determination to taxable for publication. Dr. Filion is supported by a Senior Research Scholar grant from the Fonds de recherche du Québec – Santé and a William Dawson Scholar grant from McGill University. Dr. Thombs was supported by a Tier 1 Canada Research Chair.
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Cite this article
Honeycutt, L., Huerne, K., Miller, A. et al. A systematic reappraisal of the effects of e-cigarette usage connected lung function. npj Prim. Care Respir. Med. 32, 45 (2022). https://doi.org/10.1038/s41533-022-00311-w
Received: 09 May 2022
Accepted: 06 October 2022
Published: 22 October 2022
DOI: https://doi.org/10.1038/s41533-022-00311-w
English (US)